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All reports

Inspection report

Date of Inspection: 4 February 2013
Date of Publication: 19 April 2013
Inspection Report published 19 April 2013 PDF | 82.04 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 looked at the personal care or treatment records of people who use the service, carried out a visit on 4 February 2013, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We talked with people who use the service, talked with staff and reviewed information sent to us by other authorities.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

Our judgement

The provider had a system to regularly assess and monitor the quality of service that people receive. The provider had an improved system in place to identify, assess and manage risks to the health, safety and welfare of patients who use the service.

Reasons for our judgement

There was work in progress that learning from incidents / investigations would take place and appropriate changes would be implemented. The provider took account of complaints and comments to improve the service.

During our last inspection visit to the ward, on 14 August 2012, we found that there were inadequate quality monitoring systems in place to ensure patients were protected from unsafe care and treatment. The provider wrote and told us what remedial action was to be taken to become compliant with the regulation associated with this outcome, outcome 16. We found that there was some delay in improving the auditing of the quality of care, although we found evidence that patients were now safer and had an improved standard of quality of care and treatment.

Since our last inspection visit of 14 August 2012, there has been a change in the management arrangements of Lord Byron ward. Through speaking with staff we found that the change of management has had positive outcomes for patients. This included improved and effective verbal and written communication for all grades of staff. One member of staff said that this improvement meant that patients’ admissions and discharge arrangements were not delayed and also that their inter-hospital appointments were not delayed or missed. Other members of staff who we spoke with said that they provided patients with support, care and treatment in a more organised way and saw the positive health benefits for the patients as a result of the management changes.

During our examination of the three out of 12 sets of patients’ care records we noted that there was a delay in assessing patients’ risks of falls following their admission to the ward. However, in January 2013, the provider had carried out audit of patients’ care record and noted that only 27% of patients’ care records indicated that patients’ risks for falls had been assessed within 24-hours of their admission to the ward. Action plans had been identified to improve upon these failings.

Following the change in management arrangements of the ward, the ward manager explained to us that work was in progress to carry out other audits. These included, but were not limited to, staff hand hygiene practices and carrying out an analysis to determine the causes of why patients fell.

From our examination of patients’ and visitors’ information notice boards, we noted that patients were listened to and action taken in response to their suggestions. This included improving information about the menu choices. Our visit to the ward dining area noted that this action had been carried out.

The ward manager advised us that, since they commenced their employment in September 2012, Lord Byron ward had received only one complaint regarding the inadequate heating of patients’ own rooms. Responsive action was taken to provide supplementary heating. During our visits to patients’ own rooms, we noted that portable heaters were available.