Annual Report and Accounts - The Great Western Hospital

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There is currently a vacancy for the governor position in respect of the Gloucestershire and Bath and North East Somerset Constituency. No candidates stood at the last elections in November 2011. Elections are planned for the summer 2012. In the event of an elected governor’s seat falling vacant for any reason before the end of a term of office, it shall be filled by the second (or third) placed candidate in the last held election for that seat provided they achieve at least five percent of the vote and they are known as reserve governors. 5.1.3 Elected Governors – Staff Constituency Name Constituency Date elected Term of Office Vicki Barnett Staff 10/11/11 2 years End of current term Nov 2013 Attendance Notes at meetings during 2011/12 3 of 3 Vicki Barnett was elected in November 2011 filling the seat previously held by Rachel Cross Rachel Cross Staff 01/12/08 3 years Ended 5 of 5 Rachel Cross did not stand for reelection at the end of her term of office in November 2011 Peter Hanson Staff 04/11/10 3 years Marcus Galea Staff 20/11/09 3 years Dec 2013 Dec 2012 5 of 7 5 of 7 Page 54 of 211
5.1.4 Nominated Governors Name Nominating Partner Organisation David Stevens Date nominated Term of Office PCT – Wiltshire PCT 23/11/11 3 years End of current term Nov 2014 Attendance at meetings during 2011/12 Notes David Stevens was initially nominated 01/12/08 Bill Fishlock PCT – Swindon PCT 23/11/11 3 years Nov 2014 Bill Fishlock was initially nominated 01/12/08 David Renard Local Authority – Swindon Borough Council Brian Mattock Local Authority – Swindon Borough Council 01/12/08 3 years 23/11/11 3 years Ended Dec 2011 Nov 2014 Carole Soden Local Authority – Wiltshire Council Jemima Milton Local Authority – Wiltshire Council 01/12/08 3 years 23/11/11 3 years Ended Jun 2011 Nov 2014 Carole Soden resigned 17/06/11 Andy Cresswell Other Partnerships – Thames Valley Chamber of Commerce 01/12/08 3 years Ended Sep201 1 Andy Cresswell resigned 12/09/11 Clive Bassett Other Partnerships – Prospect Hospice Lesley Donovan Other Partnerships – Swindon and North Wiltshire Health and Social Care Academy Jon Elliman Other Partnerships – Swindon and North Wiltshire Health and Social Academy Care 23/11/11 3 years 01/12/08 3 years 23/11/11 3 years Nov 2014 Ended Dec 2011 Nov 2014 Page 55 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: 5.1.2 Elected Governors - Public Co
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: Great Western Hospitals NHS Foundat
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
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a Quality Account and the opportuni
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Overall, the Trust has good plans t
Page 139 and 140:
Page 139 of 211
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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
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
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Process Board Role and Conclusions
Page 173 and 174:
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
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,
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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
Page 285 and 286:
5.6 Nominations Committee 5.6.1 The
Page 287 and 288:
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
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and Governors. We have also commenc
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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
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The three top serious incident caus
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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
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Community: • Q1 Performance April
Page 341 and 342:
The survey results demonstrate that
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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
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It was agreed that we would focus o
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Appraisal rates. The overall rate f
Page 365 and 366:
A quarterly “Voluntary Service Ma
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10 REGULATORY RATINGS REPORT 10.1 M
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10.3.2 Explanation for differences
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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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