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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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The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care (outcome 16)

Meeting this standard

We checked that people who use this service

  • Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.

How this check was done

Our judgement

We found effective systems were in place to assess and monitor the quality of service provision so that people who use services will benefit from safe quality care, treatment and support due to effective decision making and the management of risks to their health, welfare and safety. No gaps in assurance or areas of concern were identified during the assessment of this outcome for this location.

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. We found the hospital has a range of systems and processes available to assess and monitor the quality of service provision. For example, the 'quality strategy' sets out the main examples of measurements used on an ongoing basis. One example from this included an annual survey of consultant user views. We found this had been completed as the provider voluntarily sent the consultant survey which identified 4 broad areas for quality improvements.

Patient questionnaires are issued to all patients attending Claremont hospital. These are all reviewed and analysed to give statistical summaries for a period of time. A further exercise is undertaken to extract monthly patient comments from the surveys which are then discussed at the relevant meeting. (A range of comments from these surveys have been included under some outcomes in this report).

The hospital also voluntarily provided additional supporting evidence to demonstrate compliance with this outcome. It is not possible to outline all this evidence. For example, various annual reports and strategies were provided, including the 'health and safety annual report 2010' which included an outline of the year's events along with risks, opportunities, threats and recommendations. The risk assessment register was provided, which demonstrated identified risks, current risk rating along with the date of next assessment and review.

On the site visit we asked the management team about completion of various audit, including records audit. It was explained that no audit had been completed of patient records over the last 12 months. However, a new records audit process and template was explained, which is due to be rolled out as a monthly audit. This was verified by review of the tool, email communication to department heads and discussion with the ward manager and theatre manager. The management team were also asked how training and appraisal uptake were recorded. A new process of performance indicators (monthly manager's reports) for department heads has been created. We recommended that both these processes should be implemented as soon as possible to further embed the monitoring of quality provision at the hospital.