Annual Report and Accounts - The Great Western Hospital

6.5 Care Quality Commission (CQC) Inspections
There have been a total of 9 external inspections by the CQC and a schedule of work has been
developed to monitor progress with the action plans arising following each inspection.
Following 8 of those inspections (noting the ninth inspection happening in mid May, the outcome of
which is awaited), a CQC judgement of not fully compliant for the following three outcomes at Great
Western Hospital site has been made:
• Outcome 1 Respecting and Involving people who use services
In April 2011, the Trust was judged as none compliant with Outcome 1 due to its inability to
demonstrate the provision of adequate and consistent patient privacy and dignity. An action
plan was developed and completed by September 2011. In December 2011 a follow up
inspection by the CQC deemed the trust as compliant with some improvement actions.
• Outcome 4 ( Care & Welfare of people who use services
On December 8 th 2011, the CQC specialist inspection for Theatres judged the site as non
compliant due to inconsistency of WHO checklist completion.
Completion of action plan and subsequent regular internal audits and inspections for
assurance has provided clear evidence of compliance and the Trust has declared
compliance with Outcomes four as from 30 th April 2012 with the CQC.
• Outcome 5 ( Meeting nutritional needs)
On December 8 th 2011, the CQC inspectors focussed on hydration and after finding 3
incomplete fluid charts on one ward, judged the site as non compliant.
Completion of action plans, a hydration strategy internal review, Productive Ward
improvements and subsequent weekly internal audits and inspections has provided clear
evidence of compliance and the Trust has declared compliance with Outcomes five as from
30 th April 2012 with the CQC.
Other External Reviews
A dynamic database system has been created to enable tracking of all external reviews and
inspections. This system enables the Trust to track progress, actions and compliance status and is
reported to the Patient Safety and Quality Committee.
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