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Archived: Sevenacres (Inpatient Wards)

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All reports

Inspection report

Date of Inspection: 12 July 2011
Date of Publication: 5 September 2011
Inspection Report published 5 September 2011 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

Our judgement

Changes have been made in assessing and monitoring the quality of service provision since our last visit. There is a care plan audit system in place to monitor and make changes to the assessment and planning of a person’s care where necessary.

We have a minor concern that this system is not yet embedded, and that it does not always capture the risks or improvements needed and ensure that action is taken to address this.

On the basis of the evidence provided and the views of the people using the service, we found the service to be compliant with this outcome.

User experience

We did not, on this occasion, speak to people about this outcome, so cannot report what the people using the service said.

Other evidence

Our visit was a follow up to a review undertaken in March 2011 which found areas of non-compliance with this outcome relating to the effectiveness of quality monitoring systems.

Since our last visit in March 2011, the Modern Matron of Sevenacres has put in place an audit system for care records. We looked at people’s records and saw some evidence of this.

There is a weekly care plan audit at the front of all files; this had been completed weekly in most cases. The audit is comprehensive and includes physical observations undertaken, risk assessments and care plans in place, and weight charts, among other checks. In one of the records we looked at the audit had been incorrectly completed, stating that some risk assessments had not been completed on admission when in fact they had. On the back of the page is a section for comments and actions to address issues identified. We saw some records where this had been completed and the issues identified had been addressed. However this was not completed in all cases and we looked at two records where this section was blank. In some cases where it had been filled in, it did not address all of the issues identified in the audit, or did not say who would take action and when. There was no evidence that the identified issues had been addressed in some cases, and in these cases subsequent audits identified the same concerns.

The Modern Matron told us that night staff are responsible for doing the audits, and that they should write identified actions in the diary to handover to day staff. Action should then be taken by the primary nurse for the patient, and would be followed up by the Ward Manager. However this system does not appear to be resulting in the necessary action being taken – or if action is taken it is not always documented.

We spoke to nursing staff about audits. They told us that they had been doing the care plan audits outlined above for a month. One member of staff told us that they had always done reviews of care, and that they asked people if they were happy with their care. One nurse told us that she felt the audits took time away from caring for people, although they were developing new ways of working to reduce the extra work. She gave the example of taking the care plan with her when talking to a patient, so the care plan could be easily updated at the time of the conversation. She also told us that staff were now in groups of three, with one member of night staff and two day staff linked in a group. They would work together on the audits for the patients they were responsible for. She said this system worked really well.

In addition to the care plan audit of each patient’s records, the Modern Matron told us that he had undertaken a random audit of the individual care plan audits. He told us that this had been done the previous week and that he had identified areas for improvement. We looked at a copy of this audit, which was clear and comprehensive. It demonstrated that the individual care plan audits had identified gaps in some patients’ care plans, risk assessments and notes. The audit also notes that in over half of the individual care plan audits reviewed, the audit had not been fully or correctly completed. This is also what we found when we looked at the care plan audits. This demonstrates that, although there is now a process in place for care plan auditing, it is not yet functioning effectively across all three wards, and further work is needed to ensure it is embedded.

We spoke to the Chief Nurse, who had also visited the wards recently and looked at care plans, and she said she had identified similar issues. However she felt that there had been an improvement in monitoring the quality of care and that there was an enthusiasm to get this right within the staff team.

The Modern Matron said that he had discussed the areas for improvement which he had identified with ward managers, and that senior ward staff would