Annual Report and Accounts - The Great Western Hospital

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Audit / confidential enquiry title Eligible Participated Elective procedures Hip, knee and ankle replacements (National Joint Registry) Yes Yes Elective surgery (National PROMs Programme) Yes Yes Intra-thoracic transplantation (NHSBT UK Transplant Registry) No NA Liver transplantation (NHSBT UK Transplant Registry) No NA Coronary angioplasty (NICOR Adult cardiac interventions audit) Yes Yes Peripheral vascular surgery (VSGBI Vascular Surgery Database) Yes Yes Carotid interventions (Carotid Intervention Audit) Yes Yes CABG and valvular surgery (Adult cardiac surgery audit) No NA Cardiovascular disease Acute Myocardial Infarction & other ACS (MINAP) Yes Yes Heart failure (Heart Failure Audit) Yes Yes Acute stroke (SINAP) Yes Yes Cardiac arrhythmia (Cardiac Rhythm Management Audit) Yes Yes Renal disease * Renal replacement therapy (Renal Registry) No NA Renal transplantation (NHSBT UK Transplant Registry) No NA Cancer Lung cancer (National Lung Cancer Audit) Yes Yes Bowel cancer (National Bowel Cancer Audit Programme) Yes Yes Head & neck cancer (DAHNO)* Yes Yes Oesophago-gastric cancer (National O-G Cancer Audit) Yes Yes Trauma Hip fracture (National Hip Fracture Database) Yes Yes Severe trauma (Trauma Audit & Research Network) Yes Partly Psychological conditions Prescribing in mental health services (POMH) No NA Schizophrenia (National Schizophrenia Audit) No NA Blood transfusion Bedside transfusion (National Comparative Audit of Blood Transfusion) Medical use of blood (National Comparative Audit of Blood Transfusion) Yes Yes Yes Yes Health promotion Risk factors (National Health Promotion in Hospitals Audit) Yes No End of life Care of dying in hospital (NCDAH) Yes Yes National Confidential Enquiries into Patient Outcome & Death Cardiac arrest Yes Yes GWHFT is not currently participating in the National Cardiac Arrest Audit project; however the Trust has subscribed and made arrangements to participate in the next round of the National Audit. Page 90 of 211
The trust chose not to contribute to the repeat audit of National Health Promotion in Hospitals as the trust was compliant with the standards audited in the initial project and has other internal measures in place to monitor compliance. In addition the trust has now signed up to participate in severe trauma (Trauma Audit & Research Network). The Trust participated in a number of other National Audits during 2011-2012 that were considered vital in promoting the quality and effectiveness of patient care. A few of these are outlined below: Other National Clinical Audits National Cancer Patient Survey (as mandated by the National Cancer Reform Strategy) College of Emergency Medicine (CEM) - Fractured Neck of Femur's (NOF) in Emergency Department College of Emergency Medicine (CEM) - Asthma in Emergency Department CEM - National Audit of Emergency Department Discharge Data on GP Letters Inpatient Audit of Children with Diabetes (SWPDN) National Mastectomy and Breast Reconstruction Audit-(4th Round-Final) National Comparative Audit of the use of Red Cells in Neonates & Children National Diabetes Inpatient Day Audit Major Complications of Airway Management The national clinical audits and national confidential enquiries that Great Western Hospitals NHS Foundation Trust participated in, and for which data collection was completed during 2011/12, are listed below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry. Audit Title Peri-and Neo-natal Perinatal mortality (MBRRACE-UK) Submitted/Required (%) Ongoing internal review Neonatal intensive and special care (NNAP) 100% Children Paediatric pneumonia (British Thoracic Society) Ongoing- data submission deadline- Mar 2012 Paediatric asthma (British Thoracic Society) 100% Pain management (College of Emergency Medicine) 100% Childhood epilepsy (RCPH National Childhood Epilepsy Audit) 100% Diabetes (RCPH National Paediatric Diabetes Audit) 100% Acute care Emergency use of oxygen (British Thoracic Society) 100% Adult community acquired pneumonia (British Thoracic Society) Ongoing- data submission deadline- May 2012 Non invasive ventilation -adults (British Thoracic Society) Ongoing- data submission deadline- May 2012 Pleural procedures (British Thoracic Society) 100% Adult critical care (ICNARC CMPD) 100% Potential donor audit (NHS Blood & Transplant) 100% Page 91 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
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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 and 88: Part 2 - Priorities for improvement
Page 89: 6.3.1 Review of services and partic
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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Annual Report and Accounts - The Great Western Hospital

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