Annual Report and Accounts - The Great Western Hospital

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CHART - Relative risk SW Acute Trusts April 2011 – February 2012 120.0 100.0 80.0 60.0 40.0 20.0 Relative Risk SW Acutes April 11- February 2012 0.0 RR The Trust has an established Trust Mortality Group that meets on a monthly basis and includes clinician representation from each Clinical Directorate as well as representatives from Quality, Clinical Audit, Risk, Informatics and Clinical Coding. The work of this group includes monthly reports on mortality produced by the information department and centred on Dr Foster tools. Red bell alerts from Dr Foster are investigated with review of coding and clinical care. CUSUM reports also produced by Dr Foster are being used to identify areas for proactive investigation where mortality appears to be increasing prior to a red bell alert. This tool has also been introduced to monitor areas which have previously alerted to give assurance that improved performance is maintained. Audits have been presented back to the Patient Safety and Quality Committee. Action plans arising from these audits which have the potential to improve patient care, reduce the risk of preventable deaths. Further information is contained in the Quality Account 2011/12. Clinical Incidents – Never Events, Serious Incidents and Incidents Never Events: A total of three never events have been recorded in the Trust between April 2011 to March 2012. All three were surrounding surgery; 1. Wrong site surgery 2. Wrong implant/prosthesis 3. Retained foreign object post-operation Serious Incidents: All serious incidents are investigated to identify the care and service delivery problems which contributed to the root cause of the incident. These are addressed in an action plan which is then communicated within Directorate meetings and reports across the Trust to ensure learning is shared. 71 serious incidents were reported and investigated across the merged Trust during the period April 2011 to March 2012. This was a decrease from the previous year April 2010 to March 2011 of 100 (44 GWH and 56 WCHS incidents added to quantify the figures). The graph below demonstrates the number of Serious Incidents grouped by type of incident. Page 115 of 211
CHART - Serious Incidents grouped by type of incident Incidents: The Clinical Risk Team was responsible for managing 84% of incidents which occurred at the Trust over the last year. The Health and Safety Team investigate the non-clinical incidents. The graph below demonstrates the numbers of incidents reported. GRAPH - numbers of incidents reported Page 116 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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5.2 Board of Directors 5.2.1 The Bo
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Page 283 and 284: 5.3.2 The work of the Audit, Risk a
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Page 295 and 296: G.1.2 - The Board should clarify in
Page 297 and 298: and Governors. We have also commenc
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Page 313 and 314: 6.3.4 Registration with Care Qualit
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Page 321 and 322: Priority 3: To reduce harm associat
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Page 333 and 334: Priority 9: To review the clinical
Page 335 and 336: Priority 12: To undertake nutrition
Page 337 and 338: • A regular ongoing training prog
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Page 341 and 342: The survey results demonstrate that
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Page 347 and 348: 6.8.4 Wiltshire Primary Care Trust
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Page 351 and 352: 7 SUSTAINABILITY REPORTING 7.1 Stro
Page 353 and 354: Graphs 3 and 4 show energy consumpt
Page 355 and 356: Graph 7 - Water consumption in WCHS
Page 357 and 358: 8 EQUALITY REPORTING 8.1 Equality d
Page 359 and 360: 9 STAFF SURVEY REPORT 9.1 Our staff
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Page 365 and 366: A quarterly “Voluntary Service Ma
Page 367 and 368: 10 REGULATORY RATINGS REPORT 10.1 M
Page 369 and 370: 10.3.2 Explanation for differences
Page 371 and 372: 12 STATEMENT OF ACCOUNTING OFFICER
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Page 375 and 376: 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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