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Inspection report

Date of Inspection: 8 March 2011
Date of Publication: 19 August 2011
Inspection Report published 19 August 2011 PDF | 121.79 KB

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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 hold about this provider, carried out a visit on 08/03/2011, checked the provider's records, observed how people were being cared for, reviewed information from people who use the service, talked to staff and talked to people who use services.

Our judgement

The Cassel Hospital has risk management systems and processes in place to ensure that patients benefit from safe, quality care, treatment and support.

User experience

Patients said they were able to contribute their views about the service. They told us that they could use the Patient Experience Tracker (PET) to record their feedback. They also felt that staff asked for their views at the various community meetings that took place and patients said they were confident that they were listened to.

Other evidence

The hospital follows the overall trust integrated system of governance and risk management. The hospital participates in the clinical and quality audit programmes which feed into the monthly performance monitoring processes. The trust has a risk register which comprises local and trust wide risk issues and details how these were managed.

The outcomes of audits were reviewed at service delivery unit clinical governance meetings. These were then reported to the trust clinical governance committee (CGC) and then to the trust board.

The trust had implemented an updated risk management policy and incidents were reported, investigated and where there are ‘lessons to be learnt’ this is shared across the trust through the service delivery unit meetings, newsletters, intranet and an annual conference has also been held.

Staff confirmed that patients were able to use the PET however the response rate was not high as patients were able to raise any issues at the community meetings or with individual staff.