Annual Report and Accounts - The Great Western Hospital

Process
Board
Role and Conclusions
- The Board has continued to lead the organisation throughout the year with regular
reporting on finance and clinical performance, It receives and reviews minutes of
committees, with concerns and issues escalated by the Committee Chairs.
In March 2012 the Board reviewed and updated the Governance Structure,
approving new terms of references for Board Committees to ensure that the
Trust’s system of internal control reflects the current needs of the organisation and
to ensure that appropriate reporting and decision making mechanisms are in place.
Audit, Risk
and
Assurance
Committee
Internal
audits
Clinical
audits
Other
Committees
Assurance
Framework
Selfassessment
declaration
against
CQC
standards
Quarterly
reporting to
Monitor
- The Committee provides scrutiny of internal controls, including the review the
Assurance Framework and Corporate Risk.
- On the effectiveness of systems of internal control.
Audit findings are presented to the Audit, Risk and Assurance Committee and the
Board through the Audit, Risk and Assurance Committee minutes.
- The Trust Board is meticulous in keeping Clinical Audit as the key component of
clinical governance in its efforts to promote patient safety, patient experience and
to promote effectiveness of care delivered to the patients. The Trust is compliant
with the Trust Clinical Audit plan. The NICE lead is responsible for actively
disseminating and monitoring NICE compliance. Trust wide compliance of 96-
100% has been attained throughout this year.
- All committees have a clear timetable of meetings and a clear reporting structure
to allow issues to be raised. Terms of reference for each Board Committee have
been reviewed in 2011/12 to ensure ongoing effectiveness and ensure that an
appropriate level of delegation and reference back to the Board is in place.
- Provides assurance that the effectiveness of the controls to manage the risks to
the organisation in achieving its principal objectives has been reviewed. An
internal audit in January 2012 gave positive assurance to the risk management
process of the Trust and the Assurance Framework has been commended by the
Audit, Risk and Assurance Committee and external and internal auditors.
- The Trust has self assessed compliance with the CQC regulations. There have
moderate concerns with compliance with the CQC regulations for which is it
registered, but action plans are in place to address moderate and minor concerns.
External NHSLA Risk Management Standards (Acute) – level 2.
External CNST Risk Management Standards (Maternity) – level 2.
- Declarations are considered by the Executive Committee and Finance and
Investment Committee and thereafter approved by the Board on a quarterly basis
prior to submission to Monitor.
The Trust will continue to review all risks and where necessary will take approach actions to either
reduce or eliminate these. Actions taken will be monitored through the appropriate committees of the
Board, and where necessary the Chair of the committee will escalate concerns to Board.
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