The Care Quality Commission (CQC) has published a report following an inspection of medical services at Kettering General Hospital NHS Foundation Trust.
CQC inspected medical services at the trust in May due to concerns around the safety of services regarding patient falls.
Following the inspection, the trust was issued with a warning notice requiring them to make improvements around the assessment and management of risk, implementation of falls prevention and learning from serious incidents
As a result of the inspection, the overall rating of medical services changed from requires improvement to inadequate.
The trust’s overall rating is unchanged by this inspection. It remains requires improvement.
Bernadette Hanney, CQC’s head of hospital inspection, said:
“Our inspection of medical services run by Kettering General Hospital NHS Foundation Trust found a number of areas where improvements were needed to ensure patients are cared for in a safe and secure environment in order to prevent the risk of falls.
“There have been several serious incidents resulting in harm from falls where a lack of staff knowledge was identified as the cause, yet mandatory falls training was not undertaken until months later.
“It was also concerning that related to this, lessons weren’t being learnt and preventative actions to reduce the risk of people being hurt were not consistently implemented across the service.
“The design and maintenance of the hospital didn’t always keep people safe, with areas like corridors and bathrooms being used as storage spaces which posed a trip hazard.
“However, inspectors did observe improvements on Naseby ward where there had been several serious falls incidents. The number of beds had been reduced which meant staff were better able to use the space to keep eyes on people who were at a high risk of falls.
“The trust knows where we expect to see improvements. We will continue to monitor the service closely to ensure the necessary improvements are made.”
Staff did not effectively deal with specific risk issues to prevent patients from falling. Lying and standing blood pressures were not always recorded for all patients 65 years of age or those with a medical condition that would increase the risk of falling.
Not all patients at risk of falling wore a yellow falls risk wrist band, as required by trust policy with ten out of 18 patients assessed as being high risk not wearing a falls wrist band.
Bed rails were involved in some of the serious incidents where people had been hurt, and inspectors found they were used unnecessarily in six out of the 18 patients reviewed.
Following the inspection, CQC told the trust it must make several improvements, including:
- All staff involved in the care of patients must receive effective training in falls prevention and management
- Staff must be competent in their roles and processes must be in place to assess staff competency
- The trust must ensure environmental risks are appropriately assessed and mitigated
- Effective systems must be in place to assess and mitigate individual patient safety risks, including handovers where patients are transferred
- Effective systems must be in place to identify and share learning from incidents to prevent further incidents from occurring
- Complete and accurate records must be maintained that support effective risk management and describe the care and treatment delivered to patients.
Full details of the inspection are given in the report published on our website.
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