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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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- 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
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- Page 71 and 72: 5.3 Audit Committee 5.3.1 The Audit
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- Page 79 and 80: The Trust has a wide range of staff
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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
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- 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
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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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SHA - Strategic Health Authority SW
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