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Archived: Claremont Hospital

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Inspection report

Date of Inspection: 15 February 2011
Date of Publication: 4 March 2011
Inspection Report published 4 March 2011 PDF

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People should be cared for in safe and accessible surroundings that support their health and welfare (outcome 10)

Meeting this standard

We checked that people who use this service

  • Are in safe, accessible surroundings that promote their wellbeing.

How this check was done

Our judgement

We found people who use services and people who work in the location are in safe, accessible surroundings that promote their wellbeing. No gaps in assurance or areas of concern were identified during the assessment of this outcome for this location.

User experience

The hospital extracts monthly patient comments (positive and negative) from the patient surveys and these were submitted as supporting evidence. A small number of examples are set out below relevant to this outcome.

"Dirty carpet at entrance lets Claremont down" (August 2010).

"I felt the en-suite showers badly designed and need alteration to stop flooding" (September 2010).

"TV remote was missing on admission. Replacement TV provided within acceptable time" (October 2010).

"Overall atmosphere and ambience very calming" (October 2010).

"Very clean, tidy and pleasant environment" (November 2010).

"General atmosphere throughout the hospital was so friendly and comforting" (November 2010).

Other evidence

The provider declared compliance with this outcome at this location at registration with CQC October 2010.

As part of the assessment of this location the provider submitted a 'provider compliance assessment' record for this outcome. The hospital set out information, which explained in detail how this outcome was being met, with references to supporting evidence. It is not possible to outline all the information provided. The inpatient accommodation is largely single room with en-suite facilities. There is some multi-occupancy rooms but the provider reports that it provides single sex accommodation. The hospital explained there are a range of systems and processes are in place to ensure various parts of this outcome are being met in relation to health and safety, risk assessment, and contracts to ensure maintenance of the estate and ongoing compliance with the Disability Discrimination Act. We found no gaps in assurance in relation to the review of this self assessment by the hospital.

The hospital also voluntarily provided additional supporting evidence to demonstrate compliance with this outcome. For example, a range of risk and other completed assessments was included. A health and safety audit was completed by an external company in November 2010. This identified a number of areas where actions or improvements were necessary.

In November 2010 we received an anonymous concern, which outlined a number of issues in relation to practices within the operating theatre department. Most centred on moving and handling, training of staff (see outcome 14). One concern relevant to this outcome was that no risk assessment had been performed regarding the lifting of heavy instrument trays. We requested a range of information during November 2010 to demonstrate that the allegations had been investigated and actions taken to improve where necessary and the evidence submitted included a risk assessment regarding this matter. The Health and Safety Executive (HSE) conducted its own review regarding this anonymous concern (see outcome 14).

We were concerned that the hospital may not be fully compliant with this outcome so we decided to check the premises for potential areas of non compliance as part of a site visit.

A tour of the premises was conducted during the site visit performed 15 February 2011 and we found no areas that would raise immediate concerns.

On the site visit we found that the moving and handling action plan for the theatre department agreed with the HSE was in the process of being actioned. We viewed the storeroom where issues had been raised regarding the weight of some theatre trays and boxes. Temporary measures have been put in place in relation to moving them until a new way of organisation, categorisation and storage is fully implemented. The provider must ensure this action plan is fully implemented.

We also found that the actions arising out of the external health and safety audit had been actioned during tour of the premises.

The theatre department, though clean did appear cluttered in places though this did not directly limit access to fire escape routes. We talked to the senior theatre practitioner responsible for the wide range of equipment used in that department. The practitioner felt they had reached the limit of storage for operating equipment and there was very minimal space left for any new equipment. This was later discussed with the management team who plan to explore ways to improve space.