Annual Report & Accounts 2010/11 - James Paget University Hospitals

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Quality A full quality report can be found at page 89. It is available as a separate report, with a short easy to read summary. Infection prevention and control Patient safety is paramount and this includes the management of infection prevention and control. Key aims in this area are: • to have appropriate management systems in place • to provide and maintain a clean and appropriate environment for healthcare • to minimise nosocomial infections within the Trust. Our successes this year include: • sustaining a year-on-year reduction of MRSA bacteraemias – and being within our yearly target. The reduction has been due to robust infection prevention and control measures and the hard work of our staff. These measures include effective management of antibiotic prescribing, ensuring everyone cleans their hands, deep cleaning ward areas daily, screening the majority of elective and emergency admissions in line with national guidance and daily monitoring of any patients identified with MRSA • we are well within hospital-attributable Clostridium difficile targets and have seen year-on-year reductions. We have a six bedded cohort isolation ward for patients identified as having Clostridium difficile • we have achieved a Commissioning for Quality and Innovation (CQUIN) target relating to Clostridium difficile • a well managed outbreak of Group A Strep involving 10 patients in 4 clinical areas. It was an unusual strain never seen in the UK before. It has caused considerable interest from the Health Protection Unit and a paper is being published • we continue to manage Norovirus well as an organisation, which helps to reduce its spread and the closure of wards • we work closely on new building and refurbishment projects to ensure that designs are user-friendly for clinical use in relation to infection control There have been changes in the Microbiologist consultants with the functions covered by long term locum staff. The Director of Infection Prevention and Control (DIPC) responsibilities are being covered at an Executive level. Long term arrangements are being taken forward in conjunction with partner organisations. Page 14 James Paget University Hospitals NHS Foundation Trust Annual Report 2010/11 www.jpaget.nhs.uk
Mothers and babies Helping women and their families during pregnancy and birth is one of the health service’s most important responsibilities. We strive to continually improve the service we provide to meet the individual clinical and emotional needs of mothers and their families. Appropriate staffing levels ensure that all women and their families will have continuity of care with a midwife that they know and trust. Arrangements are in place for co-ordination and ongoing midwifery support should the known midwife not be available. With the support of NHS Great Yarmouth & Waveney we have been able to increase our Midwifery and Support Worker establishment to provide services that are needed in our community. A specialist team of midwives has been set up to work with marginalised groups of women and their families to support them in making life changes. Additional Midwives are also working on the Delivery Suite to ensure that everyone receives 1:1 care when in established labour. Eliminating mixed sex accommodation Every patient has the right to receive high quality care that is safe, effective and respects their privacy and dignity. This Trust is pleased to confirm that we are compliant with the Government’s requirement to eliminate mixed-sex accommodation, except when it is in the patient’s overall best interest, or reflects their personal choice. We have the necessary facilities, resources and culture to ensure that patients who are admitted to our hospitals will only sleep in individual rooms, or in bays with other patients of the same sex, with same-sex toilets and bathrooms that will be located close to their bed area. Sharing with members of the opposite sex will only happen when clinically necessary (for example where patients need specialist equipment such as in ICU or when patients actively choose to share e.g. renal), all of which is in line with national guidance If our care should fall short of the required standard we will report it internally and externally to our commissioners. We will also set up an audit mechanism to make sure that we do not misclassify any of our reports. We will publish the results of that audit at the Trust’s Board of Directors. www.jpaget.nhs.uk James Paget University Hospitals NHS Foundation Trust Annual Report 2010/11 Page 15
Page 1: James Paget University Hospitals NH
Page 4 and 5: Page 4 James Paget University Hospi
Page 6 and 7: Welcome From our Chairman, John Hem
Page 8 and 9: identify and address concerns and m
Page 10 and 11: Our Core Values Our values are the
Page 12 and 13: Those with dementia The increasing
Page 16 and 17: Education and Practice Development
Page 18 and 19: Care Quality Commission regulations
Page 20 and 21: Listening and responding to our pat
Page 22 and 23: ‘Coffee machine was broken’ Rep
Page 24 and 25: Patient Advice and Liaison Service
Page 26 and 27: Consultations There have been no fo
Page 28 and 29: • The work in QIPP development ha
Page 30 and 31: of Directors and Governors Council
Page 32 and 33: Our performance Regulatory Ratings
Page 34 and 35: Indicator Measure National Standard
Page 36 and 37: Our commissioners The main commissi
Page 38 and 39: Financial Performance The Trust ach
Page 40 and 41: Patient Care Income 31 March 2011 (
Page 42 and 43: Capital investment 2010/11 £’000
Page 44 and 45: Better Payments Practice During the
Page 46 and 47: Equality Over the last year signifi
Page 48 and 49: A year in our life April 2010 • O
Page 50 and 51: patients are admitted to our Emerge
Page 52 and 53: Midwifery-led Birthing Unit (MLBU)
Page 54 and 55: Support Services The areas that pro
Page 56 and 57: Our staff The Trust is the largest
Page 58 and 59: In 2010, the staff response rate to
Page 60 and 61: Occupational health Our occupationa
Page 62 and 63: Case Study - Project Search The Tru
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Lowestoft Hospital League of Friend
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Our directors As a Foundation Trust
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Non Executive Directors Jean Mason
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Feedback has been received and the
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Our governors The Governors Council
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Elections Governors standing for th
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Our members The Trust has two membe
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• Tracker form developed to recor
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Governors Council Nomination and Re
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Trust Remuneration Policy Executive
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Senior managers’ pension entitlem
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disclosure of this report within th
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HSMR ICU IG IT Inpatient INTRAN JPU
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James Paget University Hospitals NH
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Contents Page Foreword by Chief Exe
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The old and the very young are know
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Statement of directors' responsibil
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Current position: Patient Falls 120
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Priority 1b: Patient safety - Reduc
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Five work streams have been agreed
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No Commissioning for Quality and In
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No Commissioning for Quality and In
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The services provided by James Page
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Clinical Audits Audit Name Applicab
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(NHSBT UK Transplant Registry) Audi
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Case Study 2: Upper Gastrointestina
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The Trust has a dedicated lead for
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NHS number and GMC code validity Ja
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What others say about the Trust Car
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Current Position: Inpatient Pressur
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Metric 3 - Venous Thromboembolism (
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Monthly CVC BSI Rates 14 12 Rate of
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Metric 8 - Nutrition & Hydration Ma
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Patient Safety Incidents As at 18 t
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Never Events Never Events are serio
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Existing Commitments and National P
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Patient Experience National In-pati
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An action plan has been developed f
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Maternity National Survey The respo
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Question Area Conclusions Recommend
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Case Study: Health Service Ombudsma
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Patient Experience Measures Patient
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• 100 Key Scores Comparison 90% 8
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NHS Great Yarmouth & Waveney NHS Gr
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Glossary of Abbreviations A&E C dif
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Contents Page Statement of Accounti
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Annual Governance Statement Scope o
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Annual Governance Statement continu
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Independent Auditor's Report to the
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Foreword to the Accounts James Page
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Statement of Financial Position As
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Notes to the Accounts 1 Significant
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Notes to the Accounts continued - -
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Notes to the Accounts continued 1.6
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Notes to the Accounts continued 27.
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Annual Report & Accounts 2010/11 - James Paget University Hospitals

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