Dignity and nutrition for older people

Transcription

1 Dignity and nutrition for older people Review of compliance Royal Bolton Hospital NHS Foundation Trust Royal Bolton Hospital Region: Location address: Type of service: North West Minerva Road Farnworth Bolton BL4 0JR Acute Services Publication date: June 2011 Overview of the service: The Royal Bolton Hospital NHS Foundation Trust consists of one hospital. This serves the population of Bolton which is about 263,000. The hospital offers 628 inpatient beds plus 32 day case beds. The hospital provides a wide range of health care services to people of all ages. Page 1 of 16

2 Summary of our findings for the essential standards of quality and safety What we found overall We found that the Royal Bolton Hospital NHS Foundation Trust was meeting both of the essential standards of quality and safety we reviewed but, to maintain this, we suggested that some improvements were made. The summary below describes why we carried out the review, what we found and any action required. Why we carried out this review This review was part of a targeted inspection programme in acute NHS hospitals to assess how well older people are treated during their hospital stay. In particular, we focused on whether they were treated with dignity and respect and whether their nutritional needs were met. How we carried out this review We reviewed all the information we held about this provider, visited wards B3 Complex Care Ward (female) and B4 Complex Care Ward (male) at the Royal Bolton Hospital. During our visit we spoke with eight patients and two relatives. We looked at the health care files for seven patients, interviewed seven members of staff and observed the care and service provided on the wards. In addition we looked at information provided by the Trust. The inspection teams were led by CQC inspectors, two of which have nursing qualifications. The inspection team also included an expert by experience a person who has experience of using services (either first hand or as a carer) and who can provide the patient perspective. Page 2 of 16

3 What people told us Both wards we visited were very busy and provided care in the main to older people. Patients we spoke with were positive about the care they received and the level of involvement they had regarding decisions around their health care treatments. One patient said she was, very happy with staff doing their very best for me. Two patients said they left the detailed discussions about their health care needs to a relative. The visitors we spoke with said they were generally happy with the care their relatives received and they confirmed they were kept up to date about their health. In the main staff promoted patient privacy and dignity. We did observe however one patient requesting assistance and then waiting for 15 minutes before help was provided. Patients spoke positively about the quality, quantity and choices available at meal times. One person with diabetes said she was offered appropriate choices at meal times. Another patient said she always had enough food and the menu always contained something she liked. We were told by one patient that if she missed a meal because she was in, for example x-ray, the staff sent down to the kitchen for a meal upon her return. However health care notes did not always record fully the nutritional assessment and care needs of patients. What we found about the standards we reviewed and how well Royal Bolton Hospital NHS Foundation Trust -HQ was meeting them Outcome 1: People should be treated with respect, involved in discussions about their care and treatment and able to influence how the service is run Overall, we found that the Royal Bolton Hospital NHS Foundation Trust was meeting this essential standard but, to maintain this, we suggested that some improvements were made. Outcome 5: Food and drink should meet people s individual dietary needs Overall, we found that the Royal Bolton Hospital NHS Foundation Trust was meeting this essential standard but, to maintain this, we suggested that some improvements were made. Action we have asked the service to take We have asked the provider to send us a report within 21 days of them receiving this report, setting out the action they will take to improve. We will check to make sure that the improvements have been made. Page 3 of 16

4 What we found for each essential standard of quality and safety we reviewed Page 4 of 16

5 The following pages detail our findings and our regulatory judgement for each essential standard and outcome that we reviewed, linked to specific regulated activities where appropriate. We will have reached one of the following judgements for each essential standard. Compliant means that people who use services are experiencing the outcomes relating to the essential standard. A minor concern means that people who use services are safe but are not always experiencing the outcomes relating to this essential standard. A moderate concern means that people who use services are safe but are not always experiencing the outcomes relating to this essential standard and there is an impact on their health and wellbeing because of this. A major concern means that people who use services are not experiencing the outcomes relating to this essential standard and are not protected from unsafe or inappropriate care, treatment and support. Where we identify compliance, no further action is taken. Where we have concerns, the most appropriate action is taken to ensure that the necessary improvements are made. Where there are a number of concerns, we may look at them together to decide the level of action to take. More information about each of the outcomes can be found in the Guidance about compliance: Essential standards of quality and safety. Page 5 of 16

6 Outcome 1: Respecting and involving people who use services What the outcome says This is what people who use services should expect. 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. What we found Our judgement The provider is compliant There are minor concerns with outcome 1: Respecting and involving people who use services Our findings What people who use the service experienced and told us The wards we visited were very busy with a mix of healthcare professionals visiting patients and health care staff attending to personal care needs. The predominant age of the patients on the wards visited was over 65 years and many were very dependent, with a variety of illnesses. A number of patients were spoken with. All said that their privacy and dignity was protected. Some patients said that they were aware of their treatments and the choices open to them but that they usually left the more detailed information from the doctor for their relative to deal with. Two visitors spoken with confirmed that they had been kept up to date about the health of their relative. One patient said she was happy with the care she received. This patient confirmed that staff spoke with her appropriately and she received attention to her personal care needs whenever she requested it. Another patient said she had been on the ward some weeks and staff at first were not nice to her but she said she was now Page 6 of 16

7 happy with her care and the way she was spoken to. The patient also said that she was not offered choices in relation to her care but it was observed later that staff did offer her choices regarding her personal care and physiotherapy needs. However one patient, during the afternoon visiting period requested the toilet and was informed by a staff member that she would be with him in a minute. The patient waited 15 minutes and continued to shout loudly. Assistance was only provided when an inspector informed staff of the patient s need. We also observed that one staff member, stood at the end of a patient s bed asking another staff member what drink the patient needed. It would have been more appropriate to ask the patient directly what her wishes were. Other evidence The wards we visited were single sex wards set out in bays having between four and nine beds. Due to the communal nature of the wards privacy was compromised when staff were discussing with patients the level of assistance they required. However screening curtains were used when personal care was being delivered. A couple of staff did discuss loudly the personal needs of patients which did reduce the patient s privacy and dignity, but on the whole staff were very respectful to the patients. During the morning personal care was provided to patients, and the staff spoke to patients while they were providing care to let them know what they were doing. Nursing and care staff were overheard asking patients about the type of support and assistance they required with their morning hygiene and what their preferences were in relation to clothing attire. We observed healthcare staff encouraging patients with their independence. For example one patient was visually impaired and although she did receive support she was encouraged to help herself. The patient was told by staff where everything was. Staff checked her regularly, and the patient was able to manage with minimal support. We saw physiotherapists and occupational therapists explaining to patients how they wished to work with the patient. The therapists were professional and respectful. For example one patient was apologising to the physiotherapist for not being able to get out of bed. The physiotherapist was very reassuring, telling the patient she must not apologise, and suggesting other ways for the patient to get out of bed. Time was spent with the patient to ensure she was able to do this. We interviewed a range of staff including a senior nurse, a specialist nurse, healthcare workers, student nurses and housekeeping staff. It was clear that the staff had an understanding of how to ensure privacy and dignity were maintained and they could describe how they enabled patients to be involved in the provision of their care. Each grade of staff member interviewed was clear on their role and responsibilities. For example senior staff said they had a role in monitoring and promoting good practice, whilst junior staff were clear on when and how they would report concerns to a more senior person. Staff had some understanding about promoting equality and diversity and recognised that patients may have different cultural and religious backgrounds. We received mixed responses from staff about having enough time to do their job but in the main they all felt they did their best to provide a good service. We saw Page 7 of 16

8 that staff were very busy but on the whole patients did receive a timely service and staff responded to nurse call bells within a reasonable time. One relative said that they had had to wait on occasion when their parent needed assistance but stated that they realised that many of the patients were poorly and needed care. Another patient commented that he was sick of hearing the nurse call bell ringing. We looked at a number of patient case files including care plans, risk assessments and notes from medical and multi-disciplinary health team members. Assessment information on admission to the hospital was not completed in the majority of files viewed. Information about religious background was completed in the main but references to culture, personal wishes or preferences were not recorded. Some of the care files we saw did contain information provided to the patient about their illness, prognosis and the possible treatment options available. The information we held about the Royal Bolton Hospital NHS Foundation Trust prior to our visit showed that there was a very low risk that they were not meeting this standard. The information we had included details about the quality assurrance systems implemented at the hospital to ensure patients s opinions were listened too and this was used to improve and develop services provided. Results from patient questionnaire were available on the notice board on one of the wards visited. This showed us how well the ward had done from the patient s perspective. We saw that there were comments slips outside each ward which anyone could take and fill in. Our judgement Patients were on the whole positive about their experiences of care and treatment. Patients confirmed that their privacy and dignity was maintained. Staff were knowledgeable about how to include the patients in the decisions around the daily routines of the wards and they showed a good understanding of privacy and dignity. However on occasion staff care practices did not always promote patients dignity. Overall we found that the Royal Bolton Hospital NHS Foundation Trust was meeting this essential standard but to maintain this we suggested some improvements are made. Page 8 of 16

9 Outcome 5: Meeting nutritional needs What the outcome says This is what people who use services should expect. People who use services: Are supported to have adequate nutrition and hydration. What we found Our judgement The provider is compliant There are minor concerns with outcome 5: Meeting nutritional needs Our findings What people who use the service experienced and told us We observed the lunchtime meal service on two wards. On the male ward B4 we arrived at midday and were informed that the lunchtime meal arrived on the ward at 11.30am. However staff on the ward stated that the food arrived very hot and was not actually served until about 11.50am. Generally patients were positive about the meals they received and the choices provided. One relative said that the desserts were always jelly or rice pudding. However menus provided to patients did include a range of choices for main meal and dessert. Another patient confirmed that she was provided with diabetic choices at meal times. One patient stated that she always had enough food, and there was always something she liked. She said that they got elevenses, which was a cup of tea or coffee, but no biscuits or snacks were ever given between meals. At night she had Horlicks, but there was no snack with it. The patient said she always had biscuits in her locker that her family brought in. One patient confirmed that if she missed a meal due to having to go for example to x-ray, then staff sent down to the main kitchen for her meal. Another patient said the food was good and he thought this was down to having a good chef. Another patient said she liked her, porridge sweet and tea with two sugars, and I get it. This patient said there was a varied menu but did not believe it would be a problem if she wanted something else not on the menu. Page 9 of 16

10 The patients we spoke with had not been asked if they found the food satisfactory. We saw that patients on ward B3 appeared to enjoy their meal and they cleared their plates of all the food they received. Other evidence We were told by staff on Ward B3 that they did not currently have a system in place which identified patients who needed assistance with their meals and drinks. They told us that this was because a new method of delivery was used to transport the plated meals to the ward and the red trays used previously did not fit. Ward B4 was trialling a red jug system. This meant that people who needed support or assistance with diet and fluids were recognised by staff therefore the appropriate assistance could be provided. Observations on both wards at the lunchtime meal did show that patients were not asked if they wished to wash their hand nor were they always assisted to sit comfortably before their meal. Two staff members on ward B4 were observed standing over a patient while assisting with the meal. One of these staff members did not attempt to hold a conversation with the patient nor did he explain to the patient what the meal consisted off. In addition this staff member proceeded to hold a conversation with another patient across the bay. Patients on both wards had a diet and fluid intake record kept at the bottom of their bed. Staff recorded the diet and fluids that patients had consumed after the lunch time meal on both wards. However the records of fluids consumed by the patient were not maintained accurately. For example on ward B3 a record of drinks mid morning and at supper were rarely recorded. On ward B4 a check on the records showed that the jugs of water supplied to the patient were not always included in the fluid balance record. This meant that the record could not be relied upon to accurately reflect the number of drinks patients had consumed throughout the day. We saw a smaller folder of information was available on a patient s locker and this contained information about the ward. Patients received a menu list each day from which they could choose what they wanted to eat for their lunch time and evening meal from a varied range of choices. For example the menu identified a soft option, a higher calorie choice and the foods which contributed to the recommendations of eating five portions of fruits or vegetables daily. Information about meal times and feedback comments about the meals were provided on the back of the menu each patient received. We interviewed staff about their understanding of nutrition. Junior care staff were clear on how to monitor and detect when someone was not taking sufficient food and fluids. Staff responses to our questions indicated that they would report to the appropriate person when they had concerns about a patient s diet and fluid intake. We noted that staff training in nutrition had been provided and this appeared to be in accordance with the staff member s role and responsibilities. The staff interviewed were able to explain how they assisted patients with food and drinks and demonstrated a good understanding of how to ensure patient dignity. We saw that a system to ensure patients were not disturbed during meal times (protected mealtimes) was not always adhered to by health care professionals. One staff member was keen on promoting protected meal times because she stated her Page 10 of 16

11 observations were that once a patient was disturbed during a meal then they rarely returned to the meal. A specialist nutrition nurse is employed by the Trust. She stated that each ward had a staff member who was the nutrition link and that study days were held every three months. She also said that national initiatives and staff feedback and ideas on how to improve practice were listened to. Staff said they tried to explain to the patient what food choices there were on the menu but on occasion they made choices for the patient if the patient was unable to state a preference. One housekeeper explained that part of her role was specifically in assisting patients with their dietary choices and she got to know her patients and this helped her to help them choose. We looked at a number of patient case files for patients on both wards. We saw that nutritional assessments were available but we saw that a number of these were not completed fully. For example the patient s weight was not always recorded on admission so it was difficult to determine how the assessment tool was effective if the record of weight as base line to measure a patient s nutritional status was not recorded. A care plan as identified as a requirement of the nutritional assessments were not always recorded. However evidence was available that referrals to Speech and Language Therapy (SALT) and the dietitian were made. We saw that information about the specific consistency of diet and fluids for a patient were posted on the wall behind the patient s bed and the patient did receive food and drink at the prescribed consistency. On both wards records of diet and fluid intake were recorded but it was unclear why a diet and fluid intake record was in place as supporting care plans were not always available. The information we held about the Royal Bolton Hospital prior to our visit showed that there was a very low risk that they were not meeting this standard. A concern was placed on the NHS Choices website in October 2010 and this related to the lack of provision of specialist diets. However one diabetic spoken with at this visit confirmed that she was offered appropriate choices at meal times. A quality assurance assessment carried out in 2010 showed that patients were satisfied with the availability, quality and quantity of food. Our judgement Patients told us they were satisfied with the choice and quality of food provided. Staff interviewed showed a good understanding of the importance of nutrition. Assistance was provided to patients at meal times, and in the main this was appropriate. Nutritional assessments and care planning records were not always fully completed and the recording of patients food and fluid intake were not completed properly. Overall we found that the Royal Bolton Hospital NHS Foundation Trust was meeting this essential standard but to maintain this we suggested some improvements are made. Page 11 of 16

12 Action we have asked the provider to take Improvement actions The table below shows where improvements should be made so that the service provider maintains compliance with the essential standards of quality and safety. Regulated activity Regulation Outcome Treatment of disease, disorder and injury Diagnostic and screening procedures Nursing care 17 1 Respecting and involving people who use services Why we have concerns: On occasion staff care practices did not always promote patients dignity. Patient care assessments and care planning records were not consistently completed to a satisfactory standard so should be improved. Overall we found that the Royal Bolton Hospital NHS Foundation Trust was meeting this essential standard but to maintain this we suggested some improvements are made. Treatment of disease, disorder and injury Diagnostic and screening procedures Nursing care 14 5 Meeting nutritional needs Why we have concerns: On occasion staff care practices did not always promote good outcomes. Nutritional assessments and care planning records were not always fully completed and the recording of patients food and fluid intake were not completed properly. Overall we found that the Royal Bolton Hospital NHS Foundation Trust was meeting this essential standard but to maintain this we suggested some improvements are made. Page 12 of 16

13 The provider must send CQC a report about how they are going to maintain compliance with these essential standards. This report is requested under regulation 10(3) of the Health and Social Care Act 2008 (Regulated Activities) Regulations The provider s report should be sent within 21 days of this report being received. CQC should be informed in writing when these improvement actions are complete. Page 13 of 16

14 What is a 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 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, called Guidance about compliance: Essential standards of quality and safety. CQC licenses services if they meet essential standards and will constantly monitor whether they continue to do so. We formally review services when we receive information that is of concern and as a result decide we need to check whether a service is still meeting one or more of the essential standards. We also formally review them at least every two years to check whether a service is meeting all of the essential standards in each of their locations. Our reviews include checking all available information and intelligence we hold about a provider. We may seek further information by contacting people who use services, public representative groups and organisations such as other regulators. We may also ask for further information from the provider and carry out a visit with direct observations of care. When making our judgements about whether services are meeting essential standards, we 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 or compliance actions, or take enforcement action: Improvement 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. Compliance actions: 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. Enforcement action: 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 14 of 16

15 Dignity and nutrition reviews of compliance The Secretary of State for Health proposed a review of the quality of care for older people in the NHS, to be delivered by CQC. A targeted inspection programme has been developed to take place in acute NHS hospitals, assessing how well older people are treated during their hospital stay. In particular, we focus on whether they are treated with dignity and respect and whether their nutritional needs are met. The inspection teams are led by CQC inspectors joined by a practising, experienced nurse. The inspection team also includes an expert by experience a person who has experience of using services (either first hand or as a carer) and who can provide the patient perspective. This review involves the inspection of selected wards in 100 acute NHS hospitals. We have chosen the hospitals to visit partly on a risk assessment using the information we already hold on organisations. Some trusts have also been selected at random. The inspection programme follows the existing CQC methods and systems for compliance reviews of organisations using specific interview and observation tools. These have been developed to gain an in-depth understanding of how care is delivered to patients during their hospital stay. The reviews focus on two main outcomes of the essential standards of quality and safety: Outcome 1 - Respecting and involving people who use the services Outcome 5 - Meeting nutritional needs. Page 15 of 16

16 Information for the reader Document purpose Author Audience Further copies from Copyright Review of compliance report Care Quality Commission The general public / Copyright (2011) Care Quality Commission (CQC). 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 Website Telephone address Postal address enquiries@cqc.org.uk Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA Page 16 of 16