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North Cambridgeshire Hospital

This service was previously managed by a different provider - see old profile

All reports

Inspection report

Date of Inspection: 5 February 2013
Date of Publication: 27 April 2013
Inspection Report published 27 April 2013 PDF

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 5 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 and talked with staff.

Our judgement

The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people using the service and others.

Reasons for our judgement

Decisions about care and treatment were made by the appropriate staff at the appropriate level. People accommodated in the bay told us that they felt listened to and included in the planning and carrying out of their care and treatment. They told us that all of the medical staff checked with them that they were happy with the care and treatment they received. This was confirmed in the individual records we viewed.

We saw that improvements had been made to the patient experience of being in hospital as a result of the use of the ‘15 Steps Challenge’. The manager told us that the Challenge toolkit helped staff and management to gain an understanding of how people felt about the care provided and to identify the actions that gave them confidence. They explained that it was designed to also help organisations to understand and identify the key components of high quality care that were important to patients, services users and carers from their first contact with a hospital care setting.

The manager showed us that they completed monthly internal audits of record keeping, pressure care, wound management, medication administration, infection control and call bell answer times. They told us that audits were also completed on the number of falls people had on the ward, risk assessments and updated national guidelines. We saw that patient satisfaction questionnaires were given to each person who received care and treatment and that an improvement action plan was compiled from the suggestions and issues of concern highlighted by people. We found that the completed sample of questionnaires we viewed recorded mainly positive comments.

There was evidence that learning from incidents and investigations took place and appropriate changes were implemented. The provider took account of complaints and comments to improve the service. People spoken with told us that they did not have any complaints. We saw information on how to make a complaint on the communal notice board on the ward and in the patient information booklet. The information clearly recorded how people could complain and told them who to contact.

We found that appropriate action had been taken to contain and isolate the suspected Winter Vomiting Virus. We saw that notification of the problem had been prominently displayed on all external doors and that non essential admission to the ward was stopped. The manager told us that the last infection outbreak had been over a year ago. During our review of records we found that where an infection outbreak occurred, investigation was completed to identify the root cause of the infection and action taken to reduce or prevent further occurrences. This meant that people could be assured that whenever an infection occurred that their safety was the priority.

Staff spoken with told us that they generally felt that there was good communication between themselves and their manager. They said that through their manager they had opportunities for them to keep up to date with governance issues and to feedback their comments to the Board. Staff told us that the Chief Executive Officer (CEO) ‘back to the floor’ visits to the ward that were now in place were positive and that this had assisted in ensuring that their concerns had been answered.