Annual Report and Accounts - The Great Western Hospital

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2 OUR TRUST 2.1 Vision - Your health our passion “We will provide healthcare services that delight patients and satisfy commissioners by meeting, or exceeding, all local and national standards and providing convenient, local services so that people enjoy the best state of health and will have access to first class services when they need them.” A key theme of the vision has been for the Trust to provide ‘healthcare services’ and not solely acute hospital services. Towards achieving the 2015 vision, in June 2011 the Trust took over the running of a range of community health services and community maternity services across Wiltshire and surrounding areas, which were previously provided by Wiltshire Community Health Services (WCHS). This merger is a key step towards achieving our vision as we are now working even more closely with key local partners including the Local Authority, GPs and the third sector to deliver better care, closer to home. 2.2 Our aims and values To achieve our Vision we have the following aims, also known as strategic objectives: - 1. To provide consistently high quality, safe services which deliver desired patient outcomes and we will perform in the top 25% (upper quartile) of comparable acute trusts in delivering Hospital Standardised Mortality Rates (HSMR), patient satisfaction and staff satisfaction. 2. To improve the patient and carer experience of every aspect of the service and care that we deliver. 3. To ensure that staff are proud to work for the Trust and would recommend the Trust as a place to work and to receive treatment. 4. To secure the long term financial health of the Trust. 5. To adopt new approaches and innovate to promote health and improve services as healthcare changes whilst continuing to become even more efficient. 6. To work in partnership with others so that we provide seamless care for patients, more systematically identifying and supporting those individuals at most risk of ill health and delivering closer to home in rural areas. Page 8 of 211
Underpinning this, our values are to: - 1. always listen to our patients, local people, commissioners and staff; 2. be a good collaborator, working effectively with colleagues and with external stakeholders with mutual respect; and 3. work honestly, openly and with integrity to encourage innovation and bold decisions, striving to be an exemplary employer. 2.3 Organisational structure 2011/12 Page 9 of 211
Page 1: Great Western Hospitals NHS Foundat
Page 5 and 6: CONTENTS 1 Chair and Chief Executiv
Page 7: The Great Western Hospital became a
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 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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“Eyes and Ears” - An initiative
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5.1.12 Nominations and Remuneration
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Rowland Cobbold, Non-Executive Dire
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Lyn Hill-Tout, Chief Executive (unt
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5.2.3 Length of appointments of Non
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5.2.6 Attendance at meetings of the
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5.3 Audit Committee 5.3.1 The Audit
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5.4 Directors’ responsibility for
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Note: Angela Gillibrand and Rowland
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The Mental Health Act / Mental Capa
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The Trust has a wide range of staff
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5.8.6 Membership Strategy To encour
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5.9 Code of Governance Disclosure S
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6 QUALITY REPORTS Part 1 - Statemen
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Part 2 - Priorities for improvement
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6.3.1 Review of services and partic
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The trust chose not to contribute t
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No. Audit Title Reconstruction Audi
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The reports of 273 local clinical a
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No. Audit Title 15. Non Invasive Ve
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No. Audit Title Antibiotic Prescrib
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No. Audit Title 50. NICE CG111 - No
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Great Western Hospitals NHS Foundat
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Part 3 - Other Information 6.4 Over
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GRAPH - Clostridium Difficile WCHS2
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GRAPH - Medicine incidents by type
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Harm from falls WCHS: It was not po
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• Rolling educational programme w
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CHART - Relative risk SW Acute Trus
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Following the Trust’s merge in Ju
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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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SHA - Strategic Health Authority SW
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Annual Report and Accounts - The Great Western Hospital

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