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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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Staff should be properly trained and supervised, and have the chance to develop and improve their skills (outcome 14)

Not met this standard

We checked that people who use this service

  • Are safe and their health and welfare needs are met by competent staff.

How this check was done

Our judgement

We found that the location is not fully compliant with this outcome. We are concerned that insufficient numbers of staff have undertaken all the hospital's required annual mandatory training over the last 12 months. We are concerned that the majority of staff working in the ward and theatre departments had not had any form of appraisal within the last 12 months.

User experience

It was not possible to gain the direct views of people who use the service for this outcome.

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 how this outcome was being met, with references to supporting evidence. The hospital also voluntarily provided additional supporting evidence to demonstrate compliance with this outcome. For example, providing proposed training dates for various mandatory sessions for 2011.

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 and training of staff along with two matters that related to outcome eight. In relation to this outcome concerns were raised about moving and handling training and risks along with general mandatory training.

We requested a range of information during November 2010 to demonstrate that the allegations had been investigated and actions taken to improve where necessary. A number of items of concerns were found to have been actioned. We were concerned that uptake of mandatory training was variable (as at 2 December 2010. For example, 85% of staff had received basic life support training but only 52% of staff had received health and safety training. Only 28% of staff had received infection prevention training.

As part of the initial assessment process we contacted other stakeholders and regulatory bodies. The Health and Safety Executive (HSE) conducted its own investigation regarding this anonymous concern which they also received in November 2010. The HSE outlined their investigation specifically in relation to moving and handling in an email to us received 26 January 2011. The HSE Inspector found that appropriate training and measures were now in place in a visit conducted 6 January 2011 and a verbal action plan was agreed with the hospital manager.

We were concerned that the location may not be fully compliant with this outcome in relation to overall staff training uptake so we decided to follow up some of these issues via a site visit.

On the site visit we found that insufficient numbers of staff had received various forms of mandatory training over a 12 month period, though there had been some improvement in the theatre department numbers explained above. Current figures indicated approximately 60 percent of staff have received mandatory infection prevention training in the last 12 months (85% of clinical staff). Fire training has been received by 69% of staff along with 76% of staff for basic life support training. Health and safety has been delivered via e-learning and currently 41% have completed this (though a small number are recorded as partially completed). The figures were reflected in our discussions with a number of staff members. We are concerned that insufficient numbers of staff have undertaken all the hospital's required annual mandatory training over the last 12 months.

We also found that very few staff on both the main ward and theatre department had received any form of appraisal/personal development review within the last 12 months. The hospital's 'financial' year runs from 1st January through to 31st December. Last recorded appraisals had been undertaken for most staff in these areas between mid to late 2009. This was confirmed during our discussions with a number of staff. One staff member in the theatre department explained they had been working there over 18 months and had not had any appraisal completed. Both the ward manager and theatre manager gave reasonable explanations as to why there had been delays to appraisal completion. We are concerned that the majority of staff working in the ward and theatre departments had not had any form of appraisal within the last 12 months.

During the site visit we spoke at length with the ward manager and the theatre manager. The