Annual Report and Accounts - The Great Western Hospital

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5.2.4 Statement about the balance, completeness and appropriateness of the Board of Directors The Non-Executive Directors are all considered to be independent of the Foundation Trust and the Trust Board believes it has the correct balance, completeness and appropriateness in its composition to meet the requirements of an NHS Foundation Trust. Three Non-Executive Directors have served more than 6 years from the date of their first appointment but in each case, on reappointment the Trust considered that they remained independent in that, amongst other things, they continued to have a willingness to probe and challenge and there were no relationships which might create a conflict of interest. The Board is committed to reviewing its balance and composition in order to maintain its effectiveness. During 2011, the Trust mapped the refreshment of the Board, looking in detail at the skills and qualities needed now and in the future and mapped the composition of the Board against desired experience and knowledge on the Board. In addition, the Board recognised that Board development tools provide a framework for objectively assessing performance and in meeting our responsibilities. In 2011 an external agency was recruited to undertake development of the Board using the National Institute for Innovation and Improvement Board Development Tool for Foundation Trusts. Board development will continue in 2012/13. 5.2.5 Statement setting out that the Board of Directors undertakes a formal and rigorous evaluation of its own performance and that of its collective and individual directors In 2011/12 the Trust commissioned an independent formal review of its performance and effectiveness. This review involved an independent advisor attending and observing Board meetings, interviews with each Director and the Company Secretary and 360 degree questionnaires and feedback. The review looked at the performance of the Board and that of its collective and individual Directors with recommendations being made relating to the operation of the Board; Director’s roles; functions of the Board; Board engagement; strategy development and development generally. The Trust is continuing to use the independent advisor with further Board Development planned during 2012/13. For individual Non-Executive Directors, the Trust has in place a framework for their appraisal based on elements of the Hay Group work and best practice from other Foundation Trusts. In June 2011 a formal appraisal process for the Chairman and the Non-Executive Directors was undertaken by the Council of Governors. The evaluation of the Chair’s performance was led by the Senior Independent Director with input from the Lead Governor and the Chief Executive on behalf of the Executive Directors and having regard to the views of the other Non-Executive Directors. The Chief Executive and Non-Executive Directors’ performance was evaluated by the Chairman taking account of Governors and other Directors’ input. The Executive Directors’ appraisals were led by the Chief Executive in April 2012, through the Board Remuneration Committee following a formal appraisal process using Hay Group’s leadership competencies. All appraisals involve 360 degree evaluation and feedback. Page 68 of 211
5.2.6 Attendance at meetings of the Board of Directors during 201/12 Listed below are the Directors and Non-Executive Directors of GWH and their attendance record at the meetings of the Trust Board held during the past year. Record of attendance at each meeting = Attended = Did not attend 28.04.11 16.05.11 Extra meeting 26.05.11 26.05.11 30.06.11 28.07.11 29.09.11 27.10.11 24.11.11 22.12.11 26.01.12 23.02.12 12.03.12 – Joint Board & Council of Governors 29.03.12 Jenny Barker (up until 31.12.11) ̌ ̌ ̌ ̌ ̌ ̌ ̌ n/a n/a n/a n/a Helen Bourner ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ Robert Burns ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ Rowland Cobbold ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ Liam Coleman ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ Oonagh Fitzgerald ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ Angela Gillibrand ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ Roger Hill ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ Bruce Laurie ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ Maria Moore ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ Guy Rooney (from 01.05.11 – 03.10.11) ̌ ̌ ̌ ̌ ̌ ̌ n/a n/a n/a n/a n/a n/a n/a Sue Rowley ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ Kevin Small ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ Alf Troughton ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ Lyn Hill-Tout (until 31.05.11) ̌ n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a Nerissa Vaughan (from 03.10.11) n/a n/a n/a n/a n/a n/a ̌ ̌ ̌ ̌ ̌ ̌ ̌ ̌ Details of the number of meetings of committees and individual attendance by Executive and Non- Executive Directors is available on request to the Trust. 5.2.7 Decisions reserved for the Board of Directors There are certain matters which are reserved for the Board of Directors to decide relating to regulation and control; appointments; strategic and business planning and policy determinations; direct operational decisions; financial and performance reporting arrangements; audit arrangements and investment policy. The Reservation of Powers to the Board was reviewed in January 2012. A copy of the full reservation of powers to the Board document can be obtained from the Company Secretary. 5.2.8 Interests of Directors A Register of Interests of Directors is maintained, a copy of which can be obtained from the Company Secretary. Page 69 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
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
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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
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Page 61 and 62: 5.1.12 Nominations and Remuneration
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Page 67: 5.2.3 Length of appointments of Non
Page 71 and 72: 5.3 Audit Committee 5.3.1 The Audit
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Page 77 and 78: The Mental Health Act / Mental Capa
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Page 81 and 82: 5.8.6 Membership Strategy To encour
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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
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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
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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
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and Governors. We have also commenc
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Regulation 1. To sustain compliance
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Audit / confidential enquiry title
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Audit Title Submitted/Required (%)
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No. Audit Title Learning From The P
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No. Audit Title 8. Diabetes Ketoaci
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No. Audit Title Audit Summary/Learn
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No. Audit Title Audit Summary/Learn
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6.3.4 Registration with Care Qualit
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Steering Group, provides a quarterl
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Clostridium Difficile: The goal for
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Priority 2: To reduce harm associat
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Priority 3: To reduce harm associat
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Pressure ulcers Community: The comm
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Safe care of the patient receiving
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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
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Priority 9: To review the clinical
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Priority 12: To undertake nutrition
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• A regular ongoing training prog
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Community: • Q1 Performance April
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The survey results demonstrate that
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6.6 Performance against key nationa
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6.8 Statements from Primary Care Tr
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6.8.4 Wiltshire Primary Care Trust
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6.9 Independent Assurance Report to
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7 SUSTAINABILITY REPORTING 7.1 Stro
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Graphs 3 and 4 show energy consumpt
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Graph 7 - Water consumption in WCHS
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8 EQUALITY REPORTING 8.1 Equality d
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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
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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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Annual Report and Accounts - The Great Western Hospital

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