Annual Report and Accounts - The Great Western Hospital

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Audit Title Submitted/Required (%) Long term conditions Heavy menstrual bleeding (RCOG National Audit of HMB) 100% Chronic pain (National Pain Audit) 100% Ulcerative colitis & Crohn's disease (UK IBD Audit) 100% Parkinson's disease (National Parkinson's Audit) 100% Adult asthma (British Thoracic Society) 100% Elective procedures Hip, knee and ankle replacements (National Joint Registry) 100% Elective surgery (National PROMs Programme) 100% Coronary angioplasty (NICOR Adult cardiac interventions audit) 100% Peripheral vascular surgery (VSGBI Vascular Surgery Database) 100% Carotid interventions (Carotid Intervention Audit) 100% Cardiovascular disease Acute Myocardial Infarction & other ACS (MINAP) 100% Heart failure (Heart Failure Audit) 100% Acute stroke (SINAP) 100% Cardiac arrhythmia (Cardiac Rhythm Management Audit) 100% Cancer Lung cancer (National Lung Cancer Audit) 100% Bowel cancer (National Bowel Cancer Audit Programme) 100% Head & neck cancer (DAHNO) 100% Oesophago-gastric cancer (National O-G Cancer Audit) 100% Trauma Hip fracture (National Hip Fracture Database) 100% Blood transfusion Bedside transfusion (National Comparative Audit of Blood 100% Transfusion) Medical use of blood (National Comparative Audit of Blood 100% Transfusion) End of life Care of dying in hospital (NCDAH) 100% The reports of 21 national clinical audits were reviewed by the provider in 2011/12 and Great Western Hospitals NHS Foundation Trust intends to take the following actions to improve the quality of healthcare provided: - No. Audit Title 1. National Cancer Patient Survey 2. National Audit of Dementia 2010 3. National Mastectomy and Breast Learning From The Project Actions include- Focussed survey to assess service opportunities in Day therapy centre. Local survey was undertaken and the report is covered under “Local Audits”. The Trust performed in the middle quartile. The audit demonstrated a few areas of good practice. The action plan has been incorporated into the Trust Dementia Strategy. The Trust has signed up to participate in the next round of National Audit of Dementia. The Trust performance is in the upper 25% centiles in terms of satisfaction. The time that the clinical nurse specialists take with these patients needs to be recognised for future increase in caseload. The trust must continue to provide patients with Page 92 of 211
No. Audit Title Reconstruction Audit 4. College of Emergency Medicine (CEM) - Asthma in Emergency Department (ED) 5. College of Emergency Medicine (CEM) - Fractured Neck Of Femur's in Emergency Department (ED) 6. College of Emergency Medicine (CEM) - Pain in Children in Emergency Department (ED) 7. National Pleural Procedures Audit 2010 8. Myocardial Ischaemia National Audit Project-2010 9. NCEPOD- An Age Old Problem- Elective and Emergency Surgery in the Elderly 10. College of Emergency Medicine CEM – National Audit of Emergency Department Discharge Data on GP Letters. 11. Data for Head and Neck – DAHNO 6 th Round 12. Inpatient Audit of Children with Diabetes (SWPDN) Learning From The Project sufficient time in their consults to discuss reconstructive issues. It is recommended that those involved in the development of future guidelines on mastectomy and breast reconstruction should refer to the results of high achieving organisations. The audit demonstrated that there is a great improvement with the performance. Areas that need to improve are recording of peak flow, better recording of discharge plans, use of proforma and promote local education and training. The pain scores are not always recorded on NOF proforma and there are delays in analgesia, X-Rays & fast tracking admission. Improvement plan focuses on better recording/education, improvements in ED flow. There is improvement in pain scoring, analgesia recording & reassessment. The results reflect that 40% of chest drains with pleural effusions are being carried out by Ultrasound guidance. There is no bedside ultrasound is being carried out. High numbers of drains are being put in for undiagnosed effusions. Ultrasound machine has been purchased, local pleural effusion guidelines have been developed, pneumothorax guidelines updated. Teaching and education is done regularly. Other plans include producing a chest drain proforma. The Trust has demonstrated high compliance with the key performance indicators. The area that needs to improve is time of transfer of patients with nSTEMI (acute coronary syndrome) to cardiac beds on admission. Current practice is in line with most of the national recommendations. There are no recommendations to implement, The project organisers have not provided individual hospital reports. Local actions include implementation of recommendations from the college. The Trust is compliant with the majority of the criteria and has shown significant improvement since the last audit in intervals from referral to established diagnosis. Areas for improvement include documentation of chest imaging onto the local database. Participation rates were low, however positive with regard to paediatric diabetes staff but critical of other health professional’s knowledge. Patients and parents were happy with amount of contact with Dr, paediatric diabetes specialist nurse (PDSN) and Page 93 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
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3.27 Development of services with o
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Page 43 and 44: 3.32.5 Interests held by Directors
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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
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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 and 90: 6.3.1 Review of services and partic
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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
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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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Page 141 and 142: 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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