in touch plus

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University Hospitals Coventry and Warwickshire NHS Trust A magazine for staff, patients, visitors, volunteers and members ISSUE 1 WINTER 2014 Page 3 Getting Emergency Care Right Page 4 Five minutes with New Non Executive Directors Page 6/7 Outstanding Service and Care Awards (OSCAs) Sponsored by VINCI

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In Touch Plus is a magazine from University Hospitals Coventry and Warwickshire NHS Trust. The publication is for staff, patients, visitors, volunteers and members.

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Page 1: In Touch Plus

University HospitalsCoventry and Warwickshire

NHS Trust

A magazine for staff, patients, visitors, volunteers and membersISSUE 1 WINTER 2014

Page

3GettingEmergency CareRight

Page

4Five minutes with New NonExecutive Directors

Page

6/7OutstandingService and CareAwards (OSCAs)

Sponsored by VINCI

Page 2: In Touch Plus

Using the right local healthcare service means you will be seen quicklyand get the right care in the right place. Below you’ll find examples ofinjuries and illnesses and which service you should use.

Less severe illnessand injury - UrgentCare/Walk-inCentre/Minor Injuries- Small wounds including

those that need a few stitches

- Animal bites and stings

- Sports injuries

- Minor burns

- Tetanus immunisations

- Suspected broken bones

- Skin conditions including minor rashes

- Ear conditions e.g for objects stuck in ear

Choose Well and get the right care

Accident and Emergencyis for LIFE-THREATENINGand EMERGENCYCONDITIONS ONLY!

Severe illness andinjury - A&E

- Suspected heart attack- Chest pain- Unconsciousness- Heavy blood loss- Deep wounds- Abdominal pain- Severe breathing

difficulties- Head injury- Hip fracture- Suspected stroke- Severe burns

If it is an emergency andyou are very sick

dial 999.

Illness dealt with byGPs and pharmaciesinclude

- Cough, cold and flu symptoms

- Diarrhoea- Hay fever- Nausea and vomiting- Fever- Head lice- Constipation- Thrush- Conjunctivitis- Skin conditions- Blood pressure checks- Medication checks- Warts and verrucas- Insect bites and Stings

Welcome

2013 started off as a difficult year for allof us in the NHS. First of all we had oneof the longest winters which broughtwith it the inevitable extra pressures onstaff and beds. Then of course we hadthe publication of the Francis Report intothe failings at Mid-Staffordshire and thelessons that we all had to take on boardas members of the NHS responsible forsafe care for our patients.

However, there was a lot of positivework too which took place within theTrust in 2013. As a Trust we’ve beenshortlisted and won many awards forinfection control, research, ICT, pressureulcers, sustainability and leadership.Since September there has also been ahuge amount of passion, hard work and

enthusiasm dedicated to the GettingEmergency Care Right campaign. Thishas already seen a massive improvementin patient flow, an improvement inpatient experience as shown through theFriends and Family Test scores andimproved our reputation externally as wecontinue to meet the 95% target.Whenever I go around the Trust now, Ican see and feel the difference in theatmosphere and morale of staff.

And then there's the investments - newradiotherapy machines at a cost of£3.2million, the refurbishment of theArden Cancer Centre reception (kindlyjoint funded by Coventry HospitalsCharity and UHCW Charity) and therefurbishment of the Rehabilitation

Centre at StCross.

I am also excited to announce that aninnovative Da Vinci Robot, used forspecific keyhole surgery, has beenpurchased again with funds fromCoventry Hospital Charity and UHCWCharity. It uses minimally invasivetechniques for better patient outcomesand I know a number of our surgicalcolleagues are extremely excited aboutits arrival.

There are lots of exciting plans for 2014,and we hope to keep you updatedthrough this magazine. Enjoy!

Andy Hardy - Chief Executive Officer

I would like to welcome you to the first edition of InTouch Plus. This is a magazine for staff, patients,visitors, volunteers and members to keep updated about some of the amazing work which takesplace in our hospitals - University Hospital, Coventry and the Hospital of St Cross, Rugby.

Page 3: In Touch Plus

Getting Emergency Care Right

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In order to improve the care,experience and safety of patientscoming to us for Emergency care,our Chief Medical Officer MeghanaPandit and Chief Nursing OfficerMark Radford launched ‘GettingEmergency Care Right’ (GECR) inSeptember.

It has five key principles which makeup our FREED message:

- Facilitate effective discharge.

- Right person, right place.

- Early specialist input.

- Eliminate unnecessary tests.

- Daily senior review.

Within two weeks 1,600 clinicalstaff had been trained in theseprinciples. Simple measures, whichwere published on the Trustintranet, were used to track keyaspects including daily discharges,readmissions, mortality, and thenumbers of patients admitted fromthe Emergency Department.

Meghana also introduced 25 safetystandards covering emergency careand ensured these were metincluding:

- Ensuring specialist clinicians attended A&E within 60 minutes

- Daily senior review on wards.

Importantly, we also introduced acommand structure with managerssuch as Clinical Directors, ModernMatrons and Group Managers,meeting daily at 8am to plan and5pm to review and ensure all is inplace overnight so we can deliverthe best and timely care for ourpatients.

Our top 100 leaders, made up ofclinical and non-clinical managers,have undertaken ‘Check andChallenge’ visits to wards to assess ifGECR has been embedded withinthe practice of doctors and nurses.

Four months on and our Friends andFamily Test score improved from 52in September 2013 to 58 inNovember 2013 for A&E patients.For inpatients this has increasedfrom 57 in May 2013 to 64 inNovember 2013.

For October to December 2013 ourfour hour performance was 96.7%which was the first time in two years

we had met the performance for aquarter. The national target is that95% of patients should be seen,admitted or discharged within fourhours of arriving at A&E.

A survey sent out to all those whohad taken part in the programmedemonstrated that 96.3% wereaware of it, 92.5% agreed with itand 81.7% think the care ofpatients coming to us for Emergencycare has improved since it waslaunched.

Mark and Meghana said: “Thiscampaign has improved the care wegive to patients and proves culturechange does not take years toimplement.

“We have shown that by workingtogether, practical change thatimproves patient experience canhappen quickly and be sustained.”

If you would like to know moreabout GECR please contact KerryBeadling-Barron in theCommunications Department [email protected]

After a lot of hard work over two years, and having sought opinions from external experts, we were stillin the 10 worst performing Trusts for A&E performance. This meant that our patients coming through ourA&E departments were having to wait longer than they should to be admitted.

Chief Medical Officer Meghana Pandit and Chief NursingOfficer Mark Radford lead the GECR campaign

Page 4: In Touch Plus

Five minutes with.... our new Non Executive Directors

Why did you want tobecome a NED? I have worked in the NHSat Board level for the past15 years. When I retiredlast year I did not want tolose contact with theservice, so have done anumber of things to keepconnected, but when theopportunity arose tobecome a NED of the localteaching hospital, I jumpedat the chance. I wasdelighted to be appointed.

What was it thatattracted you to NHSTrust?My NHS career has mostlybeen in the south ofEngland. However, mywife and I moved to theCotswolds three yearsago, and I joined theMembership of the localNHS providers includingSouth WarwickshireFoundation Trust,Coventry andWarwickshire PartnershipTrust, and UniversityHospitals Coventry andWarwickshire NHS Trust. Ihave enjoyed finding outmore about the local NHSwhich I was not previouslyfamiliar with, and havebeen impressed with thebest of what is going onin the region. Our Trusthas more to do to getahead of all the pressuresthat the NHS faces, and I'llbe trying to help the Trust

to do just that byimproving quality,improving patientexperience, and managingthe money.

What do you see as themain aspect of yourjob?I see two key tasks. Thefirst is to support theExecutives and the staff todo a great job. I amtherefore delighted tohave been asked to Chairthe Quality andGovernance Committee,and would like the workof this important group tobecome better known tostaff. The second task is tobe resolute in driving forhigh quality services,knowing that is what Iwould want if I wasadmitted for care, andknowing that is what thevast majority of staff wantto deliver when they cometo work.

What has been yourproudest achievementat work?I took on the NHS systemin Buckinghamshire a fewyears ago when staff weredemoralised, and keytargets and money werebeing missed. Between uswe set a new clinicalstrategy for the system,and made some radicalchanges to how it allworked, such that wecame out of the historicdifficulties and set off in anew direction - the workis still in progress as thesethings often are, changetakes time!

Tell us something aboutyou that would surpriseus?I have a degree in forestry- helps me see the woodfor the trees (sorry!).

Ed Macalister-SmithNon Executive Director

Why did you want tobecome a NED?It is a bit of a cliché but Ireally do want to givesomething to anorganisation which I trulybelieve in. I have beenfortunate in my businesscareer and now have thetime to assist and

hopefully put to positiveuse some of the learningand experiences from thecommercial world to thebenefit of patients.

What was it thatattracted you toUHCW?I live in Warwickshire soam able to listen tocomments from thosewho use its services,UHCW, whilst not perfect,has a reputation forstriving to get things rightand putting the patientfirst. The link withUniversity of Warwickpresents real opportunitiesto make UHCW one ofthe best hospitals in thecountry. Care, Achieveand Innovate resonateswith my personalaspirations and values.

What do you see as themain aspect of yourjob?To challenge the board toensure we develop thebest strategies fordelivering effective, safeand patient friendlyservices for the optimumcost. The NHS nationallyprovokes comment in themedia on a daily basis.UHCW must stay focusedon the objectives it has setitself, whilst constantlybeing vigilant andlearning lessons whenthings have failed or notgone well elsewhere.

What has been yourproudest achievementat work?My business, AdvancedCommunication andInformation Systems, was

awarded The Queen’sAward for Innovation,which I received from TheQueen at BuckinghamPalace. This representedexternalacknowledgement of agreat deal of exceptional,hard and clever work fromour entire workforce.

Tell us something aboutyou that would surpriseus?I have competed in TheRound the Island Race(sailing around the Isle ofWight) and want to sailaround the world, when Iretire!

Ian BuckleyNon Executive Director

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Page 5: In Touch Plus

Meet the team whosupport older patients withconfusion and dementiaUHCW is committed toensuring older patients withdementia and confusionreceive effective andcompassionate care when theycome to hospital.

Nurses who support frail olderpeople and patients with dementiaat University Hospital, Coventry,are Rose O’Malley, Liz Kiernan andTracey Chapman. Debbie Harris,Specialist Mental Health Nursesupports all patients 65 and overat the Hospital of St Cross, Rugby.

UHCW has a long history ofpractices designed to raise thestandards of care for those withdementia and confusion, to ensureall patients are treated with dignityand respect. The Older People’sTeam has continued to seek newways to improve the care itprovides for people with dementiaacross the Trust at every level.

Clinical Nurse Specialist, LizKiernan said: “One of the mostimportant Trust-wide initiatives sofar introduced is UHCW’s Forget-Me-Not Care Bundle. The carebundle is a proven set ofinterventions to help older patientswith dementia or confusion orwho are frail have a better qualityof stay during their time inhospital. These interventionsinclude filling out a Getting toKnow Me Form; staff to beperson-centred andcompassionate; ensuringadequate assistance with eatingand drinking and adapting thephysical environment of thehospital to improve the day-to-daylives of patients with dementia.”

The team encourages all relatives,carers and staff to fill out aGetting to Know Me Form, whichis available atwww.uhcw.nhs.uk/for-patients-and-visitors/dementia-care-at-uhcw

or by asking a member of staff fora copy of the form for frail,confused and patients withdementia. Collecting additionalinformation is the key to theTrust’s person-centred approach.Being aware of a patient’sinterests, preferences, likes anddislikes allows staff at the Trust todo their job better.

Liz went on to say: “Hospital cansometimes be a scary place,particularly for patients withdementia or confusion so weencourage carers and relatives tobring in an item from home tohelp orientate these patients. Itcan help calm a patient ifsomething familiar is nearby suchas a photograph, an ornamentfrom home or a cushion. There arealso flexible visiting times in placefor relatives and carers of patientswith dementia or confusion,please speak to the WardManager to organise your visitingarrangements.”

To find out more about dementiacare at UHCW please call: 024 7696 8333.

Please note patients do notneed a diagnosis of dementiato be supported by this team.

Dementia FriendsPeople with dementiasometimes need a helpinghand to go about their dailylives and feel included intheir local community.

Dementia Friends is givingpeople an understanding ofdementia and the smallthings they can do that canmake a difference to peopleliving with dementia - fromhelping someone find theright bus to spreading theword about dementia. Theaim is to create a networkof a million DementiaFriends across England by2015.

You can get involved in twoways by becoming aDementia Friends Championor become a DementiaFriend. To find out moreinformation please visitwww.dementiafriends.org.uk. Dementia Friends is anAlzheimer's Society initiative.

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Debbie Harris, Tracey Chapman, Dr Pijush Ray,Rose O’Malley and Liz Kiernan

Page 6: In Touch Plus

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Page 7: In Touch Plus

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1Chief Executive Officer’s AwardSharon Wyman and the Complaints TeamThe work of this team undoubtedly contributes to the strategicpriorities of the Trust. Learning from its complaints the Trust is able toimprove the quality of its services.

2Going the Extra Mile Award - Bibi Rosander, Discharge Facilitator.Bibi is enthusiastic and committed to the patients she comes into contactwith as part of her discharge facilitating role.

3Non-clinical Team or Individual of the Year Award Anne Dela CernaAnne received many nominations from the Practice Development Teamwho she provides first class administrative support for. She wasdescribed as the oracle of knowledge.

10Achieving Innovation and Service Development AwardTransnasal Oesophagoscopy Team A team of doctors and nurses have worked together to introduce oneof the most innovative services in the NHS that has brought manyadvantages to patients and to the Trust alike.

8Leader of the Year Award - Val PilgrimVal’s hard work and dedication has transformed the experience ofpatients with Parkinson's disease and their carers. She lead a team tosuccessfully develop and expand a six week self management coursefor small groups of patients and carers in the Rehabilitation Unit.

7Promoting Equality and Diversity Award - Barry ShawBarry Shaw was nominated for this award by a patient who has autism.The patient described him as caring with a lot of patience and that heexplained the treatment the patient was to receive in simple, easy tounderstand terms.

9UHCW Charity Supporter of the Year Award - Heather and Diane ScottHeather and Diane are a dream duo when it comes to helping peoplewithin their community to fundraise for local causes.

6ISS Partnership Award - Fiona WellsSince Fiona started with the Infection Control Team she has alwaysbeen positive and constantly has a smile on her face. She alwaysinvolves ISS in all of her achievements on the wards and instils pride inISS staff.

5The Vinci Partnership Award - Chris Beck and Adam CheaterThey provide outstanding help and assistance during times where Vinciare required to resolve building problems for the Trust.

4Project Co Award - Bill Rooke and Adam CheaterBill and Adam who work for Vinci have helped contribute to thesuccess of the Trust’s Healing Arts Programme.

Outstanding Service and CareAwards (OSCAs) 2013Now in its sixth year, the Outstanding Service and Care Awards (OSCAs)ceremony is held annually by UHCW NHS Trust. These awards give Trust staff andmembers of the public the opportunity to nominate individuals and teams thatthey think deserve recognition for always going above and beyond.

The ceremony was sponsored by Vinci, ISS, Coventry and Rugby HospitalCompany, Coventry University, Warwick Medical School, LloydsPharmacy, andUHCW Charity.

Page 8: In Touch Plus

Innovation and partnership working in association with Vinci Facilities

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Vinci Facilities are looking forward to 2014, working with theTrust in our long term partnership to provide responsiveservices and maintain the excellent facilities that make up thehospital estate. We are having a big drive on innovation andpartnership working this year in regards to the manner andpractices we deploy our in services. I hope you find theupdates below interesting and if you have any ideas on howthe facilities can be maintained differently or modified in ourhospitals, please email: [email protected].

John Newberry - Vinci Project Director

In November last year, Vinci wereproud to be part of the openingceremony of the first electric carcharging points on a hospital site inthe Midlands. The scheme cost£25,000 and Vinci contributed 40%of the capital investment. The ideaoriginated between the Trust andVinci as we shared an ambition toparticipate in the Plugged InMidlands scheme delivering chargingpoints across the region. The deliveryof the project exactly matches theTrust’s and Vinci’s sustainabilityagenda providing environmentallyfriendly solutions to the community.Vinci has since provided a dedicatedelectric car for Vinci and TrustFacilities staff to use when travellingbetween the Hospital of St Cross andUniversity Hospital. If you have anyinnovative ideas to do withmaintenance or the facilities please

email [email protected] ensure you mark the emailINNOVATION IDEA so we canregister it correctly and respond toyou.

Partnership working:In December, Vinci Facilities alongwith grounds maintenancecontractor Fallons donated andinstalled the Christmas tree that wassituated at the main entrance ofUniversity Hospital. Lincoln Dawkin,Director of Estates and Facilities said:“Each year we are grateful for thesupport of Vinci and Fallons inproviding the Christmas tree andlights for University Hospital.” Anyideas for next year’s Christmasdecorations please let us know.

Vinci also continue to work closelywith Allison Bradley from theInfection Control Team supporting

the initiatives around C-Diffreduction targets throughcontributing to the awards providedto wards and departments thatachieve 100 Days C-Diff Free targets.We also donated an iPad to theirannual award in December for themost inspirational and dedicatedstaff member that contributes to andchampions Infection Control. Welldone Cheryl Ashmore from Ward 33for scooping the big prize.

Sustainability drive:The Trust and Vinci Facilities want tolook at ways of saving waterconsumption on site. One of theways that staff or visitors can aid thisis to report any urinals or toilets thatare continuously flushing to theEstates and Facilities Helpdesk on:024 7696 5555 (extension 25555) sowe can respond and repair the unit.

Improvements on the way for the hospital visitorsUniversity Hospital in Coventry has started work toimprove the experience for visitors coming on site.

The first element of the improvements was the relocationof the existing taxi rank to an area outside the ClinicalSciences Building. The new rank includes two lanes fortaxis and as part of phase two of the scheme, a brandnew drop-off point for visitors is being added.

Lincoln Dawkin, Director for Estates and Facilities said:“The creation of a bigger and better drop-off point isgood news for patients who are driven to and collectedfrom hospital by a family member or friend.

“The scheme is just one of a series of traffic flow changesand additional parking we are introducing over the next18 months to improve the experience for visitors to thehospital site. The improvements, which started onDecember 2, 2013 include relocating the existing taxi

rank, increasing the number ofparking spaces and improvedsignage.”

Lincoln added: “We apologise tovisitors for any inconvenience whilework is carried out and ask that theylook out for information signs. Anydisruption will be kept to aminimum at all times.”

The plans for the site, approved inMay 2013 by Coventry City Council, have been designedto improve on site traffic flow and increase the numbersof parking spaces for visitors.

There are already an extra 150 spaces available for thepublic and once the extra works are completed on site,these will increase by another 250.

Lincoln DawkinDirector of Estates

Page 9: In Touch Plus

@nhsuhcw 9 years agoagainst all odds medics savedmy beautiful baby girl's life. #nhs #blessedFleur Sexton

A selection of the best of your comments from Facebook and Twitter

9

Critical

care nurses @nhsuhcw

are amazing. Skilled,

dedicated, caring &

compassionate. Couldn't ask for

better care for my mum

Sharon Giles

Hadto take my 12 year old sonto A&E this morning. So pleased with

his care, he saw a surgical registrar within10 mins of Triage nurse. Thank you so

much Children's A&E, Coventry.Sam Flossy DeeproseEverytime

I go to my barber, he

waxes lyrical about his

radiotherapy treatment in '94. Still

going strong 20 years later, good

job @nhsuhcw

Qasim RavatJacobhas beendischarged fromUHCW! We would like tothank Dr Morgan for all herhelp she is fantastic and wewill miss her @nhsuhcw :)

Jacobs Journey

@nhsuhcwand thewonderful Prof Poole,things would be different.But I do have the best familyand the most wonderful

friends, THANKYOU allKerry Burton

Fantasticcare today at@nhsuhcw a and e. Thankyou for taking care of mylittle one Lis Basner

/nhsuhcw

@nhsuhcw

In

2013 I was d

iagnosed

with ca

ncer. I am in remissi

on

thanks to th

e wonderful people at

@nhsuhcw& Ward 34 and my

great family..

.

Dean Judge

Just

taken my mum for laser

eye treatment at the fabulous

University Hospital. Excellent

treatment, staff and facilities

Steve Turner

Page 10: In Touch Plus

Members’ LoungeWelcome to the exclusive ‘Members’ Lounge’. This area is full ofhandy tips and information on how you can get the most from yourFoundation Trust membership. From discounts to important dates foryour dairy, it’s all right here for your information. We now have over9,200 public members and are working towards 10,000 members.

@nhsuhcw

You can follow us on Twitter and Facebook and keep up-to-date with news and happenings at UHCW.

www.facebook.com/nhsuhcw

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Where are my personaldetails held?We employ MembershipEngagement Services (MES), anexternal database company, tomanage our membership database.All information is kept strictlyconfidential in accordance with theData Protection Act 1988. If youwould like to find out more aboutMES please visit their websitewww.membra.co.uk

NHS DiscountsMembers can register with NHSDiscounts to receive discounts ontop brand goods and services,including gas and electricity as wellas discounts at retailers such asCurrys, Apple, Radley and BHS. Goto www.nhsdiscounts.com toregister. When completing the ‘yourjob’ section, answer ‘yes’ to workingfor the NHS and then select‘Foundation Member’ as the jobcategory.

Public RegisterWhen we become an NHSFoundation Trust we will be requiredby law to publish a register ofmembers. This will include yourname plus the constituency to whichyou belong. You may apply to haveyour name excluded from the publicregister should you wish. Just tell usby emailing, telephoning or writingto us, giving your full name, addressand date of birth.

Young Persons AdvisoryCouncilWe are looking for people to joinour Young Persons Advisory Councilworking with our Partner Schooland other groups. If you are aged11-19 and interested in joiningplease contact the FoundationOffice on 024 7696 4747

Your feedback is importantto usLet us know if you would like us toarrange a talk or tour on a specificissue or area that is of interest toyou by calling 024 7696 4747 [email protected].

Encourage your family andfriends to get on boardUHCW now has 9,200 publicmembers. Thank you to all of youwho are spreading the word andhave helped recruit friends, familyand colleagues. Friends and familycan register as members in thefollowing ways.

Fill in the on-line applicationform on our website:www.uhcw.nhs.uk/foundation-trust

E-mail or ring Andrea Phillips:[email protected] phone 024 7696 4747

Dates for your Diary24.02.14 - Aortic Aneurism24.03.14 - Asthma30.04.14 - Calf Pain in your legs27.05.14 - Research10.06.14 - Hypertension27.08.14 - Dementia

All the events are free and takeplace in the Clinical Science Buildingwhich is located near the mainhospital, between 5pm - 6pm.

To book these events please callAndrea Phillips on 024 7696 4747or email:[email protected]

Have your details changed?Have any of your personaldetails changed (ie: have youmoved or changed your emailaddress?)

If so, then please inform theFoundation Trust Office so that wecan make sure we address anycorrespondence correctly and keepyou up-to-date with what’s going onat UHCW.

Andrea Phillips is our FoundationTrust Membership Manager and isyour first point of contact at theTrust regarding your membership.

The Trust has access to interpreting and translation services. If you need this information in anotherlanguage or format, we will do our best to meet your need. Please contact 024 7696 7596

Page 11: In Touch Plus

Foundation Trust Membership Application FormMany thanks for deciding to become a memberPlease fill in and send us this form so we can welcome you aboard as soon as possible. Please note that all fieldsmarked * must be completed for us to be able to register you. Needless to say, we would also very much appreciateyou filling in the other field too, ensuring you sign the declaration (overleaf).

Your name and contact details

* Title:

* First name:

* Last name:

* Address:

* Post code:

* Home tel:

Work tel:

Mobile:

Email:

*Date of Birth:

Tick the box to select your preferred method of contact

Post Home tel Work tel

Mobile Text Email

How did you hear about us?

Hospital

TV

Radio

Local Press

Leaflet

Friend

Family

Hospital Staff

Mailing

Other (please specify)

How do you want to be involved?

Learn more about how to improve my ownhealth and take part in health promotioncampaigns

Consider standing for election as a Governor

Volunteer at the Trust

Receive additional membership forms forfamily/friends

Take part in consultation of the Trust’s plans

Advocate the Trust within the community

Be sent regular information about the Trust (e.g. newsletters)

Help recruit more members

Help us develop better information for patientsand carers

Other (please specify)

Which services are you interested in?

General medical care

Women & children

Surgery

Renal (kidney)

Maternity

Cancer

Other (please specify)

Diabetes

Cardiac (heart)

Rehabilitation

Emergency care

Stroke

Neuro (brain)

What is your connection with the Trust?

Have previously applied to be a member of this Trust

Carer of someone who is, or has been, a patient

Have worked for the Trust in the past

Student/work placement

Family member of a staff member

Patient

Visitor

Family member of a patient

Other (please specify)

If you have a particular interest in one or more areas ofhealthcare, we’d very much like to know. Maybe it’s cancercare, diabetes or emergency care - whatever interests youhave, please let us know:

Male Female

Data ProtectionUniversity Hospitals Coventry and Warwickshire NHS Trust would like to use your information for communication and research purposes. We may contact youfrom time to time by telephone, email or post to invite you to take part in surveys and questionnaires about our hospitals. If you do not wish your informationto be used for this purpose, please tick this box.

We would also like to share your information with the charity/fundrasing arm of University Hospitals Coventry and Warwickshire NHS Trust. If you do not wishyour information to be used for this purpose, please tick this box.

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Page 12: In Touch Plus

More about youIt is important to us that our membership reflects all the different communities that we serve, so that we can make sure that ourhospital services meet their individual needs, and that we treat everyone in a way that respects their views, culture, disability anddignity. To help us to do this we ask you to provide some information about yourself. This is entirely voluntary. If you choose notto provide the information it will not affect your membership application.

Are you registered disabled?

Yes If yes, please specify:

A physical disability

A visual impairment Other

A hearing impairment

Other special needs

No

Please tell us about your ethnic origin

White:

White British

If other, please state:

White Irish

Black or Black British:

Caribbean

If other, please state:

African British

Asian or British Asian:

Indian

If other, please state:

Pakistani Bangladesh

Chinese

If other, please state:

Other Ethnic

Getting your family and friends involvedIt would be great if you could encourage your friends, familyand other people you know in the community to getinvolved too. If you would like to suggest any person whowe could send information to regarding membership pleaseprovide their details here:

Title:

First name:

Last name:

Address:

Post code:Mixed:

White and Caribbean

If other, please state:

White and Black African

White and Asian

Declaration I would like to be a member of the Foundation Trust, whenauthorised

Thanks again for deciding to become a memberThank you for taking time to complete this form and we look forward to you becoming a member andgetting involved. We will send your welcome letter and membership card as soon as we have processedyour registration. For more information about our Foundation Trust aspirations, please visit our websitewww.uhcw.nhs.uk/foundationtrust or call us on 024 7696 4747

Please return the completed form to: (No stamp required)

Freepost RSCT-YUXG-GHZXUniversity Hospitals Coventry and Warwickshire NHS TrustFoundation Trust Office, 3rd FloorUHCW NHS TrustClifford Bridge RoadCoventry, CV2 2DX

D D / /M M Y Y Y Y

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Signature:

Date: