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BMI The Blackheath Hospital Good

All reports

Inspection report

Date of Inspection: 30 October 2012
Date of Publication: 18 December 2012
Inspection Report published 18 December 2012 PDF

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

We looked at the personal care or treatment records of people who use the service, carried out a visit on 30 October 2012, observed how people were being cared for and talked with people who use the service. We talked with staff.

Our judgement

The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people using the service and others.

Reasons for our judgement

Our inspection of 31 January 2012 found that the quality assurance arrangements did not identify and address shortfalls in the equipment maintenance programme. The provider told us that they would ensure staff awareness, ownership and responsibilities for equipment maintenance. The arrangements for equipment maintenance and suitability would also be monitored from 05 March 2012.

When we inspected on 30 October 2012, we found that equipment champions were identified in key departments, and had link roles to ensure that the service remained compliant with equipment maintenance, that equipment was fit for purpose, and repairs were carried out promptly. Equipment maintenance records and audits were also in place, which highlighted when repairs and service visits were due, and action was taken accordingly.

Decisions about care and treatment were made by the appropriate staff at the appropriate level. Pre-admission assessments were carried out for all NHS and longer stay patients. The assessments were carried out by a dedicated nursing staff team.

Assessments were completed for all patients on admission for a range of risks including falls, tissue viability and mental health. Appropriate amendments were made to patients' plans of care based on the outcomes of the risk assessments, for example, bed rails may be used to reduce the risks of falls from beds, and a pressure relieving mattress may be used where people may be at risk of developing pressure sores.

There was evidence that learning from incidents and investigations took place and appropriate changes were implemented. Monthly clinical effectiveness meetings took place, and were attended by the ward manager, ward sister and representatives from other hospital departments, such as pharmacy and imaging. Ongoing investigations were discussed at these meetings and action plans were developed and monitored to improve the service.

Monthly summaries of all incidents were disseminated by heads of departments to their teams. This allowed the staff team to have an overview of the types of incidents that had occurred and the preventative measures put in place to reduce them.

An audit schedule was in place, which specified the planned areas for audit in the current year. The area, frequency of audit and the responsible auditor or department were included in the schedule. For example, monthly audits of controlled drugs and drug charts were planned, expected to be led by the pharmacy department.

The provider took account of complaints and comments to improve the service. Patients were encouraged to complete feedback forms prior to their discharge from the hospital. The feedback was anonymous and all the freehand comments were reviewed and shared with the relevant department on a monthly basis.