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Archived: St Mary's Hospital

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Inspection report

Date of Inspection: 16 July 2013
Date of Publication: 15 August 2013
Inspection Report published 15 August 2013 PDF | 79.64 KB

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 16 July 2013, 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 to regularly assess and monitor the quality of service that people received.

Reasons for our judgement

We received no specific comments from patients about assessing and monitoring the quality of service at the hospital. Observation of staff showed that they worked using safe practices, for example, moving people using manual handling equipment. Staff told us, and records confirmed that appropriate and relevant training was available and undertaken, and staff felt supported.

Patients could make their views known via national systems such as NHS Choices or via national and in house inpatient and outpatient surveys. We also heard that the patient experience, such as results of the Department of Health Friends and Family test (F&FT) (instigated by the trust before the required deadline), which asks for feedback from patients about their care and treatment, was used to help inform the trust board of what patients thought of their care and treatment.

We were told about the range of quality monitoring systems in place to review the care and treatment offered at the hospital. These included a range of clinical and health and safety audits, monitoring of patient feedback, staff training and reviews of all accidents, incidents and complaints. There were committees in place to monitor risks, which included medical advisory, clinical governance and health and safety committees.

Each week the nurse in charge of the ward was required to complete checks on the ward. For example, how tidy and clean the ward was, whether infection control equipment was in place and working appropriately and checking of medical equipment. These records were available to the staff and patients on the notice board. The hospital matron also carried out a monitoring visit to the ward and completed a written record evidencing the findings from these visits.

Patients had been requested to take part in the quality monitoring exercises. We were shown records, which identified the views of patients. For example regarding the cleanliness of the ward, how well staff followed the hand hygiene procedures, the food provided, the noise, response by the staff to the call bells, privacy and support from staff.