Review of compliance. Redcar and Cleveland PCT Redcar Primary Care Hospital. North East. Region: West Dyke Road Redcar TS10 4NW.

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1 Review of compliance Redcar and Cleveland PCT Redcar Primary Care Hospital Region: Location address: Type of service: Regulated activities provided: Type of review: Date of site visit (where applicable): Name of site(s) visited (where applicable): North East West Dyke Road Redcar TS10 4NW Acute services; Hospice services; Rehabilitation services; Long term conditions services; Urgent care services Treatment of disease, disorder or injury; Transport services, triage and medical advice provided remotely Planned Review Not applicable Not applicable Date of publication: November 2010 Page 1 of 45

2 Information for the reader Document purpose Review of compliance report Author Care Quality Commission Audience The general public Further copies from / Copyright Care Quality Commission This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Quality Commission Internet address Telephone address Postal address Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA Page 2 of 45

3 Introduction to our review of compliance By law, providers of certain adult social care and health care services have a legal responsibility to make sure they are meeting essential standards of quality and safety. These are the standards that everyone should be able to expect when they receive care. The Care Quality Commission (CQC) has written guidance about what people who use services should experience when providers are meeting essential standards. This is called Guidance about compliance: Essential standards of quality and safety. CQC licenses services if they meet essential standards and we will constantly monitor whether they continue to do so. We formally review a service when we receive information that is of concern and, as a result, decide we need to check whether it is still meeting one or more of the essential standards. We also formally review services at least every two years to check whether they are meeting all of the essential standards in each of their locations. Our reviews include checking all the available information and intelligence we hold about a provider. We may seek more information by contacting people who use services, public representative groups and organisations such as other regulators. We may also ask for more information from the provider, and carry out a site visit with direct observations of care. When we make our judgements about whether services are meeting essential standards, we will decide whether we need to take further regulatory action. This might include discussions with the provider about how they could improve. We only use this approach where issues can be resolved quickly, easily and where there is no immediate risk of serious harm to people. Where we have concerns that providers are not meeting essential standards, or where we judge that they are not going to keep meeting them, we may also set improvement actions, compliance actions or take enforcement action: Improvement actions Compliance actions Enforcement actions These are actions a provider should take so that they maintain continuous compliance with essential standards. Where a provider is complying with essential standards, but we are concerned that they will not be able to maintain this, we ask them to send us a report describing the improvements they will make to enable them to do so. These are actions a provider must take so that they achieve compliance with the essential standards. Where a provider is not meeting the essential standards, but people are not at immediate risk of serious harm, we ask them to send us a report that says what they will do to make sure they comply. We monitor the implementation of action plans in these reports and, if necessary, take further action to make sure that essential standards are met. These are actions we take using the criminal and/or civil procedures in the Health and Adult Social Care Act 2008 and relevant regulations. These enforcement powers are set out in the law and mean that we can take swift, targeted action where services are failing people. Page 3 of 45

4 How this report is presented On page 5 below, there is a summary that shows whether the essential standards about quality and safety that were checked during this review of compliance are being met. The section on each outcome is set out in this way: Outcome XX: The outcome number and title Judgement Whether the service provider is compliant, or whether we have minor, moderate or major concerns about their compliance Following the summary, there is a detailed section on the outcomes for each of the essential standards that we looked at. The evidence that we used when making our judgements for each one is set out in the following way: Outcome XX (number): Outcome title Details of the outcome, taken from our Guidance about compliance: Essential standards of quality and safety. What we found for the Outcome Our judgement Our judgement about whether the <service/provider> meets the outcome described in the Guidance about compliance: Essential standards of quality and safety, or whether there are minor, moderate, or major concerns in relation to compliance. Our findings A summary of the evidence and findings used to reach our judgement, related to regulated activities as appropriate. At the end of the report you will find details of: Any improvement and/or compliance action(s) that the service provider should make to maintain or achieve compliance with the essential standards of quality and safety. Any formal enforcement action that we are taking against the service provider. Page 4 of 45

5 Summary of findings for the essential standards of quality and safety The table below shows the judgement that we reached for each of the essential standard outcomes that we reviewed. Outcome Judgement 1: Respecting and involving people who use services Compliant 2: Consent to care and treatment Minor concern 4: Care and welfare of people who use services Compliant 5: Meeting nutritional needs Compliant 6: Cooperating with other providers Compliant 7: Safeguarding people who use services from abuse Compliant 8: Cleanliness and infection control Compliant 9: Management of medicines Compliant 10: Safety and suitability of premises Compliant 11: Safety, availability and suitability of equipment Minor concern Page 5 of 45

6 12: Requirements relating to workers Compliant 13: Staffing Compliant 14: Supporting workers Compliant 16: Assessing and monitoring the quality of service provision Minor concern 17: Complaints Compliant 21: Records Compliant Summary of key findings: The purpose of the planned review was to carry out a full check of compliance with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, focussing on the outcomes for the 16 essential standards most directly related to the quality and safety of care. This included an assessment of the provider s progress against the action plans they had submitted at the point of registration for one regulation for which they had declared non-compliance. This review involved assessment of information already held by the Care Quality Commission and further review of information requested from the provider. We found evidence that people who had used services at Redcar Primary Care Hospital had understood the care, treatment and support choices available to them and had found that their privacy and dignity had been respected. Regarding consent to care and treatment, we found that although there were procedures in place, there was not enough available evidence that demonstrated the procedures to get valid consent were followed in practice, monitored and reviewed. Therefore minor concerns exist and compliance action is required by the provider. We found that people who used the services were generally satisfied with the care they had received and their involvement in decisions about their treatment and care. The organisation could demonstrate that peoples' needs had been assessed and care had been planned and delivered. Page 6 of 45

7 We found evidence that people who use the services were supported to have adequate nutrition and hydration. We found evidence that the provider cooperates with other providers to support the delivery of safe and coordinated care and treatment and effective safeguarding processes were in place which protect people who use the services from abuse. Following an unannounced inspection of infection control within the organisation in June 2010, we found no cause for concern regarding the provider s compliance with the regulation on cleanliness and infection control. We found that the organisation had systems in place which were monitored and reviewed so people who used the service received their medicines appropriately and safely. We found evidence that the premises were safe, suitable and accessible. We found effective systems were in place to ensure the safety, availability and suitability of equipment, with the exception of responding to alerts received from the central alerting system. These include concerns regarding equipment. Although these were recorded, they were not always acted upon in a timely fashion. Therefore minor concerns exist and compliance action is required by the provider. We found no evidence that recruitment and selection procedures for workers were not effective. Relevant checks have been carried out, where necessary, to ensure staff are registered with the relevant professional regulator or professional body. The organisation had declared non-compliance at the point of registration under the Health and Social Care Act 2008 regarding staffing. In particular, this related to a lack of a needs analysis or risk assessment as the basis for deciding sufficient staffing levels. An action plan had been put in place and evidence was presented which demonstrated the health and welfare needs of people who use the services are met by sufficient numbers of appropriate staff. We found evidence that the needs of people who use the service are met by competent staff. We found effective systems were in place to assess and monitor the quality of service provision, with the exception of managing risks in relation to the alerts received from the central alerting system. Although these were recorded, there was insufficient evidence to demonstrate they were always acted upon in a timely fashion. Therefore minor concerns exist and compliance action is required by the provider. We found evidence that comments and complaints were listened to and acted on effectively. We found that personal records are accurate, fit for purpose, held securely and kept confidential. Page 7 of 45

8 What we found for each essential standard of quality and safety The section below details the findings and our regulatory judgement for each essential standard and outcome that we reviewed, linked to specific regulated activities where appropriate. Further detail about each of the outcomes described below can be found in the Guidance about compliance: Essential standards of quality and safety. Page 8 of 45

9 Outcome 1: Respecting and involving people who use services People who use services: Understand the care, treatment and support choices available to them. Can express their views, so far as they are able to do so, and are involved in making decisions about their care, treatment and support. Have their privacy, dignity and independence respected. Have their views and experiences taken into account in the way the service is provided and delivered. Those acting on behalf of people who use services: Understand the care, treatment and support choices available to the people who use services. Can represent the views of the person using the service by expressing these on their behalf, and are involved appropriately in making decisions about their care, treatment and support. This is because providers who comply with the regulations will: Recognise the diversity, values and human rights of people who use services. Uphold and maintain the privacy, dignity and independence of people who use services. Put people who use services at the centre of their care, treatment and support by enabling them to make decisions. Provide information that supports people who use services, or others acting on their behalf, to make decisions about their care, treatment and support. Support people who use services, or others acting on their behalf, to understand the care, treatment and support provided. Enable people who use services to care for themselves where this is possible. Encourage and enable people who use services to be involved in how the service is run. Encourage and enable people who use services to be an active part of their community in appropriate settings. Page 9 of 45

10 What we found for Outcome 1 Our judgement The provider is compliant with Outcome 1: Respecting and involving people who use services Our findings The trust declared compliance with this outcome at the point of registration under the Health & Social Care Act The Care Quality Commission s quality and risk profile suggested that there was no concern and no recent change to the risk of non-compliance. The quality and risk profile is an internal document that contains a collection of data held by the Commission from internal and external sources. This data helps us determine whether a provider is at risk of non-compliance. No concerning information has been received by the Care Quality Commission from relevant stakeholders. Redcar and Cleveland local involvement network (LINk) reported they have an excellent relationship with Redcar and Cleveland PCT. Members of the Redcar and Cleveland LINk have been involved through previous Patient and Public Involvement mechanisms in the planning of the Redcar Primary Care Hospital and have continued to be involved in projects since it opened in December 2009, for example, improving signs in and around the hospital. People who responded to a survey undertaken by the LINk in January 2010 said that staff responded to their needs, made them feel the centre of the care and treated them with dignity and respect. The LINk has a formal working agreement with the trust and has involved the LINk in projects such as the design of the new NHS Redcar and Cleveland website. A patient satisfaction survey, undertaken by the organisation and entitled 'Have your say', showed that 99.2% of respondents felt they were treated with dignity and respect and 94.9% felt fully involved in decisions about their treatment or care. Page 10 of 45

11 Outcome 2: Consent to care and treatment People who use services: Where they are able, give valid consent to the examination, care, treatment and support they receive. Understand and know how to change any decisions about examination, care, treatment and support that has been previously agreed. Can be confident that their human rights are respected and taken into account. This is because providers who comply with the regulations will: Have systems in place to gain and review consent from people who use services, and act on them. Page 11 of 45

12 What we found for Outcome 2 Our judgement There are minor concerns with Outcome 2: Consent to care and treatment Our findings The trust declared compliance with this outcome at the point of registration under the Health & Social Care Act The Care Quality Commission s quality and risk profile did not contain sufficient information to determine their risk of non-compliance. The organisation has a consent policy which sets out requirements regarding consent. This included meeting the requirements of the Mental Health Act 1983, the Mental Capacity Act 2005 and the Children Act The policy specifies that all clinical areas must undertake an annual audit to ensure that clinical staff are aware how to access the policy, have read the policy, are aware of procedures in their area requiring written consent and ensure written consent forms are being completed appropriately. The organisation provided examples of where consent had been incorporated into care records or electronic systems, however we found there was insufficient evidence provided by the organisation to demonstrate that the procedures to get valid consent are followed in practice, monitored and reviewed, for example, no audits have been undertaken to determine whether the procedures to get valid consent are followed in practice. This is a concern as people who use services may not be giving consent to care and treatment, where it is appropriate and they are able. There is no specific training regarding consent, however the issue of consent to care and treatment is included in relevant training courses, for example, immunisation and vaccines training, mental capacity act awareness training. Records demonstrated 96.7% of applicable staff had received mental capacity act awareness training. The organisation undertook a patient satisfaction survey, entitled 'Have your say'. This showed that 94.9% of respondents felt fully involved in decisions about their treatment or care. A further 4.1% were not sure or felt this did not apply to them. There are no records of complaints or concerns regarding consent. Page 12 of 45

13 Outcome 4: Care and welfare of people who use services People who use services: Experience effective, safe and appropriate care, treatment and support that meets their needs and protects their rights. This is because providers who comply with the regulations will: Reduce the risk of people receiving unsafe or inappropriate care treatment and support by: o assessing the needs of people who use services o planning and delivering care, treatment and support so that people are safe, their welfare is protected and their needs are met o taking account of published research and guidance o making reasonable adjustments to reflect people s needs, values and diversity o having arrangements for dealing with foreseeable emergencies. Page 13 of 45

14 What we found for Outcome 4 Our judgement The provider is compliant with Outcome 4: Care and welfare of people who use services Our findings The trust declared compliance with this outcome at the point of registration under the Health & Social Care Act The Care Quality Commission s quality and risk profile suggested that there was no high level of concern and no recent change to the risk of noncompliance. No concerning information has been received by the Care Quality Commission from relevant stakeholders. People who responded to a survey undertaken by the LINk in January 2010 said that staff explained ongoing care, for example discussed their care plan, referral to another service and follow-up appointments. This supported the results of a patient satisfaction survey undertaken by the organisation in 2009 which showed 94.9% of respondents felt fully involved in decisions about their treatment and/or care. A further 4.1% of respondents were either not sure or felt this did not apply to them. Audits have been undertaken by the organisation to ensure that clinical risk assessment tools have been completed to identify and address risks. These include individual assessments of the risk of developing pressure sores. An audit of records undertaken by the organisation demonstrated people who use the services had a care plan or treatment goals identified. The organisation has plans in place to deal with foreseeable emergencies, for example major incident plans. Page 14 of 45

15 Outcome 5: Meeting nutritional needs People who use services: Are supported to have adequate nutrition and hydration. This is because providers who comply with the regulations will: Reduce the risk of poor nutrition and dehydration by encouraging and supporting people to receive adequate nutrition and hydration. Provide choices of food and drink for people to meet their diverse needs making sure the food and drink they provide is nutritionally balanced and supports their health. Page 15 of 45

16 What we found for Outcome 5 Our judgement The provider is compliant with Outcome 5: Meeting nutritional needs Our findings The trust declared compliance with this outcome at the point of registration under the Health & Social Care Act The Care Quality Commission s quality and risk profile suggested that there was no high level of concern and no recent change to the risk of noncompliance. No concerning information has been received by the Care Quality Commission from relevant stakeholders. Assessment by the Patient Environment Action Team (PEAT) showed that the hospital performed as expected or much better than expected in relation to food and food services at Redcar Primary Care Hospital. Page 16 of 45

17 Outcome 6: Cooperating with other providers People who use services: Receive safe and coordinated care, treatment and support where more than one provider is involved, or they are moved between services. This is because providers who comply with the regulations will: Cooperate with others involved in the care, treatment and support of a person who uses services when the provider responsibility is shared or transferred to one or more services, individuals, teams or agencies. Share information in a confidential manner with all relevant services, individuals, teams or agencies to enable the care, treatment and support needs of people who uses services to be met. Work with other services, individuals, teams or agencies to respond to emergency situations. Support people who use services to access other health and social care services they need. Page 17 of 45

18 What we found for Outcome 6 Our judgement The provider is compliant with Outcome 6: Cooperating with other providers Our findings The trust declared compliance with this outcome at the point of registration under the Health & Social Care Act The Care Quality Commission s quality and risk profile suggested that there was a low level of concern and no recent change to the risk of noncompliance. No concerning information has been received by the Care Quality Commission from relevant stakeholders. The trust demonstrated cooperating with other providers when they responded to information requests by the Care Quality Commission regarding the implementation of the Mental Capacity Act and specifically those aspects relating to the deprivation of liberty. They reported collaborative working with the respective local authorities on Teeside and the progressing of partnership agreements with each Local Authority. The agreements enable NHS bodies and local authorities to delegate or cooperate in functions and resources. Joint project posts have ensured implementation of the requirements relating to deprivation of liberty safeguards across the PCT and local authorities. We found information sharing protocols to be in place, for example a Tees-wide confidential inquiry protocol. This illustrates how and when information is shared between partner organisations. An audit of records undertaken by the trust demonstrated care records contained information such as the patient's details, medical history, allergies. It also demonstrated information from the source of referral is received. During no incidents relating to transfer of care or discharges were recorded. Page 18 of 45

19 Outcome 7: Safeguarding people who use services from abuse People who use services: Are protected from abuse, or the risk of abuse, and their human rights are respected and upheld. This is because providers who comply with the regulations will: Take action to identify and prevent abuse from happening in a service. Respond appropriately when it is suspected that abuse has occurred or is at risk of occurring. Ensure that Government and local guidance about safeguarding people from abuse is accessible to all staff and put into practice. Make sure that the use of restraint is always appropriate, reasonable, proportionate and justifiable to that individual. Only use de-escalation or restraint in a way that respects dignity and protects human rights, and where possible respects the preferences of people who use services. Understand how diversity, beliefs and values of people who use services may influence the identification, prevention and response to safeguarding concerns. Protect others from the negative effect of any behaviour by people who use services. Where applicable, only use Deprivation of Liberty Safeguards when it is in the best interests of the person who uses the service and in accordance with the Mental Capacity Act Page 19 of 45

20 What we found for Outcome 7 Our judgement The provider is compliant with Outcome 7: Safeguarding people who use services from abuse Our findings The organisation declared compliance with this outcome at the point of registration under the Health & Social Care Act The Care Quality Commission s quality and risk profile suggested that there was no high level of concern and no recent change to the risk of noncompliance. No concerning information has been received by the Care Quality Commission from relevant stakeholders. The organisation has policies and procedures to be followed in practice for the management of alleged abuse. These policies have been developed collaboratively with other stakeholders across Teesside. Staff can access the policies and procedures on the trust intranet. Audits have been undertaken which demonstrated compliance with the procedures. In addition, we found a safeguarding training policy was in place. We found that the percentage of applicable staff who have attended relevant training is excellent. Almost all relevant staff have received safeguarding training as part of the induction process; other staff have received the appropriate level of child protection training and protection of vulnerable adult training. The organisation also reported that nurses and health care assistants had recently attended an update day which included a session on adult protection. The organisation has designated leads in safeguarding for both children and adults. These individuals work across the organisation providing advice and support to all staff to ensure they are aware of how to identify signs and raise concerns and are supported through this process. Safeguarding 'champions' have also been identified across the organisation. They help ensure safeguarding issues are communicated at service level. The organisation reported that leaflets and posters are in place to ensure service users are aware of the procedure for raising any concerns. The organisation has an effective incident reporting system. We saw evidence that incidents, concerns and complaints that have the potential to become an abuse or safeguarding concern were reported, monitored and reviewed. We found evidence that multi-agency planning meetings have been held where safeguarding concerns have been identified and plans developed to ensure the safety of the service user and to plan future care needs. We also found evidence that the organisation works collaboratively with other agencies in relation to safeguarding matters. The executive lead for safeguarding within the organisation participates in the local safeguarding children's board and the Tees-wide adult safeguarding board meetings. Collaborative polices have been developed. The organisation has systems in place to ensure effective internal communication regarding safeguarding concerns. The organisation has identified leads regarding the Mental Capacity Act 2005 Deprivation Page 20 of 45

21 of Liberty Safeguards. The Care Quality Commission has not received any notifications of applications for the deprivation of liberty from the organisation. Page 21 of 45

22 Outcome 8: Cleanliness and infection control Providers of services comply with the requirements of regulation 12, with regard to the Code of Practice for health and adult social care on the prevention and control of infections and related guidance. Page 22 of 45

23 What we found for Outcome 8 Our judgement The provider is compliant with Outcome 8: Cleanliness and infection control Our findings The trust declared compliance with this outcome at the point of registration under the Health & Social Care Act The Care Quality Commission s quality and risk profile suggested that there was no concern and no recent change to the risk of non-compliance. No concerning information has been received by the Care Quality Commission from relevant stakeholders. In June 2010, CQC undertook an unannounced inspection of infection control within the PCT. We analysed information on how the trust manages infection prevention and control, such as its risk registers, the frameworks used to assure the board that plans are happening in practice, and the results of audits. We found no cause for concern regarding the provider s compliance with the regulation on cleanliness and infection control. Page 23 of 45

24 Outcome 9: Management of medicines People who use services: Will have their medicines at the times they need them, and in a safe way. Wherever possible will have information about the medicine being prescribed made available to them or others acting on their behalf. This is because providers who comply with the regulations will: Handle medicines safely, securely and appropriately. Ensure that medicines are prescribed and given by people safely. Follow published guidance about how to use medicines safely. Page 24 of 45

25 What we found for Outcome 9 Our judgement The provider is compliant with Outcome 9: Management of medicines Our findings The trust declared compliance with this outcome at the point of registration under the Health & Social Care Act The Care Quality Commission s quality and risk profile suggested that there was no high level concern and no recent change to the risk of noncompliance. No concerning information has been received by the Care Quality Commission from relevant stakeholders. A policy for the safe and secure use of medicines and other related polices and guidelines, such as medicines reconciliation on admission to hospital, are available to staff via the intranet. Systems are in place for staff training and almost all relevant staff had attended training regarding the medicines policy. We found evidence that the organisation has systems in place to support the safe use of medicines. Compliance with the policies and guidelines has been checked by regularly auditing practice in relation to medicines, for example antibiotic prescribing, safe and secure use of medicines and waste audit. Actions to improve practice have been identified, however there were no significant areas of concern. The organisation is a member of the Tees-wide medicines management group. It has also established an implementation group to oversee the uptake of National Institute of Clinical Excellence (NICE) guidance. A system is in place for reporting adverse events, incidents and near misses both locally and nationally. For further detail please refer to outcome 16. Safety alerts are received into the organisation through the central alerting system (CAS). We found evidence that medicines related alerts were acted upon in a timely manner. We found evidence that procedures are followed in practice for controlled drugs. Audits of practice have been undertaken. The Controlled Drugs (Supervision of Management and Use) Regulations 2006 come into force in England on 1st January The regulations state that all NHS healthcare providers and independent hospitals must appoint an Accountable Officer to be responsible for the management of controlled drugs and related governance issues in their organisation. The trust has complied with this requirement. The local intelligence network, which is a forum for sharing concerns about the use of controlled drugs, is attended by an appropriate member of the organisation. Page 25 of 45

26 Outcome 10: Safety and suitability of premises People who use services: Are in safe, accessible surroundings that promote their wellbeing. This is because providers who comply with the regulations will: Make sure that people who use services, staff and others know they are protected against the risks of unsafe or unsuitable premises by: o the design and layout of the premises being suitable for carrying out the regulated activity o appropriate measures being in place to ensure the security of the premises o the premises and any grounds being adequately maintained o compliance with any legal requirements relating to the premises Take account of any relevant design, technical and operational standards and manage all risks in relation to the premises. Page 26 of 45

27 What we found for Outcome 10 Our judgement The provider is compliant with Outcome 10: Safety and suitability of premises Our findings The trust declared compliance with this outcome at the point of registration under the Health & Social Care Act The Care Quality Commission s quality and risk profile suggested that there was no high level of concern and no recent change to the risk of noncompliance. No concerning information has been received by the Care Quality Commission from relevant stakeholders. Redcar Primary Care Hospital is a custom built hospital funded through the private finance initiative (PFI) scheme. It opened in December The building met all requirements of the Health and Safety at Work Act 1974, Regulatory Reform (Fire Safety) Order 2005 and Department of Health guidance. Members of the local involvement network (LINk) have been involved in improvements in the signage in and around the hospital and also involved with an inspection regarding compliance with the Disability Discrimination Act (1995). Patient Environment Action Team (PEAT) audits are an annual assessment of inpatient healthcare sites in England with more than 10 beds. The most recent results for Redcar Primary Care Hospital indicated the score for both the environment and privacy and dignity to be 'excellent'. The organisation have issued a declaration stating mixed sex accommodation has been virtually eliminated and sharing with members of the opposite sex will only happen by exception based on a clinical need or when patients choose to share (for instance married couples). As a PFI building all maintenance and inspection and servicing is provided through the contract. Maintenance of the premises and grounds has been undertaken, where necessary, in a timely manner. The contractor has undertaken checks and maintenance on all aspects of the building, for example fire alarm testing, water temperature tests. Fire risk assessments have been undertaken by organisational staff for their service areas and agreed co-ordinated arrangements put into place. The organisation undertook a patient satisfaction survey which indicated the vast majority of patients found the venues to be clean, tidy and easy to get to. Systems are in place to manage risks about the premises between the PCT and the provider organisation. For example, medical gases are installed and maintained through a commissioned contract. The organisation undertook an audit based on guidance from the National Patient Safety Agency regarding oxygen safety. Good practice and actions required were identified and are being implemented. We found arrangements and licences in place for the management of waste. Audits have been undertaken to ensure the correct segregation and storage of waste. We also found that arrangements are in place to meet the Control of Substances Hazardous to Health Regulations 2001 as amended. Security arrangements have been assessed by the Local Security Management Service. Page 27 of 45

28 No current concerns regarding security arrangements were identified. We found that business continuity and major incident plans are in place, emergency response exercises have been undertaken with partner organisations and fire drills and evacuations have been practiced, as appropriate. Page 28 of 45

29 Outcome 11: Safety, availability and suitability of equipment People who use services: Are not at risk of harm from unsafe or unsuitable equipment (medical and nonmedical equipment, furnishings or fittings). Benefit from equipment that is comfortable and meets their needs. This is because providers who comply with the regulations will: Make sure that equipment: o is suitable for its purpose o is available o is properly maintained o is used correctly and safely in line with manufacturers instructions o promotes independence o is comfortable. Follow published guidance about how to use medical devices safely. Page 29 of 45

30 What we found for Outcome 11 Our judgement There are minor concerns with Outcome 11: Safety, availability and suitability of equipment Our findings The trust declared compliance with this outcome at the point of registration under the Health & Social Care Act The Care Quality Commission s quality and risk profile suggested that there was no high level of concern and no recent change to the risk of noncompliance. No concerning information has been received by the Care Quality Commission from relevant stakeholders. Over 95% of staff, where it is applicable to their role, have received training in the use of medical devices. An electronic asset register is maintained which includes online equipment manuals. A medical devices policy and a procurement policy is in place which sets out the organisation's arrangements to ensure that the equipment is safe and appropriate. A medical device group oversees arrangements for ensuring the safe procurement, maintenance and use of equipment. The organisation uses a designated procurement service to ensure equipment being purchased complies with all relevant laws and standards. A service level agreement is in place for the maintenance, inspection and testing of equipment. A planned maintenance programme is in place and regular checks have been undertaken and confirm that all equipment is appropriately maintained. The organisation has systems in place for reporting faults in equipment and demonstrated examples of where action had been taken. Matrons or Senior Nurses undertake regular 'walkabouts'. These include checks that equipment is clean and appropriately stored. Alerts received from external bodies regarding equipment, for example via the central alerting system, are managed centrally. We reviewed information from the organisation and found that although there was a record of the alerts received, there was insufficient evidence that action had been taken in a timely manner. This is a concern as people who use the services may not receive care that has been improved by learning from adverse events, incidents, errors and near misses. There was no evidence of insufficient quantities of equipment being available. Page 30 of 45

31 Outcome 12: Requirements relating to workers People who use services: Are safe and their health and welfare needs are met by staff who are fit, appropriately qualified and are physically and mentally able to do their job. This is because providers who comply with the regulations will: Have effective recruitment and selection procedures in place. Carry out relevant checks when they employ staff. Ensure that staff are registered with the relevant professional regulator or professional body where necessary and are allowed to work by that body. Refer staff who are thought to be no longer fit to work in health and adult social care, and meet the requirement for referral, to the appropriate bodies. Page 31 of 45

32 What we found for Outcome 12 Our judgement The provider is compliant with Outcome 12: Requirements relating to workers Our findings The trust declared compliance with this outcome at the point of registration under the Health & Social Care Act The Care Quality Commission s quality and risk profile suggested that there was no high level of concern and no recent change to the risk of noncompliance. No concerning information has been received by the Care Quality Commission from relevant stakeholders. We found no evidence that recruitment and selection procedures were not effective. Relevant checks have been carried out, where necessary, to ensure staff are registered with the relevant professional regulator or professional body. Page 32 of 45

33 Outcome 13: Staffing People who use services: Are safe and their health and welfare needs are met by sufficient numbers of appropriate staff. This is because providers who comply with the regulations will: Make sure that there are sufficient staff with the right knowledge, experience, qualifications and skills to support people. Page 33 of 45

34 What we found for Outcome 13 Our judgement The provider is compliant with Outcome 13: Staffing Our findings The trust declared non-compliance with this outcome at the point of registration under the Health & Social Care Act The Care Quality Commission s quality and risk profile suggested that there was no high level of concern and no recent change to the risk of non-compliance. No concerning information has been received by the Care Quality Commission from relevant stakeholders. The trust reported that although on a day to day basis clinical matrons ensured that there are sufficient numbers of staff to meet the needs of people who use the service, there was no documented needs analysis and risk assessment to demonstrate the basis for deciding sufficient staffing levels. An external report was commissioned and has been produced. The data is currently being utilised to identify actions required, but does not raise high levels of concern. Additional evidence demonstrated that staffing is being monitored by senior management and any issues raised and addressed appropriately. Business continuity plans are in place and include staffing issues. Staff absences have been monitored, for example sickness rates and the potential impact on service users recognised. Action plans and contingency plans are in place. There is evidence the organisation has effectively responded to changing circumstances in the service. In a patient satisfaction survey undertaken by the organisation, 98.4% of respondents felt that staff spent enough time with them, which suggests sufficient numbers of staff were available to meet the needs of people who use the services. Page 34 of 45

35 Outcome 14: Supporting workers People who use services: Are safe and their health and welfare needs are met by competent staff. This is because providers who comply with the regulations will: Ensure that staff are properly supported to provide care and treatment to people who use services. Ensure that staff are properly trained, supervised and appraised. Enable staff to acquire further skills and qualifications that are relevant to the work they undertake. Page 35 of 45

36 What we found for Outcome 14 Our judgement The provider is compliant with Outcome 14: Supporting workers Our findings The trust declared compliance with this outcome at the point of registration under the Health & Social Care Act No concerning information has been received by the Care Quality Commission from relevant stakeholders. The Care Quality Commission s quality and risk profile suggested that there was no high level of concern and no recent change to the risk of non-compliance. However, it did highlight potential concerns regarding supporting staff identified in the national staff survey from 2009, for example job satisfaction, staff receiving relevant training. We found new staff have received a comprehensive corporate induction. Mandatory or essential training needs have been identified and over 95% of staff have attended the appropriate essential training for their role. Approximtely 60% of staff within the organisation have had an annual appraisal; this was not identified as an issue in the last national staff survey. Over 75% of staff have a personal development plan. A system of 'communication cells' is in place. These are places where teams meet to review performance and agree actions to deliver improvements. Across the organisation, 46 teams have communication cells in place. An action plan is in place to address those issues that were highlighted by the annual staff survey. The organisation has made reasonable adjustments, where necessary, for individual members of staff to be able to carry out their roles. The organisation has designated leads in safeguarding for both children and adults. These individuals work across the organisation providing advice and support to all staff to ensure they are aware of how to identify signs and raise concerns and are supported through this process. Safeguarding 'champions' have also been identified across the organisation. They help ensure safeguarding issues are communicated at service level. Page 36 of 45

37 Outcome 16: Assessing and monitoring the quality of service provision People who use services: Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety. This is because providers who comply with the regulations will: Monitor the quality of service that people receive. Identify, monitor and manage risks to people who use, work in or visit the service. Get professional advice about how to run the service safely, where they do not have the knowledge themselves. Take account of: o comments and complaints o investigations into poor practice o records held by the service o advice from and reports by the Care Quality Commission. Improve the service by learning from adverse events, incidents, errors and near misses that happen, the outcome from comments and complaints, and the advice of other expert bodies where this information shows the service is not fully compliant. Have arrangements that say who can make decisions that affect the health, welfare and safety of people who use the service. Page 37 of 45

38 What we found for Outcome 16 Our judgement There are minor concerns with Outcome 16: Assessing and monitoring the quality of service provision Our findings The trust declared compliance with this outcome at the point of registration under the Health & Social Care Act No concerning information has been received by the Care Quality Commission from relevant stakeholders. The Care Quality Commission s quality and risk profile suggested that there was no high level of concern and no recent change to the risk of non-compliance. However, it did highlight potential concerns regarding reporting to the national reporting and learning system (NRLS) and responding to alerts issued via the Central Alerting System (CAS). We found there was evidence of monitoring of patient outcomes and recognition by the organisation that this would need to be developed further. For example, the musculoskeletal service had piloted the use of the Measure Yourself Medical Outcome Profile (MYMOP) which allows patients to set their own goals in relation to their health and, after treatment, evaluate how they have improved. This showed 92% of patients reported that they had improved following treatment. The organisation demonstrated a commitment to use outcome measures in other parts of the service. The board had identified potential risks to patient safety and taken action to make sure people who use the services were not harmed. Middlesbrough, Redcar and Cleveland Community Services, who provide services within the PCT piloted the use of quality reports. Quality reports will be published annually by NHS organisations and are part of the NHS Quality Framework. This demonstrated the organisational commitment to quality and the involvement of the public, Carers Together, LINks, Clinical Leaders, Commissioners and a Community Services Reference Group. The trust has an electronic quality management system which has modules for incident reporting, complaints, concerns, claims and risks. Reports are regularly produced from these systems to assess and monitor the quality of the services. However, the Organisation Patient Safety Incident Report produced by the National Patient Safety Agency identifies the organisation is in the lowest 25% of reporters of incidents. Organisations that report more incidents usually have a better and more effective safety culture. The trust explained this was due to data transfer issues which have now been resolved. This was supported by information that has been submitted to the Care Quality Commission via the National Reporting and Learning System. The national staff survey from 2009 demonstrated that staff found procedures for reporting errors, near misses or incidents to be effective. An audit of the patient safety culture within the senior leaders has taken place and feedback has been provided to staff. The trust has a compliance committee in place which monitors and has identified issues and escalated these to the board. Appropriate action plans were then put in place. There is an annual audit plan in place and we found evidence this had been implemented. The plan is developed taking into consideration risks identified through the previous years audit, incidents, claims, complaints, user feedback and national requirements. Learning from clinical and other audits and reviews undertaken on a regional or national Page 38 of 45

39 level are also incorporated to ensure that the services have implemented recommendations. For example, the trust took part in the National Audit of the Organisation of Services for Falls and Bone Health of Older People in March There is evidence that issues were identified from the audit and are being addressed, for example falls screening tools being used. An internal audit showed 93% of people who use the service are being screened in accordance with the policy. The use of the screening tools can help improve patient outcomes. We found evidence that incidents are reported, investigated and appropriate action taken to minimise the potential for recurrence. The organisation has a whistleblowing policy in place with identified named individuals that staff can approach. Generic and service specific risk assessments have been undertaken to evaluate risk and ensure appropriate control mechanisms are in place. Clinical risk assessment tools are used by clinical staff to identify specific patient risks such as the falls and pressure sore development. There is a general compliance with local policies in relation to these clinical risk assessments. The levels of compliance are monitored by the trust and action plans are made to address areas where improvement is required. The services at this location have been involved in a recognised programme of continuous quality improvement. The outcomes of the 'Equip for lean programme' were shared with other staff members to promote service improvements. Alerts received from the central alerting system (CAS) are monitored centrally by the organisation. A record of action taken is held by the organisation. However, information from the central alerting system indicated that the organisation had not always responded in a timely manner to the alerts. We reviewed information from the organisation and found that although there was a record of the alerts received, there was insufficient evidence that action had been taken in a timely manner. This is a concern as people who use the services may not receive care that has been improved by learning from adverse events, incidents, errors and near misses. Page 39 of 45

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