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Inspection report

Date of Inspection: 15 March and 13 April 2011
Date of Publication: 6 June 2011
Inspection Report published 6 June 2011 PDF

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Before people are given any examination, care, treatment or support, they should be asked if they agree to it (outcome 2)

Meeting this standard

We checked that people who use this service

  • Where they are able, give valid consent to the examination, care, treatment and support they receive.
  • Understand and know how to change any decisions about examination, care, treatment and support that has been previously agreed.
  • Can be confident that their human rights are respected and taken into account.

How this check was done

Our judgement

People who use services usually give valid consent to the examination, care and treatment they receive, but procedures to gain consent from adults without the capacity to give consent are not always followed.

User experience

We visited the outpatient department and surgical ward where we spoke with staff and patients and looked at patient information and patient records. All the patients we spoke with told us they had been very well informed about their surgery or other treatment through written and verbal information, before giving their consent. They also confirmed that they knew they could change their minds at any time.

The patient records we looked at documented that the doctor had explained the risks and benefits of a procedure during the outpatient appointment. We saw that consent forms were completed and signed. Patients told us everything was explained to them; one described how he was presented with three options for treatment, and he decided on one which involved surgery. He said, “…it was all made very clear.” CQC’s Survey of Adult Inpatients in the NHS (April 2011) found that across the trust, patients said that staff did not always explain or answer their questions about procedures and operations, but overall, patients were positive about being informed about their condition and getting answers they could understand.

Other evidence

It is a general legal and ethical principle that valid consent must be obtained before starting treatment, investigation, or personal care. For consent to be valid, it must be given voluntarily by an appropriately informed person who has the capacity to consent to the intervention in question. The trust’s Policy for Consent to Examination or Treatment is up to date and provides a framework for employees to follow when seeking consent for treatment, procedures or clinical photography relating to patient care. All the staff we spoke with knew where to find the policy, and receive emails that tell them about any changes. They also attend a formal update session each year.

Nursing staff told us they gain verbal consent from patients before providing care such as helping with hygiene or taking blood. Senior staff told us they monitor this informally by being present in the departments and observing the care their staff provide. We did not see any verbal consent recorded in nursing notes but in all the physiotherapy and occupational therapy treatment notes we looked at, patients’ verbal consent to treatment was recorded. Staff told us that signed consent to an operation is usually taken by the consultant in outpatients. When the patient attends for surgery, the ward staff make sure the patient has understood the procedure, including the potential benefits and risks, and then sign the consent form to confirm the patient has given valid consent.

We asked staff about gaining consent from children and adults who do not have the capacity to consent to the procedure. They described appropriate courses of action in line with Department of Health guidance and the trust’s consent policy. There is a special consent form used when adults are unable to consent, which enables recording of taking a decision in the best interests of the patient under the Mental Capacity Act (1995). The Act protects people who lack capacity to make a decision for themselves because of permanent or temporary problems such as mental illness, brain injury or learning disability. The consent form contains clear guidance on taking consent in this case and documents the decision making process including the views of the patient, their family or carers, and the health professional involved.

When we looked at patient case notes on the medical wards, we found that mental capacity was not part of the assessment on admission; none of the case notes recorded an assessment of capacity to make decisions, although some contained conflicting information about confusion. One person’s case notes contained cognitive screening tools (Mini Mental State Examination and Montreal Cognitive Assessment), used to check if people have problems like dementia, but these were not completed, nor referred to in the medical notes, indicating that there had been no formal assessment of the patient’s mental state.

There was nowhere in the care plans to record issues like a Power of Attorney or the need for an advocate. Nursing staff told us mental capacity was assessed by a social worker, occupational therapist (OT) or a doctor. The trust provided evidence that a range of medical, nursing, allied health and support staff had received training in the Mental Capacity Act in the last year, but not the proportion of staff still to receive training. The trust told us that further training is scheduled over the next few months and there is an e-learning resource available on the trust intranet.

We observed one patient in a deep-seated chair, often called a “fall out chair” because it prevents the person falling out; in effect it prevents them from getting out of the chair un-aided, and is used to maintain the safety and comfort of a confused person who may wander, or someone with poor postural control. It is a form of physical restraint and its use should be assessed as in the patient’s best interests. We looked at this patient’s notes and saw that she had a history of falls, dementia and Parkinson’s