Annual Report and Accounts - The Great Western Hospital

More documents

Recommendations

Info

The Musculoskeletal Disorder team and the Occupational Health team including physiotherapy input have worked closely together to carry out workplace assessments along with early intervention treatment. Over the past 12 months there has been a very clear correlation between the number of referrals received within Occupational Health from line managers and the number of staff off sick. For example in December there was a dramatic fall in referrals and a marked increase in sickness absence, compared to January, where there was a high number of OH interventions and a noted fall in sickness absence numbers. 9.10 Swine / Seasonal Flu Vaccinations The seasonal Flu campaign obtained a 26% uptake across the Trust in 2010, but, with recent national media coverage featuring the Chief Medical Officer at the Department of Health 2011 resulted in 39.5%. 9.11 Health and Safety During 2011 we commenced implementation of a suitable safety management system throughout the combined geographical area. Notable improvements are already being appreciated by staff, visitors and patients across the enlarged trust and a new governance structure has been implemented with monitoring via the Trust and Wiltshire Health and Safety Committees and regular progress reports to the Executive Committee. Major targeted improvements have included: • Implementation of new Safeguard Incident Management system across Wiltshire and commencement of an electronic incident reporting process across all sites within the enlarged Trust to speed up and improve quality of reports and investigations. • Roll out of a comprehensive H&S Audit programme across all Wiltshire sites to benchmark current compliance with legal / Policy H&S requirements and to provide clear improvement advice to all departmental managers. • Fire safety management improvements in reducing unwanted fire signals at GWH from 35 last year to 22 [against a target threshold of 32] in partnership with Carillion and also providing a comprehensive fire safety warden structure and training programme throughout the enlarged trust. • Sustained performance in serious RIDDOR reportable accidents for GWH which remain at 9 for the year and introduction of a centralised RIDDOR reporting requirement across Wiltshire instead of manager self reporting. This has resulted in 7 RIDDOR incidents being reported by the H&S Department from Wiltshire over the past year. • Introduction of a comprehensive H&S Representative training programme for the newly appointed department Reps and Department Managers throughout the Wiltshire sites. • Amalgamation of Wiltshire and GWH Policies and procedures accessible via a new versatile H&S Intranet web page. Please note that the Trust has disclosed information on the above as required under the Companies Act that is relevant to its operations. Page 155 of 211
10 REGULATORY RATINGS REPORT 10.1 Monitor the Independent Regulator As a Foundation Trust, GWH is regulated by Monitor, the independent regulator of all NHS Foundation Trusts. Monitor’s relationship with GWH is to ensure that the Trust does not breach the terms of its authorisation which were agreed when GWH became a Foundation Trust in December 2008. The Terms of Authorisation are a set of detailed requirements covering how GWH will operate – in summary they include: • the general requirement to operate effectively, efficiently and economically; • requirements to meet healthcare targets and national standards; and • the requirement to cooperate with other NHS organisations. Monitor requires each Foundation Trust board to submit an annual plan, quarterly and ad hoc reports. Performance is monitored against these plans to identify where potential and actual problems might arise. Monitor publishes quarterly and annual reports on these submissions and assigns each Foundation Trust with an annual and quarterly risk rating. These risk ratings are designed to indicate the risk of a failure to comply with the terms of authorisation. Monitor publishes three risk ratings for each NHS Foundation Trust as follows: - • financial rating; and • governance risk rating. The future role of Monitor and the regulatory regime is changing in light of new legislation. Providers of healthcare services will be licensed and Monitor will ensure that providers comply with licensing conditions. 10.2 Risk ratings from Monitor 10.2.1 Financial risk rating The Trust has been rated as 3 for Finance (rated range from 1-5, where 1 represents the highest risk and 5 the lowest). This means that there are regulatory concerns in one or more components but significant breach is unlikely. When assessing financial risk, Monitor will assign quarterly and annual risk ratings using a system which looks at four criteria, namely achievement of plan; underlying performance; financial efficiency; and liquidity. The risk rating is forward-looking and is intended to reflect the likelihood of an actual or potential financial breach of the Foundation Trust’s terms of authorisation. Page 156 of 211
Page 1:
Great Western Hospitals NHS Foundat
Page 5 and 6:
CONTENTS 1 Chair and Chief Executiv
Page 7 and 8:
The Great Western Hospital became a
Page 9 and 10:
Underpinning this, our values are t
Page 11 and 12:
3.2 Principal activities of the Tru
Page 13 and 14:
Further Companies Act Disclosures 3
Page 15 and 16:
Business Review / Management Commen
Page 17 and 18:
3. To ensure that staff are proud t
Page 19 and 20:
6. To work in partnership with othe
Page 21 and 22:
With funding received from the Depa
Page 23 and 24:
3.13 Contractual arrangements The T
Page 25 and 26:
Patient care 3.16 Development of se
Page 27 and 28:
3.20 New or significantly revised s
Page 29 and 30:
3.24 Complaints Handling For the Tr
Page 31 and 32:
The Trust actively responds to feed
Page 33 and 34:
3.25 Using patient experience to dr
Page 35 and 36:
The table below shows the CQUIN res
Page 37 and 38:
Action plans based on the Quarterly
Page 39 and 40:
3.27 Development of services with o
Page 41 and 42:
3.29 Health and Overview Scrutiny C
Page 43 and 44:
3.32.5 Interests held by Directors
Page 45 and 46:
4.3 Attendance at meetings of the R
Page 47 and 48:
4.7 Board of Directors’ employmen
Page 49 and 50:
Remuneration Name Title Salary (Ban
Page 51 and 52:
4.8.4 Additional disclosures The Tr
Page 53 and 54:
5.1.2 Elected Governors - Public Co
Page 55 and 56:
5.1.4 Nominated Governors Name Nomi
Page 57 and 58:
5.1.6 Lead and Deputy Lead Governor
Page 59 and 60:
“Eyes and Ears” - An initiative
Page 61 and 62:
5.1.12 Nominations and Remuneration
Page 63 and 64:
Rowland Cobbold, Non-Executive Dire
Page 65 and 66:
Lyn Hill-Tout, Chief Executive (unt
Page 67 and 68:
5.2.3 Length of appointments of Non
Page 69 and 70:
5.2.6 Attendance at meetings of the
Page 71 and 72:
5.3 Audit Committee 5.3.1 The Audit
Page 73 and 74:
5.4 Directors’ responsibility for
Page 75 and 76:
Note: Angela Gillibrand and Rowland
Page 77 and 78:
The Mental Health Act / Mental Capa
Page 79 and 80:
The Trust has a wide range of staff
Page 81 and 82:
5.8.6 Membership Strategy To encour
Page 83 and 84:
5.9 Code of Governance Disclosure S
Page 85 and 86:
6 QUALITY REPORTS Part 1 - Statemen
Page 87 and 88:
Part 2 - Priorities for improvement
Page 89 and 90:
6.3.1 Review of services and partic
Page 91 and 92:
The trust chose not to contribute t
Page 93 and 94:
No. Audit Title Reconstruction Audi
Page 95 and 96:
The reports of 273 local clinical a
Page 97 and 98:
No. Audit Title 15. Non Invasive Ve
Page 99 and 100:
No. Audit Title Antibiotic Prescrib
Page 101 and 102:
No. Audit Title 50. NICE CG111 - No
Page 103 and 104:
Page 105 and 106:
Part 3 - Other Information 6.4 Over
Page 107 and 108:
GRAPH - Clostridium Difficile WCHS2
Page 109 and 110:
GRAPH - Medicine incidents by type
Page 111 and 112:
Harm from falls WCHS: It was not po
Page 113 and 114:
• Rolling educational programme w
Page 115 and 116:
CHART - Relative risk SW Acute Trus
Page 117 and 118:
Following the Trust’s merge in Ju
Page 119 and 120:
Priority 7: Participation on the Re
Page 121 and 122:
All the guidelines have been dissem
Page 123 and 124:
This has been achieved by: • Mont
Page 125 and 126:
• As a result of complaints and c
Page 127 and 128:
CHART - National Sentinel Stroke Au
Page 129 and 130:
Priority 16: To ensure patients are
Page 131 and 132:
6.5 Care Quality Commission (CQC) I
Page 133 and 134:
6.7 Statement of Directors’ respo
Page 135 and 136:
a Quality Account and the opportuni
Page 137 and 138:
Overall, the Trust has good plans t
Page 139 and 140:
Page 139 of 211
Page 141 and 142:
Graph 1 - GWH carbon footprint (ton
Page 143 and 144:
The Trust is working with local bus
Page 145 and 146:
Graph 9 - Total tonnes of waste pro
Page 147 and 148:
The Trust will be working towards a
Page 149 and 150:
Detailed below is a summary of the
Page 151 and 152:
Wiltshire Community Health Services
Page 153 and 154:
providers. Feedback obtained across
Page 155 and 156:
The Musculoskeletal Disorder team a
Page 157 and 158:
10.2.2 Governance risk rating The t
Page 159 and 160:
11 OTHER DISCLOSURES IN PUBLIC INTE
Page 161 and 162:
13 AUDITOR’S OPINION AND CERTIFIC
Page 163 and 164:
14 ANNUAL GOVERNANCE STATEMENT 14.1
Page 165 and 166:
• the key controls to mitigate ag
Page 167 and 168:
14.4.6 Organisation Culture The Tru
Page 169 and 170:
14.5 Review of economy, efficiency
Page 171 and 172:
Process Board Role and Conclusions
Page 173 and 174:
15 GLOSSARY OF TERMS BARS - Blood A
Page 175 and 176:
16 FOREWORD TO THE ACCOUNTS 16.1 Fo
Page 177 and 178:
Page 179 and 180:
Page 181 and 182:
Page 183 and 184:
Page 185 and 186:
Page 187 and 188:
Page 189 and 190:
Page 191 and 192:
Page 193 and 194:
Page 195 and 196:
Page 197 and 198:
Page 199 and 200:
Page 201 and 202:
Page 203 and 204:
Page 205 and 206:
Page 207 and 208:
Page 209:
Page 214:
Page 217 and 218:
1 CHAIR AND CHIEF EXECUTIVE’S REP
Page 219 and 220:
2 OUR TRUST 2.1 Vision - Your healt
Page 221 and 222:
3 DIRECTOR’S REPORT General Compa
Page 223 and 224:
3.3.2 The Brunel Treatment Centre O
Page 225 and 226:
14 In relation to the use of financ
Page 227 and 228:
Checklist, a World Health Organisat
Page 229 and 230:
organisations to adapt to these cha
Page 231 and 232:
TABLE - Wiltshire Community Activit
Page 233 and 234:
The Trust is currently reviewing it
Page 235 and 236:
Enhanced Quality Governance Reporti
Page 237 and 238:
The Trust is using its foundation t
Page 239 and 240:
of implementing the programme. Incl
Page 241 and 242:
As part of the corporate back offic
Page 243 and 244:
What patients and service users hav
Page 245 and 246:
3.25.3 Patient Surveys The PICKER I
Page 247 and 248:
3.25.5 Annual Inpatient Survey The
Page 249 and 250:
CHART - Percentage of patients who
Page 251 and 252:
3.28 Working with our partners to s
Page 253 and 254:
3.31 Statement as to disclosures to
Page 255 and 256:
4 REMUNERATION REPORT Information n
Page 257 and 258:
4.5 Remuneration of senior managers
Page 259 and 260:
4.8 Pension Benefits and Remunerati
Page 261 and 262:
The accounting policies for pension
Page 263 and 264:
5 NHS FOUNDATION TRUST CODE OF GOVE
Page 265 and 266:
There is currently a vacancy for th
Page 267 and 268:
5.1.5 Attendance at meetings of the
Page 269 and 270:
In addition, in preparing the Trust
Page 271 and 272:
5.1.11 Council of Governors Meeting
Page 273 and 274:
5.2 Board of Directors 5.2.1 The Bo
Page 275 and 276:
Roger Hill, Non-Executive Director
Page 277 and 278:
Helen Bourner, Director of Business
Page 279 and 280:
5.2.4 Statement about the balance,
Page 281 and 282:
5.2.9 Significant Commitments of th
Page 283 and 284:
5.3.2 The work of the Audit, Risk a
Page 285 and 286:
5.6 Nominations Committee 5.6.1 The
Page 287 and 288:
5.7 Mental Health Act / Mental Capa
Page 289 and 290:
5.8 Membership 5.8.1 Membership The
Page 291 and 292:
The groupings of the members in the
Page 293 and 294:
5.8.8 Membership development propos
Page 295 and 296:
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 and 348: 6.8.4 Wiltshire Primary Care Trust
Page 349 and 350: 6.9 Independent Assurance Report to
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: A quarterly “Voluntary Service Ma
Page 369 and 370: 10.3.2 Explanation for differences
Page 371 and 372: 12 STATEMENT OF ACCOUNTING OFFICER
Page 373 and 374: Page 162 of 211
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
Page 417 and 418:
Page 419 and 420:
show all

Annual Report and Accounts - The Great Western Hospital

Create successful ePaper yourself

Delete template?

Save as template?