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Inspection report

Date of Inspection: 5 December 2012
Date of Publication: 31 January 2013
Inspection Report published 31 January 2013 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 reviewed all the information we have gathered about Leighton Hospital, looked at the personal care or treatment records of people who use the service, reviewed information sent to us by the provider and carried out a visit on 5 December 2012. We observed how people were being cared for, talked with people who use the service, talked with carers and / or family members and talked with staff.

Our judgement

The provider had an effective system to regularly assess and monitor the quality of service that people receive.

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

Reasons for our judgement

Following our visit we asked The Trust for documents known as the Provider Compliance Assessment (PCA) for this outcome. These describe how the organisation considers it meets the requirements of the regulations. These documents gave a cogent account of how the organisation met its responsibilities and were consistent with the information we gathered during the inspection.

NHS trusts are required to submit adverse incident information to the National Reporting and Learning Service (NRLS) which analyses it and passes information to CQC. One of the indicators looked at is the reporting rate for adverse incidents, where a high rate is considered a positive indicator as it can reflect open culture with good reporting systems. Prior to this inspection we looked at the information we held and noted The Trust to have a particularly low rate of notifications which caused us concern.

When we discussed this issue with senior managers on the day of inspection they were surprised because they considered their reporting rates to be high, something we later noted that they had commented on as positive evidence in their PCA for this outcome. Following the inspection we asked The Trust to provide evidence of this and we also independently obtained information from the NRLS. This information showed that The Trust was consistently recorded as a high reporter being in the top 25% for three of the last four quarters.

When we carried out our inspection visit we spoke to staff on wards 2 and 21b about the arrangements for reporting and leaning from adverse incidents or “near misses”. We were told that incidents were reported using the “IR1 system” which referred to a form that was completed under these circumstances. We understood that this information was held on a specialised computer system know as “Ulysses”.

We asked about the training arrangements for staff to enable them to report incidents and we were told that it was covered in The Trust’s Biennial Mandatory Update (BEMU) programme which all staff attended every two years as well as being covered on induction for all new staff. We looked at the relevant training syllabuses to confirm this and requested training completion figures. The figures showed that training took place as did our conversations with the staff we spoke to..

When we visited Ward 2 we asked the Ward Manager for an example of an adverse incident recently reported by the ward. We were told of an incident involving a medicine overdose in October 2012. We followed this incident through and found that it had been appropriately investigated with the support of the Medicines Management department and that root causes had been identified. We were told that as a result of the investigation staff had received additional training and that feedback had been given to all staff on the ward. We asked staff about this and they recalled the incident and that training they had been given. We also saw that reference was made to the incident in the notes of the ward meeting.

We asked The Trust on the morning of our visit for reports of incidents that had take place on the wards we visited. They were able to provide this at short notice demonstrating their ability to analyse and sort the information held on their Ulysses system.

One of the means that CQC uses to provide information on NHS trusts is to look at mortality outlier figures provided by government and other bodies such as Dr Foster. A mortality outlier is when there is a higher number of deaths for a particular group of patients than might be expected. A higher number is not in itself a cause for concern but should prompt the hospital and others to ask further questions.

These alerts occur throughout the year and CQC often speaks to trusts to ask for a report and explanation of the figures. This might result in the issue being judged as no concern or the trust might notice the opportunity for improvement and produce an action plan. We gain assurance that action plans are i