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We are carrying out checks at Chesterfield Royal Hospital. We will publish a report when our check is complete.
All reports

Inspection report

Date of Inspection: 26, 27 November 2013
Date of Publication: 9 January 2014
Inspection Report published 09 January 2014 PDF | 89.32 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)

Not met 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 26 November 2013 and 27 November 2013, observed how people were being cared for and talked with people who use the service. We talked with carers and / or family members, talked with staff, reviewed information given to us by the provider and reviewed information sent to us by local groups of people in the community or voluntary sector. We talked with other regulators or the Department of Health, were accompanied by a specialist advisor and used information from local Healthwatch to inform our inspection.

We were supported on this inspection by an expert-by-experience. This is a person who has personal experience of using or caring for someone who uses this type of care service.

Our judgement

The provider had systems in place to regularly assess the quality of service that people received. However, the systems were not always effective in relation to monitoring the quality of the service or assessing and managing the risks to the health and welfare of people using the service.

Reasons for our judgement

We did not intend to look at this standard at this inspection. However, we found evidence that the provider’s systems for assessing and monitoring the quality of the services provided were not always effective. This meant that people using the service were not protected against the risks of unsafe or inappropriate care or treatment.

We found that people using the service were regularly asked for their views about their care and treatment. There was also regular quality monitoring covering all aspects of the service provided, such as infection control, meals, and records. The results were used to inform managers and staff about the standard of the service provided. However, we found a lack of effective action taken to address areas where concerns or deficits were identified.

We looked at the monthly audits carried out of inpatient wards against the CQC essential standards of quality and safety. We saw the results for July, August and September 2013 for the inpatient wards we visited. We saw that the results for two wards for 'Records' were significantly worse in September. The audits completed did not always show what was intended to be done to improve things. Remedial actions were sometimes recorded but did not always specify the person responsible for taking the action or the date by which the action was to be completed. Some had details of the issues observed, rather than a description of the action to be taken. For instance, one stated, "Not all care plans clearly indicate level of support required. Nursing evaluations do no (sic) reflect whether or not adequate nutrition has been provided." Another stated, "Inconsistent hours on essential rounding chart." The two wards had action plans in place to address these results. However, the action plans were not SMART – that is, not specific, measurable, attainable, relevant and timely. In addition, the action plans did not address all of the deficits identified.

We looked at the results of the ward assurance audits for the inpatient wards we visited. These checked a sample of patients’ notes and other records and were carried out monthly. The audit used a green, amber or red rating to indicate the standard achieved. We saw that two wards we visited had scored red for some aspects of documentation for the previous three months. However, the action plans in place did not always address these areas. We saw that data from the ward assurance audits were presented to the provider’s Quality Delivery Group in October 2013. Four areas were highlighted in relation to the introduction of new documentation, sharing good practice, clinical supervision and staff awareness of standards.

During our last inspection we reviewed the provider's audit of Do Not Attempt Resuscitation (DNAR) forms carried out in April 2013. DNAR forms are used to record the reasons why and how a decision has been made not to attempt cardiopulmonary resuscitation for a specific person. The audit concluded that documentation of the involvement of patients, relatives, and multi-disciplinary team members remained poor and there was little consistency in the completion of the forms. The provider carried out a further audit in June 2013. This found that the forms were not always fully completed in line with national guidance. The audit report commented that some of the findings were worse than previous audits and that, "Our recommendations are much the same as they have been in recent years." This indicated that action taken had not been effective in addressing the issues found. We spoke with the provider’s Head of Clinical Governance who told us that further action had been taken. This included more audits and reminding doctors of their responsibilities in completing the forms.

The provider recently commissioned an independent review of its quality governance and is putting in place new ways of working to address the findings of the review.