Annual Report and Accounts - The Great Western Hospital

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• Rolling educational programme with community staff to which all staff attend • Developed link nurse group (33% of qualified nurses within each team) who have regular pressure ulcer educational updates and training with equipment • Development of the RCA’s investigation form in line with the NPSA Investigation report to identify any patient focused learning outcomes • Completion of RCA’s for every Category 3 and 4 pressure ulcer with regular feedback given to the NT’s at all staffing levels and the Community Operations meeting. This feedback is patient focused and informs the educational program • Educational program with social service and agency staff working with patients within Wiltshire community to ensure that all new and existing staff can recognise and respond appropriately to their client group who are at risk of developing pressure ulcer and the early signs of pressure damage Priority 5: To Provide Safe Blood Transfusions Safe Blood Transfusions - During 2011/12 there have been no ‘wrong blood to wrong patient’ incidents within the Great Western Hospital, Savernake, Chippenham and Warminster Community Hospitals. Under the Blood Safety and Quality Regulations 2005 there is a legislative requirement for all blood and blood components to be fully traceable from donor to recipient. The Great Western Hospital uses the Blood Audit and Release System (BARS) which is an electronic blood tracking system. We are also responsible for the traceability of blood components at SwICC, Prospect Hospice and Savernake Hospital. For these areas we use a paper system. Blood component traceability is constantly monitored on a monthly basis and has on average been running at 98.2%. Chippenham and Warminster community hospitals and the Princess Anne Wing have their blood provided by the Royal United Hospital, Bath which is responsible for the traceability. CHART - Blood Component Traceability Jan 2011 – Dec 2011 120% Blood Component Traceability January - December 2011 100% 80% Traceability 60% 40% 20% 0% Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 RBC 100% 98% 100% 98% 99% 100% 100% 100% 99.08% 99.00% 96.00% 91% Platelets 100% 100% 100% 100% 99% 100% 100% 100% 100.00% 99.00% 98.00% 97% FFP 98% 100% 84% 100% 100% 100% 100% 100% 100.00% 94.00% 79.00% 80% Cryo 100% 100% 100% 100% 100% 100% 100% 100% 100.00% 100.00% 100.00% 83% Octaplas 100% 100% 100% 100% 100% 100% 100% 100.00% 50.00% 100.00% 100.00% Overall Percentage 99.44% 98.65% 98.15% 98.86% 98.95% 99.75% 99.62% 99.74% 99.21% 98.35% 96.46% 91.21% Page 113 of 211
Safe care of the patient receiving blood component transfusions has been regularly monitored via audit of transfusion observations. Minimum monitoring of the patient should include temperature, pulse, blood pressure and respiration rate. These should be recorded no more than 60 minutes prior to commencing the unit, 15 minutes into the unit (this includes observations undertaken within a 5 minute window either side of the 15 minutes) and no more than 60 minutes after completion of the unit. This is stipulated within the Trust’s transfusion guidelines and will be monitored via audit at least once a year. The National Patient Safety Agency (NPSA) competency based training for blood administration and venepuncture continues. The Trust is working towards achieving the set target of 100% for all staff involved in transfusion. However this is a very fluid process due to staff leaving and joining the organisation, maternity leave, long term sick leave etc. Staff who do not have a current relevant competency can no longer perform the procedure. Work is ongoing to monitor transfusion related competencies. A clear process of action was approved utilising the Matrons actively in policing and managing staff competencies. A ‘transfusion breech form’ is generated whenever blood is administered by someone who, according to our records, does not have the relevant competency. The number of breaches is falling month on month which shows that we are making good progress. Priority 6: To Reduce Preventable Hospital Mortalities Hospital Standardised Mortality Rate - The Trust has maintained an aggregate 98.7 Hospital Standardised Mortality Rate (HSMR) below (better than) 100 for the year to date (April – February). The graph below shows how the Trust is performing when compared to the average for the South West SHA and against the national expected level of 100. It can be seen that over the last 13 months the Trust’s trend has broadly followed that of the SHA average although at a higher level with some peaks. CHART – Hospital Standardised Mortality Rate GWH and SHA most recent 13 months 120.0 HSMR Mortality GWH and SHA - Most Recent 13 Months 110.0 100.0 90.0 80.0 GWH SHA 70.0 Nat Expected 60.0 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 The graph below shows in more detail how the Trust compares against the other Acute Trusts in the SHA for HSMR relative risk for the current year. It can be seen that performance is generally good in the SHA. Page 114 of 211
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Great Western Hospitals NHS Foundat
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CONTENTS 1 Chair and Chief Executiv
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The Great Western Hospital became a
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Underpinning this, our values are t
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3.2 Principal activities of the Tru
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Further Companies Act Disclosures 3
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Business Review / Management Commen
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3. To ensure that staff are proud t
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6. To work in partnership with othe
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With funding received from the Depa
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3.13 Contractual arrangements The T
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Patient care 3.16 Development of se
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3.20 New or significantly revised s
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3.24 Complaints Handling For the Tr
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The Trust actively responds to feed
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3.25 Using patient experience to dr
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The table below shows the CQUIN res
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Action plans based on the Quarterly
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3.27 Development of services with o
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3.29 Health and Overview Scrutiny C
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3.32.5 Interests held by Directors
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4.3 Attendance at meetings of the R
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4.7 Board of Directors’ employmen
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Remuneration Name Title Salary (Ban
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4.8.4 Additional disclosures The Tr
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5.1.2 Elected Governors - Public Co
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5.1.4 Nominated Governors Name Nomi
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5.1.6 Lead and Deputy Lead Governor
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“Eyes and Ears” - An initiative
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5.1.12 Nominations and Remuneration
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Rowland Cobbold, Non-Executive Dire
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Lyn Hill-Tout, Chief Executive (unt
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5.2.3 Length of appointments of Non
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5.2.6 Attendance at meetings of the
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5.3 Audit Committee 5.3.1 The Audit
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5.4 Directors’ responsibility for
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Note: Angela Gillibrand and Rowland
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The Mental Health Act / Mental Capa
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The Trust has a wide range of staff
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5.8.6 Membership Strategy To encour
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5.9 Code of Governance Disclosure S
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6 QUALITY REPORTS Part 1 - Statemen
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Part 2 - Priorities for improvement
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6.3.1 Review of services and partic
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The trust chose not to contribute t
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No. Audit Title Reconstruction Audi
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The reports of 273 local clinical a
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No. Audit Title 15. Non Invasive Ve
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No. Audit Title Antibiotic Prescrib
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No. Audit Title 50. NICE CG111 - No
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Part 3 - Other Information 6.4 Over
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GRAPH - Clostridium Difficile WCHS2
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GRAPH - Medicine incidents by type
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Harm from falls WCHS: It was not po
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• Rolling educational programme w
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CHART - Relative risk SW Acute Trus
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Following the Trust’s merge in Ju
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Priority 7: Participation on the Re
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All the guidelines have been dissem
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This has been achieved by: • Mont
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• As a result of complaints and c
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CHART - National Sentinel Stroke Au
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Priority 16: To ensure patients are
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6.5 Care Quality Commission (CQC) I
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6.7 Statement of Directors’ respo
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a Quality Account and the opportuni
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Overall, the Trust has good plans t
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Graph 1 - GWH carbon footprint (ton
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The Trust is working with local bus
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Graph 9 - Total tonnes of waste pro
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The Trust will be working towards a
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Detailed below is a summary of the
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Wiltshire Community Health Services
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providers. Feedback obtained across
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The Musculoskeletal Disorder team a
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10.2.2 Governance risk rating The t
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11 OTHER DISCLOSURES IN PUBLIC INTE
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13 AUDITOR’S OPINION AND CERTIFIC
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14 ANNUAL GOVERNANCE STATEMENT 14.1
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• the key controls to mitigate ag
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14.4.6 Organisation Culture The Tru
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14.5 Review of economy, efficiency
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Process Board Role and Conclusions
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15 GLOSSARY OF TERMS BARS - Blood A
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16 FOREWORD TO THE ACCOUNTS 16.1 Fo
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1 CHAIR AND CHIEF EXECUTIVE’S REP
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2 OUR TRUST 2.1 Vision - Your healt
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3 DIRECTOR’S REPORT General Compa
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3.3.2 The Brunel Treatment Centre O
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14 In relation to the use of financ
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Checklist, a World Health Organisat
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organisations to adapt to these cha
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TABLE - Wiltshire Community Activit
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The Trust is currently reviewing it
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Enhanced Quality Governance Reporti
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The Trust is using its foundation t
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of implementing the programme. Incl
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As part of the corporate back offic
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What patients and service users hav
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3.25.3 Patient Surveys The PICKER I
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3.25.5 Annual Inpatient Survey The
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CHART - Percentage of patients who
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3.28 Working with our partners to s
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3.31 Statement as to disclosures to
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4 REMUNERATION REPORT Information n
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4.5 Remuneration of senior managers
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4.8 Pension Benefits and Remunerati
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The accounting policies for pension
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5 NHS FOUNDATION TRUST CODE OF GOVE
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There is currently a vacancy for th
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5.1.5 Attendance at meetings of the
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In addition, in preparing the Trust
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5.1.11 Council of Governors Meeting
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Page 357 and 358: 8 EQUALITY REPORTING 8.1 Equality d
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Page 371 and 372: 12 STATEMENT OF ACCOUNTING OFFICER
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14.4 The risk and control framework
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Risk Licence to operate (compliance
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The governors and wider stakeholder
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Steps which have been put in place
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14.8 Conclusion I have not identifi
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SHA - Strategic Health Authority SW
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Annual Report and Accounts - The Great Western Hospital

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