Annual Report and Financial Accounts 2010/11


Quality Report 2010/11


Ongoing reporting and investigation of adverse events. Implementation of the updated Never Events framework


Ensuring learning from the Francis Report on Mid-Staffordshire NHS Foundation Trust.


Ongoing


Report on progress to Board of Directors in July 2010. Action plan was expanded to include the recommendations of the Airedale Report. All ward staffing templates reviewed in February 2010. Patient dependency audit undertaken in October 2010. Board walkabouts undertaken to several clinical areas including at night.


Ensuring high standards for pressure ulcer prevention and management


Medicines Management - compliance with National Patient Safety Agency alerts.


Reducing hospital mortality rates.


Sustain achievement in reduction of Hospital Acquired Infections


Clinical Effectiveness Review clinical data following publication by Patient Reported Outcome Measures (PROMS) team.


Implementation of Venous Thromboembolism (VTE) risk assessment and VTE prophylaxis policy and procedures. Implementation of IT solution to ensure routine data capture of completion to ensure verification of compliance with Department of Health and CQUIN targets


Improve use of Malnutrition Screening Tool (MUST). Fully implement Protected Mealtimes (PMT) initiative. Appoint nutrition nurse specialist for education and audit.


Pressure ulcer prevention included within mandatory training programme. Audit tool implemented. Links with Adult Safeguarding Team established.


Work of Medication Governance Committee continues. Robust action plans in place for NPSA alert compliance.


Mortality Group well established and meets monthly. Improvements to coding made. Regular case reviews undertaken.


Sustained


No clinical data available from National PROMS Team at this stage.


VTE risk assessment tool designed, implemented and monitored in compliance with Department of Health guidelines. Education and training provided to support implementation. IT solution designed to enable routine data capture of compliance. June 2010 - March 2011 results presented monthly to Trust Board of Directors. Compliance for March 2011 was 94.87%


Nutritional nurse specialist in post. MUST audit completed 2010. 71% of eligible patients had a form completed although accuracy of recording was lower. Ward based training provided. PMT audit completed 2010. 18% of patients surveyed experienced one or more interruption (non urgent) during their meal (figure was 50% prior to the introduction of PMT). Use of PMT also shown to improve patients’ energy (kcal) intake per meal. Reports presented to Clinical Governance Committee.


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