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Inspection report

Date of Inspection: 10 December 2013
Date of Publication: 8 January 2014
Inspection Report published 08 January 2014 PDF

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

We looked at the personal care or treatment records of people who use the service, carried out a visit on 10 December 2013, observed how people were being cared for and talked with people who use the service. We talked with staff and reviewed information given to us by the provider.

Our judgement

People who use the service, staff and visitors were protected against the risks of unsafe or unsuitable premises.

Reasons for our judgement

The provider had a range of policies and procedures in place to ensure the premises were maintained and monitored safely, for example, the ‘engineering, property maintenance policy manual.’ There was a detailed preventative maintenance plan in place. Emergency contingency plans were also available so that services could be maintained during an emergency such as the loss of electricity or other utility supply. Various environmental and other risk assessments had been completed and reviewed regularly, for example, fire safety. The hospital employed a maintenance team. There was a corporate electronic reporting system 'maintenance management system' (MMS) which allowed members of staff to report all repairs. This meant there were systems and processes in place to ensure risks associated with premises and the environment had been appropriately managed.

We found the hospital had also undertaken a range of detailed monthly checks using the provider’s ‘monthly department workplace tool’ which covered a number of departments within the hospital. Each department had been checked for general housekeeping, machinery/tools/equipment, first aid, personal protective equipment, hazardous substances along with other areas such as risks associated with shelving and racking. We reviewed other documentation which showed various other audit checks and reports had been completed, for example, the ‘safety, health and environment 2012 report and 2013 improvement plan.’ The director of operations explained the hospital also employed additional maintenance staff such as a gardener and a maintenance man who concentrated on ‘quick fix’ jobs so that the other maintenance men could concentrate on larger repairs.

We conducted a full tour of the premises and found they were safe, clean and tidy. We found Mappin ward continued to appear tired in terms of décor, carpeting and fitments with dull lighting in some areas. In contrast, Fulwood ward had been refurbished a few years ago and was bright and airy. The executive director and director of operations explained the provider was investing capital expenditure on the building and equipment. For example, we found the sterile services unit within the operating theatre department had been significantly altered and improved when compared with previous visits. The senior management team were hopeful the provider would shortly approve the refurbishment of Mappin ward.