Statement regarding Care Quality Commission report

Posted: January 26, 2012

Trust response to CQC Review of Compliance published on 26th January

Nerissa Vaughan, Chief Executive at Great Western Hospitals NHS Foundation Trust said:

"We take inspections by the Care Quality Commission very seriously and use their findings as an opportunity to explore ways we can improve the care we provide.

"At the Great Western Hospital, our staff see and treat over 400,000 people a year providing them with very good, personal care.  We know from the feedback we receive the vast majority of patients have a positive experience but we know there will always be areas where we need to improve to ensure patients are getting the best care possible.

"As the CQC inspections are a snapshot of the way we provide care on a particular day, it cannot represent the entirety of what we do, so we don't just rely on these inspections to tell us how we are doing.  We also use patient feedback and a vast range of quality measures to understand how we provide care and what we can do differently in the future.

"We have completed an action plan which has been sent to the CQC addressing the points raised and its progress will be monitored by the Trust Board to ensure we have covered all of the key issues."

Initial actions taken include:


  • Re-launching the World Health Organisation Safer Surgical Checklist to ensure thorough checks before and after surgery are carried out reducing the risk of surgical errors.  We are looking to make sure that there is a consistent approach to these checks across all of our 15 theatres so that the 71,000 operations we do each year have the relevant checks carried out to the same standard.
  • Placing responsibility for these checks with the Surgeons alone and one of our Surgeons (Mr Adam Brooks) will be the surgical champion for this initiative across the Trust.  This line of accountability and responsibility will help strengthen processes and procedures to reduce the risk of mistakes in the future.
  • Recently we invited staff from Plymouth Hospital to come to the GWH to share their learning and experience following a number of 'Never Events' that happened at their hospital.  Plymouth are now considered to be leading the way on safety in this area and it is important we learn form other organisations who have had to go through similar learning experiences as we have.

Extra bed spaces

What are extra beds?

Extra beds are the same as the other beds used on wards.  A bay usually has four beds. As a hospital we always remain open and there are occasions when we need extra beds to treat patients so we do not turn anybody away.  In these instances we put a fifth bed in the bay and ensure they have access to the same sorts of facilities as the other beds and some privacy.

What we are doing

  • Ensuring all extra bed spaces have access to lights, call bells, lockers and curtains to maintain privacy and dignity giving access to the same type of facilities available in other beds on the ward.  This work has already been completed as noted by the CQC in their report.
  • Matrons monitor the use of extra beds spaces to check that no patients are being cared for in areas without these facilities.
  • Undertaking a bed reconfiguration review to ensure we have the right number of beds in the right location to meet patient needs.  One of the aims of which is to reduce the use of extra beds to a minimum using them only when absolutely necessary during the busiest times.

Nutrition and hydration

  • Rolling out a new hydration device called the Hydrant which makes it easier for patients with mobility issues to drink fluid without assistance helping them to maintain a regular intake of water.  This has been trialled on Jupiter Ward recently and has proved successful in making a real difference to ensuring proper hydration. Read page 16 of our Trust magazine detailing this new device.
  • Putting in place weekly Matrons 'walk arounds' specifically looking at issues of nutrition and hydration checking documentation to monitor how records are being completed to seek assurance that patients are receiving the food and drink they need to assist with their recovery.  These 'walk arounds' will be in addition to the other general rounds the Matrons carry out to maintain standards in their area.


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