Annual Report and Accounts - The Great Western Hospital

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Overall, the Trust has good plans to improve quality during 2012/13, and with the impending transition from Primary Care Trusts to Clinical Commissioning Groups we look forward to working together to ensure that quality of care and services remains key. Page 137 of 211
6.9 Independent Assurance Report to the Council of Governors of Great Western Hospitals NHS Foundation Trust on the Annual Quality Report Page 138 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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Roger Hill, Non-Executive Director
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Helen Bourner, Director of Business
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5.2.4 Statement about the balance,
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5.2.9 Significant Commitments of th
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5.3.2 The work of the Audit, Risk a
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5.6 Nominations Committee 5.6.1 The
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5.7 Mental Health Act / Mental Capa
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5.8 Membership 5.8.1 Membership The
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The groupings of the members in the
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5.8.8 Membership development propos
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G.1.2 - The Board should clarify in
Page 297 and 298: and Governors. We have also commenc
Page 299 and 300: Regulation 1. To sustain compliance
Page 301 and 302: Audit / confidential enquiry title
Page 303 and 304: Audit Title Submitted/Required (%)
Page 305 and 306: No. Audit Title Learning From The P
Page 307 and 308: No. Audit Title 8. Diabetes Ketoaci
Page 309 and 310: No. Audit Title Audit Summary/Learn
Page 311 and 312: No. Audit Title Audit Summary/Learn
Page 313 and 314: 6.3.4 Registration with Care Qualit
Page 315 and 316: Steering Group, provides a quarterl
Page 317 and 318: Clostridium Difficile: The goal for
Page 319 and 320: Priority 2: To reduce harm associat
Page 321 and 322: Priority 3: To reduce harm associat
Page 323 and 324: Pressure ulcers Community: The comm
Page 325 and 326: Safe care of the patient receiving
Page 327 and 328: CHART - Serious Incidents grouped b
Page 329 and 330: The three top serious incident caus
Page 331 and 332: West conference call in August 2011
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
Page 339 and 340: Community: • Q1 Performance April
Page 341 and 342: The survey results demonstrate that
Page 343 and 344: 6.6 Performance against key nationa
Page 345 and 346: 6.8 Statements from Primary Care Tr
Page 347: 6.8.4 Wiltshire Primary Care Trust
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
Page 361 and 362: It was agreed that we would focus o
Page 363 and 364: Appraisal rates. The overall rate f
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
Page 377 and 378: Risk Licence to operate (compliance
Page 379 and 380: The governors and wider stakeholder
Page 381 and 382: Steps which have been put in place
Page 383 and 384: 14.8 Conclusion I have not identifi
Page 385 and 386: SHA - Strategic Health Authority SW
Page 387 and 388: Great Western Hospitals NHS Foundat
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Annual Report and Accounts - The Great Western Hospital

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