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Tarporley War Memorial Hospital Requires improvement

We are carrying out checks at Tarporley War Memorial Hospital using our new way of inspecting services. We will publish a report when our check is complete.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 23 June 2017

Tarporley War Memorial Hospital was rated ‘Requires Improvement’. The regulated activities we inspected were; diagnostic and screening procedures, treatment of disease, disorder or injury.

Our findings were as follows:

we found the following issues that the service provider needs to improve:

  • Although there was an incident reporting system in place, we found that there was limited assurance that all incidents were reported and that learning took place following incidents that were reported.

  • The main incidents reported were medicine errors and patient falls, we saw some evidence that these had been analysed for trends and patterns. However, in response to medication incidents we saw that the hospital advised ‘we will remind staff to take extra care when administering medicines’, as opposed to reviewing practices and competencies of staff.

  • Information provided by the hospital showed that there had been no cases of MRSA and clostridium difficile (c.difficile) for the period April 2016 to December 2016. An audit for infection control was undertaken in November 2015, the audit showed good compliance with standards, however further audits have not since been completed.

  • The risk register was not robust and did not identify clear processes for mitigating risks and ongoing monitoring with given time scales. The process for staff to escalate local level ideas and risks was unclear.

  • The hospital did not always follow evidence based care and treatment guidance and the National Institute for Health and Care Excellence (NICE) guidance. The hospital did not participate in national audits, but they undertook some local audits. They have recently started following aspects of the safety thermometer which was submitted to the Quality advisory group and Trustee board.

  • There was evidence of multidisciplinary input and involvement in patient care. A multidisciplinary meeting was undertaken every Monday to discuss the plan of care for each patient. This involved occupational therapists, physiotherapists and registered nurses.

  • We spoke to trustees of the hospital who had strong ideas on the vision for the future of the hospital; however, the hospital staff could not describe the overarching vision or stated values. There was no quality strategy or clearly articulated quality priorities.

We found the following areas of good practice:

  • Data provided by the hospital showed that 85% of staff had received an appraisal in the last twelve months.

  • Patients were extremely positive about the care provided by staff. We saw that patients were treated with care and compassion and that their privacy and dignity was maintained. The hospital had very good patient feedback and positive feedback on their patient satisfaction surveys.

  • Patients who were suitable for rehabilitation were assessed by physiotherapists and occupational therapist within 48 hours of admission. Individualised rehabilitation care plan were implemented.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, to help it move to a higher rating. Details are at the end of the report.

Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

Inspection areas

Safe

Requires improvement

Updated 23 June 2017

We rated community health inpatient services as ‘Requires Improvement’ for safe. This was because:

  • There was no documented evidence that those patients deemed at risk of pressure ulcers were provided with the correct control measures to mitigate the risk of pressure damage such as monitoring and implementing a repositioning regime.

  • Although there was an incident reporting system in place, we found that there was limited assurance that all incidents were reported and that learning took place following incidents that were reported.

  • The hospital was not a purpose built healthcare facility and was an older building. This posed some challenges from an environmental point of view.

  • The acuity tool used to determine staffing levels did not provide a measurable level that would indicate when extra staff were required.

  • Archived patient records were not stored appropriately.

  • Staff treating children and young people for minor injuries were not trained to level 3 safeguarding.

  • The hospital policy for the use of bed rails by gaining consent from a relative rather than assessing if the patient had capacity is contrary to the Mental Capacity Act 2015.

However we also found;

  • Tarporley War Memorial hospital recorded safety thermometer information to enable them to determine their levels of harm free care.

  • The hospital reported no serious incidents and greater than moderate harm to their patients during the reporting period February 2016 to January 2017.

  • The hospital understood their responsibilities regarding safeguarding vulnerable adults, 85% of staff had completed training on safeguarding to level two and the hospital had not made any referrals during the reporting period.

  • Medicines were stored securely and there were processes in place to ensure they remained suitable for use.

  • Resuscitation equipment was in place and records indicated this was consistently checked.

  • Other equipment was serviced and maintained regularly and appropriate records kept.

  • Satisfactory minimum levels of staff were on duty to maintain patient safety.

  • Staff were up to date with their mandatory training at 92%.

Effective

Requires improvement

Updated 23 June 2017

We rated community health inpatient services as ‘Requires Improvement’ for effective. This was because:

  • The hospital did not always follow evidence based care and treatment guidance and the National Institute for Health and Care Excellence (NICE) guidance.

  • We found ten out of 13 ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) forms were incorrectly completed.

  • The hospital did not have a system to ascertain which NICE guidance applied to their scope of practice.

  • The hospital failed to follow best practice in relation to the NICE guidance on the prevention of pressure ulcers.

  • There was limited assurance of an adequate and effective auditing programme.

  • We identified a lack of understanding and incorrect application of the Mental Capacity Act legislation. Some patients did not have satisfactory evidence of the two stage mental capacity assessment documented. The hospital’s own policy was not aligned with mental capacity act legislation.

  • We saw limited assurance that the competency of health care assistants was assessed and recorded when acting as second checker for medicines administered in the absence of a second registered nurse.

However we also found;

  • The hospital followed evidence based guidance in connection with wound care and risk assessments.

  • Rehabilitation patients received assessments and input around their activities of daily living from occupational therapists and physiotherapists.

  • Patients stated they were asked about pain and were satisfied with their pain relief.

  • Nutrition and hydration needs were assessed and recorded; food provision was both appetising and nutritious.

  • There was evidence of multidisciplinary input and involvement in patient care.

  • Staff were generally competent and received the appropriate training to undertake their roles.

  • A formal induction policy was in place for new staff.

Caring

Good

Updated 23 June 2017

We rated community health inpatient services as ‘Good’ for caring. This was because:

  • Patients were extremely positive about the care provided by staff.

  • We saw that patients were treated with care and compassion and that their privacy and dignity was maintained.

  • The hospital had very good patient feedback and positive feedback on their patient satisfaction surveys.

  • We found many positive examples that demonstrated the kindness and thoughtfulness of staff towards their patients.

  • Patients and those close to them were involved and consulted in their care and treatment.

  • Provision was made for the emotional and psychological support of patients during their stay at the hospital.

Responsive

Requires improvement

Updated 23 June 2017

We rated Community health inpatient services as ‘Requires improvement’ for responsive. This was because:

  • The hospital did not gather information to identify the types of people who used the service. For example, the number of children who used the mini minor injuries service or the number of people living with dementia who used the hospital was not monitored. Trends in the reasons why people were admitted for respite care were not identified. This meant plans to develop the hospital were not informed by information about the types of people who became patients.

  • More consideration was needed in relation to responding to people living with dementia or in vulnerable circumstances such as better signage throughout the hospital; large print leaflets readily available or a colour scheme in the public areas which separated private from public areas.

  • Equality and diversity needs of patients and their families were not addressed by the service.

  • The criteria for admission and the admission processes were not robust which meant people could be admitted to the service whose needs could not be met.

  • Patients’ needs were not reassessed before each admission for respite care.

  • The complaints policy did not provide correct information and was not accessible to patients.

  • Complaints received were fully investigated and independent specialists were involved when appropriate. Findings were discussed with the complainant and the outcomes shared with staff involved at the team brief.

However we found:

  • Patients were able to get involved with planning and providing a service through involvement in the fundraising initiatives and volunteer schemes.

  • Patients were able to access the service in a timely manner and care and treatment was co-ordinated with other providers.

  • Bed occupancy rates for 2015/16 was 62% which meant people had ready access to the service.

  • The service worked with a clinical commissioning group (CCG) to plan and deliver step down bed for patients who did not need to be in acute hospitals.

  • Systems were in place to inform the local hospitals, GPs and others about beds available at the hospital.

  • For those staff who could not attend the team brief a written team brief was circulated, however staff we spoke to on inspection did not know about the team brief.

Well-led

Requires improvement

Updated 23 June 2017

We rated Community health inpatient services as ‘Requires improvement’ for Well-led. This was because:

We found:

  • There was no central vision shared by managers and staff concerning the care and treatment of patients.

  • Governance arrangements were not embedded and were not robust enough to fully monitor quality, performance and patient safety.

  • The hospital did not participate in national audits, but they undertook some local audits, however, there was no actual analysis of audit findings, improvement actions or monitoring.

  • The risk register was not robust and did not identify clear processes for mitigating risks and ongoing monitoring with given time scales.

  • The process for staff to escalate local level ideas and risks was unclear.

However we found:

  • There was clear evidence that information from meetings was shared so all staff were aware. The Hospital Director was visible and staff told us they felt supported and valued by their peers and direct line managers.

  • There was an open culture and staff felt they would be able to raise any concerns however they did not always receive feedback.

  • There was a turnaround plan which identified areas that needed to be developed and improved in all aspects of managing the hospital.

  • Patient feedback was positive and the local population were involved in planning and providing the service.

Checks on specific services

Community health inpatient services

Requires improvement

Updated 23 June 2017