Annual Report and Accounts - The Great Western Hospital

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5.7 Mental Health Act / Mental Capacity Act Committee 5.7.1 The Mental Health Act / Mental Capacity Act Committee Under the terms of the Mental Health Act 1983, (MHA) the Trust has a key responsibility for looking after patients who come to the hospital with problems associated with their mental health and to ensure that that the requirements of the Act are followed. The Trust must: • ensure that patients are detained only as the MHA allows; • ensure that patients’ treatment and care accords fully with the provision of the Act; • patients are fully informed of, and supported in, exercising their rights; • patients’ cases are dealt with in line with other relevant statutory legislation including the Mental Capacity Act 2005, Human Rights Act 1998, The Race Relations Act, Disability Discrimination Act 1995 or Data Protection Act 1998. Membership of the Mental Health Act and Mental Capacity Act Committee • Non-Executive Directors x two • Director of Nursing - Executive Lead for Mental Health Services • Deputy Director of Nursing – Trust Lead for Mental Health Services • Mental Health Act Administrator • Representatives from the Child and Adolescent Mental Health Service (CAMHS) x three (General Manager/Clinician/Nurse) • Senior Representative from the Adult Mental Health Services (AWP) • Senior Representative from Older People’s Mental Health Services (AWP) • Senior Nurse/Matron (Great Western Hospital) • Representative from Swindon Primary Care Trust. 5.7.2 Meetings during 2010/11 and attendance The Mental Health Act / Mental Capacity Act Committee members Jun 2011 Sep 2011 Dec 2011 Cancelled Mar 2012 Bruce Laurie (Chair) Chairman of the Trust √ √ √ Rowland Cobbold (Deputy Non Executive Director x √ √ Chair) Sue Rowley Director of Nursing and Midwifery x √ √ Carole Crocker Deputy Director of Nursing √ Left the Trust Joy Gobey Mental Health Act Administrator √ √ √ Teresa Harding Joanne Smith, Senior Nurse Paediatrics - deputy General Manager, Women and Children’s’ Department x x √ Joanne Smith Dick Eyre Child Psychiatrist x √ √ Attendance as either / both with Amanda Cadder Amanda Cadder Attendance as either/both with Dick Eyre Nurse Manager x x x Page 76 of 211
The Mental Health Act / Mental Capacity Act Committee members Jun 2011 Sep 2011 Dec 2011 Cancelled Mar 2012 Neil Mason (deputy for Gill McKinnon) Community Service Manager and Adults Service Manager AWP (Liaison) x x x Gill McKinnon Service Manager (Specialist √ √ √ Services) Older People's SBU Jane Higgins for Joi Demery AMHP √ Kieran Holland (deputy for Jenny MacDonald) Modern Matron, Sandalwood Court x √ x Anthony Harrison Consultant Nurse (Liaison Psychiatry) AWP - - √ Donna Bosson Senior Nurse Unscheduled Care x √ x Julie Dart Mental Capacity Act Programme Manager Joint appointment with Swindon Borough Council and Swindon Primary Care Trust, Adult Social Care x √ x GWH and Avon and Wiltshire Mental Health Partnership (AWP) have a two way service level agreement (SLA) signed off. The provision of mental health liaison psychiatry has been extended to include out of hours and weekends. The provision of older people liaison psychiatry service for Wiltshire was withdrawn in April 2011 but extended to September 2011 has not been in place following the extension. The reinstatement of this service has been high on the agenda and it is envisage that this will be resolved in the first quarter of 2012. With regards to section 12 of the Act the Trust continues to have delays in accessing a psychiatrist as the responsible clinician. The Deputy Director of Nursing is having discussions with AWP and commissioners in order that the issues are resolved as early as possible. 5.7.3 Application of the Mental Health Act (MHA) in the Trust The Mental Health Act Administrator provides a three monthly report on the application of the Mental Health Act in the Trust. The report is considered by the Mental Health Act and Mental Capacity Act Committee at each meeting. From April 2011 – 7 th March 2012, the use of the Mental Health Act was applied on 75 occasions in regard of 30 patients. The 75 occasions relate to 30 inpatients at the Great Western Hospital which include those patients on Section 17 authorisation of leave from other organisations. Page 77 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
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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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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: Note: Angela Gillibrand and Rowland
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
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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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Annual Report and Accounts - The Great Western Hospital

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