Annual Report and Accounts - The Great Western Hospital

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Regulation 1. To sustain compliance with the CQC regulations 2. To sustain NHSLA and Maternity Standards and develop longer term plans to achieve Level 3 3. To implement plans to improve results of the national staff survey 4. To sustain compliance with the Mental Health Capacity Act 5. To sustain compliance with Safeguarding Children 6.2.2 Priorities 2012/13 Our commitment to quality will continue through a number of priorities for 2012/13 which have been agreed in accordance with the views and comments from clinical staff commissioners, the Trust Governors and key external stake holders and the PSQC. Our priorities will be: Safe Care • Continue to reduce healthcare associated infections including MRSA and Clostridium difficile (CQUIN) • Continue to reduce harm associated with patient falls • Continue to reduce hospital and community acquired pressure ulcers • Continue to reduce avoidable mortality, disability and chronic health through improved assessment and management of venous thromboembolism (CQUIN) Effective Care • Improve the care and management of patients through implementation of the Trust Nutrition and Hydration strategy • Improve our Hospital Standardised Mortality Ratio (HSMR) year on year (100 or below) • Improve the management of the deteriorating patient by full completion of the Early Warning Score Patient Experience • Continue to improve the quality of end of life care for patients and improve access to palliative care services (CQUIN) • Improve care and access to services for patients with dementia (CQUIN) • Improve patient satisfaction by improving upon the Trusts outcome measures within the National Patient Experience (PICKER) survey (CQUIN) 6.3 Statements of assurance from the Board During 2011/12 the Great Western Hospitals NHS Foundation Trust provided and/or sub-contracted 7 NHS services. The Great Western Hospitals NHS Foundation Trust has reviewed all the data available to them on the quality of care in 7 of these NHS services. The income generated by the NHS services reviewed in 2011/12 represents 100 per cent of the total income generated from the provision of NHS services by the Great Western Hospitals NHS Foundation Trust for 2011/12. Page 88 of 211
6.3.1 Review of services and participation in clinical audits and national confidential enquiries During 2011/12 42 national clinical audits and 4 national confidential enquiries covered NHS services that Great Western Hospitals NHS Foundation Trust provides. During 2011/12 Great Western Hospitals NHS Foundation Trust participated in 86% national clinical audits and 100% national confidential enquiries of the national clinical audits and national confidential enquiries which it was eligible to participate in. The national clinical audits and national confidential enquiries that Great Western Hospitals NHS Foundation Trust was eligible to participate in during 2011/12 and those that Great Western Hospitals NHS Foundation Trust participated in are as follows: - Audit / confidential enquiry title Eligible Participated Peri-and Neo-natal Perinatal mortality (MBRRACE-UK) Yes No Neonatal intensive and special care (NNAP) Yes Yes Children Paediatric pneumonia (British Thoracic Society) Yes Yes Paediatric asthma (British Thoracic Society) Yes Yes Pain management (College of Emergency Medicine) Yes Yes Childhood epilepsy (RCPH National Childhood Epilepsy Audit) Yes Yes Paediatric intensive care (PICANet) No NA Paediatric cardiac surgery (NICOR Congenital Heart Disease Audit) No NA Diabetes (RCPH National Paediatric Diabetes Audit) Yes Yes Acute care Emergency use of oxygen (British Thoracic Society) Yes Yes Adult community acquired pneumonia (British Thoracic Society) Yes Yes Non invasive ventilation -adults (British Thoracic Society) Yes Yes Pleural procedures (British Thoracic Society) Yes Yes Cardiac arrest (National Cardiac Arrest Audit) Yes No Severe sepsis & septic shock (College of Emergency Medicine) Yes No Adult critical care (ICNARC CMPD) Yes Yes Potential donor audit (NHS Blood & Transplant) Yes Yes Seizure management (National Audit of Seizure Management) Yes No Long term conditions Diabetes (National Adult Diabetes Audit) Yes No Heavy menstrual bleeding (RCOG National Audit of HMB) Yes Yes Chronic pain (National Pain Audit) Yes Yes Ulcerative colitis & Crohn's disease (UK IBD Audit) Yes Yes Parkinson's disease (National Parkinson's Audit) Yes Yes Adult asthma (British Thoracic Society) Yes Yes Bronchiectasis (British Thoracic Society) Yes No Page 89 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
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Patient care 3.16 Development of se
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3.20 New or significantly revised s
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3.24 Complaints Handling For the Tr
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The Trust actively responds to feed
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3.25 Using patient experience to dr
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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 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: Part 2 - Priorities for improvement
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
Page 135 and 136: a Quality Account and the opportuni
Page 137 and 138: 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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