Annual Report and Accounts - The Great Western Hospital

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No. Audit Title Audit Summary/Learning and Action 23. Hip Resurfacing This Review was undertaken following Medicines and Healthcare products Regulatory Agency (MHRA) Alert- Revision of MoM (Metal on Metal) hip replacements. The concerns involved soft tissue reactions which may be associated with unexplained hip pain. The Orthopaedic Department categorised the affected patients with plans to follow-up patients. 24. NICE CG56 - Ordering of Scans in Paediatrics Incorporating Head Injury Results demonstrate compliance with the NICE guidance and that there is appropriate ordering and undertaking of CT Scans. 25. Neonatal Readmissions to the Children's Ward 0-28 Days of Age 26. SALT (Speech and Language Therapy) - Service Evaluation of the interface between agencies supporting children with Autistic Spectrum Disorders (ASD). 27. Venous Thromboembolism (VTE) 28. Induction of Labour 29. VTE Assessment of Screening Prophylaxis 30. Delayed and Omitted Medicines Audit Results reflect good communication of breastfeeding care. Actions include- Infant coordinator to continue in-house training. Use of Breastfeed observation charts to pick up ineffective feeding at an earlier stage. Actions include improved sharing of information using Communication Assessment Form and better communication between the SALT Service and other multi-agencies. The results demonstrated that overall compliance was very high. Actions include possibility of using a sticker stating the VTE assessment at each ante natal admission. There was low compliance with documentation of the discussion with the mother about induction of labour in the maternal records. Actions include- Remind all midwives of the importance of discussion of prolonged pregnancy and induction of labour and giving leaflet to supplement these discussions. The results reflected very high compliance with the majority of criterion. Actions include all blank missed doses to be reported to the Ward Manager and investigated. 31. Death Certificate Completion Areas for improvement identified were recording of Doctor’s grade and name, training and education and guidance notes that include clarification on confirmation and certifying deaths. 32. End of Life Base line audit results demonstrate that the Trust performance is better that the nationally published data. Actions include- discussion of results with the Commissioners to agree a CQUIN target. 33. Compliance with Joint Guidelines in Regard to Overall compliance is excellent. Further actions include educating prescribers to ensure patients are switched from Intravenous to oral antibiotics. Page 98 of 211
No. Audit Title Antibiotic Prescribing 34. Health Records Audit Q2 – Warminster Neighbourhood Team. 35. Health Records Audit Q2 – Bradford on Avon, Trowbridge and Melksham Neighbourhood Team’s 36. NICE CG124 – Hip Fracture 37. Audit on Causes of Delays in Theatre Start Times 38. Parenthood Education with WCHS 39. Privacy and Dignity at Hillcote 40. Health Records Audit – Minor Injury Unit (MIU) Health Records Audit – Wilton and Amesbury Neighbourhood teams 41. Omitted and Delayed Medicines Audit – Beech Omitted and Delayed Medicines Audit - Longleat 42. Privacy and Dignity Mixed Sex Accommodation Audit Summary/Learning and Action Audit demonstrates a very high compliance. Audit demonstrates compliance with majority of standards. Areas for improvement include encouraging recording of name and designation of each signatory. Audit demonstrated an improvement since 2008. Actions include further teaching sessions to improve further compliance. There is ongoing monitoring of this practice to monitor compliance. There is considerable room for improvement. This includes identification of poor risk patients in advance and receiving the patients into a dedicated holding bay. The re-audit demonstrates high satisfaction rates. There is improvement since the previous audit in 2009/10. Further actions include checks on induction process and protocol review to promote this further. There are some areas for improvement including improving documentation, recording NHS numbers and ensuring that there are no spaces between entries. Areas for action include reporting of blank missed doses and drug availability appropriately. Majority of criteria was compliant. Only action was to ensure staff wear ID badges visible on their uniforms and are easily identified by patients. . Page 99 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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3.29 Health and Overview Scrutiny C
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3.32.5 Interests held by Directors
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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 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: No. Audit Title 15. Non Invasive Ve
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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Page 141 and 142: Graph 1 - GWH carbon footprint (ton
Page 143 and 144: The Trust is working with local bus
Page 145 and 146: Graph 9 - Total tonnes of waste pro
Page 147 and 148: 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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