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Inspection report

Date of Inspection: 12 July 2011
Date of Publication: 18 October 2011
Inspection Report published 18 October 2011 PDF | 107.78 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)

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 12/07/2011, observed how people were being cared for, talked to staff and talked to people who use services.

Our judgement

There was evidence that most, but not all, of the concerns raised in our last review of compliance were addressed.

The trust had made significant progress in implementing a new committee and reporting structure at strategic and senior clinical levels of management. The trust had comprehensive governance information and data available to identify areas of concern. We found evidence that reporting processes on patient safety, quality, and risk have become more comprehensive across the divisions. This information provided improved assurance for the quality and trust board committees. There was good evidence provided in some areas that action plans were resulting in improvements for patients including around cancer care waits and radiology reporting. However, there was some evidence that not all issues were systematically addressed at divisional level. There was also limited evidence from minutes that learning of effective approaches was shared across the divisions. In addition, levels of venous thromboembolism assessments across some divisions required improvement.

Overall, we found that the Churchill Hospital was meeting this essential standard but, to maintain this, we suggested that some improvements were made.

User experience

We did not speak to people about requirements relating to this essential standard.

Other evidence

Our last review of compliance of this hospital identified that it was not meeting this essential standard. The concerns from our last compliance review were:

• Reporting arrangements and the quality of information produced to monitor the quality and safety of patient care across the organisation were not effective.

• Lack of a systematic process in place to ensure actions required to improve services were implemented, followed-up and their impact monitored.

In the past nine months, the trust has restructured both its management and committee structure. The trust board approved a revised sub-committee structure in October 2010 and the new committee structure was implemented on 1 January 2011. The board had four subcommittees: the board in committee, the quality committee (to replace the governance committee), the audit committee and the remuneration and appointments committee.

In February 2011, revised terms of reference were approved for the trust management executive. There were eight new sub-committees which included the clinical governance committee which met monthly. The clinical governance committee had comprehensive membership consisting of senior clinical and managerial staff from clinical divisions and other corporate areas. The quality committee (which reports to the board) had quarterly meetings and minutes from the clinical governance committee were tabled on the agenda.

The trust provided evidence of improvements made to reporting processes for clinical governance. Managers of the trust’s six clinical divisions were required from March 2011 to provide monthly reports using a specific template. The template had key areas to be populated relating to patient safety, quality and risk. These were presented as a ‘dashboard’ so that key areas of risk were easily identified. The reports also included details of staffing levels, clinical outcomes and patient experience. Examples of two divisional reports were provided. Minutes of the clinical governance meetings from April to July 2011 showed discussion of the reports by division. There was some evidence of progress being discussed across a range of issues including monitoring of assessments for venous thromboembolism (VTE) and single sex accommodation breaches. However, these discussions focused mainly on reporting results with limited (minuted) discussion of actions taken or evidence that learning was being shared across the divisions.

Quality reports were collated and tabled at both the quality committee and the board. The individual divisional reports were also provided. The minutes of the board meetings showed discussion of the quality reports, including feedback on how the reporting process could be further improved. Other reports on the quality of patient care have been tabled at board meetings over the past 6 months including the infection control annual report, action plans for improving care and ombudsman’s reports. Detailed complaints reports were also provided at the quality committee and board meetings. These documents detailed the analysis of complaints and actions taken in response to complaints including recommendations for learning. Complaints were monitored at divisional level.

Further evidence of progress in improving governance and risk management systems was provided. In July 2010, an independent review of paediatric cardiac care was commissioned by the Strategic Health Authority (SHA) following four deaths after paediatric surgery in a short space of time. The review identified that a number of areas required improvements across the trust, including systems for risk management, clinical governance systems and the management of new clinical staff. The trust developed an action plan following the review. In April 2011, the trust submitted a report that stated that all actions had been completed with three exceptions. Based on a review of documents and discussions with senior management, the SHA panel agreed that progress had been made against the re