Annual Report and Accounts 2012/13 - Royal Bournemouth Hospital

Financial AccountsThere has been an increase in the numberof Information Governance incidentsreported, which demonstrates growingawareness of Information Governanceas a result of mandatory training. Thisincluded three serious incidents whichhave subsequently been reported tothe Information Commissioner’s Office.The Information Commissioner’s Officehas decided to take no further actionat this time in relation to two of theseincidents and has not yet concluded itsinvestigation of the third incident.At the end of the financial year, theTrust was in the process of recalling anumber of patients who had previouslybeen treated at the Royal BournemouthHospital. This was due to the concernsraised by the consultants who run thebreast clinic regarding a junior doctor,who is no longer working in the Trust, andthe way in which an initial assessment ofsome patients may have been carried out.This assessment potentially did not meetthe Trust’s usual high standards and asubsequent external review of processeshas been commissioned.The organisation’s major risks arecategorised below in terms of current andfuture risks:Current risks:Control of Exposure to Legionella riskon two Medicine for the Elderly wards.Positive sample results continue tobe detected in samples pre and postchlorination. The risk to patients andstaff is very low due to current controls inplace. However the results are above the1000 action limit therefore in accordancewith the Trust’s Safe Water Policy therisk assessment will remain “High” until asufficient number of negative results areobtained. Re-piping of the affected area isplanned for summer 2013.Risk that the Competition Commissionmay not grant approval for mergerresulting in financial instability. A detailedaction plan is in progress monitored bythe Joint Programme Board.High levels of Emergency Activity. Actionplans are in place and reviewed weekly bythe Chief Operating Officer. A detailed riskassessment against the CQC Outcomeshas been developed and will be reviewedregularly at the Trust’s PerformanceManagement Group. Detailed actionplans are in place with ExecutiveDirector leadership provided by the ChiefOperating Officer.Loss of Cellular Pathology CPAAccreditation status resulting in potentialloss of contractual work and income.The Trust is currently appealing the CPAdecision to downgrade and is activelyworking with them to re-establishaccreditation status and all relevantparties have been informed. No risk toclinical care.18 week admitted Referral to TreatmentPerformance - Risk of breaching 90%contracted required per speciality.Significant risk in Upper GI and Urology.The action plan includes further additionalWaiting List Initiative lists to increasecapacity in Urology and Upper GI, jobplanning in relation to a new theatretimetable, a new theatre timetable/increase in theatre capacity andconsideration of outsourcing.Nursing skills in the Acute MedicalUnit fall below the Society for AcuteMedicine recommendations and currentstaffing levels restrict the unit’s abilityto train staff. All vacancies are currentlybeing advertised. The staffing templatenow includes supervisory time for theclinical leader and the nurse resourcepool is being used to support shortfalls.Mentorship is being provided to the unitClinical Leader and Senior Nurse supporthas been initiated.Future risks:Control of Exposure to Legionella risk.The risk assessment will remain “High”until a sufficient number of negativeresults are obtained. As indicated in thecurrent risk identified above, re-piping ofthe affected area is planned for summer2013.Annual Report and Accounts 2012/13 9