We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

Transcription

1 Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Warrington Hospital Lovely Lane, Warrington, WA5 1QG Tel: Date of Inspection: 23 January 2013 We inspected the following standards as part of a routine inspection. This is what we found: Consent to care and treatment Care and welfare of people who use services Safeguarding people who use services from abuse Management of medicines Staffing Assessing and monitoring the quality of service provision Records Inspection Report Warrington Hospital March

2 Details about this location Registered Provider Overview of the service Type of services Regulated activities Warrington and Halton Hospitals NHS Foundation Trust Warrington Hospital has 500 in patient beds as well as a range of out-patient services. There is also an accident and emergency department and a maternity service. The hospital is the headquarters of Warrington and Halton Hospitals NHS Foundation Trust and is located to the north of Warrington town centre, close to the M6, M62 and M56 motorways. It is well served by local public transport networks. Acute services with overnight beds Diagnostic and/or screening service Rehabilitation services Urgent care services Assessment or medical treatment for persons detained under the Mental Health Act 1983 Diagnostic and screening procedures Family planning Maternity and midwifery services Surgical procedures Termination of pregnancies Treatment of disease, disorder or injury Inspection Report Warrington Hospital March

3 Contents When you read this report, you may find it useful to read the sections towards the back called 'About CQC inspections' and 'How we define our judgements'. Summary of this inspection: Page Why we carried out this inspection 4 How we carried out this inspection 4 What people told us and what we found 4 More information about the provider 5 Our judgements for each standard inspected: Consent to care and treatment 6 Care and welfare of people who use services 8 Safeguarding people who use services from abuse 10 Management of medicines 11 Staffing 13 Assessing and monitoring the quality of service provision 14 Records 16 About CQC Inspections 17 How we define our judgements 18 Glossary of terms we use in this report 20 Contact us 22 Inspection Report Warrington Hospital March

4 Summary of this inspection Why we carried out this inspection This was a routine inspection to check that essential standards of quality and safety referred to on the front page were being met. We sometimes describe this as a scheduled inspection. This was an unannounced inspection. How we carried out this inspection We reviewed all the information we have gathered about Warrington Hospital, looked at the personal care or treatment records of people who use the service, carried out a visit on 23 January 2013 and observed how people were being cared for. We checked how people were cared for at each stage of their treatment and care, talked with people who use the service, talked with carers and / or family members and talked with staff. We talked with other regulators or the Department of Health. We were supported on this inspection by an expert-by-experience. This is a person who has personal experience of using or caring for someone who uses this type of care service. What people told us and what we found During our inspection we spoke with 18 people including patients, relatives and other visitors in various wards and departments. Most of the feedback we received was positive. We heard comments such as "the staff are brilliant, nothing is too much trouble for them"; "I give them 90%"; and staff are marvellous and "staff have been good." We received very few negative comments about the services. One person felt they had a long wait in the accident and emergency department and another person stated that their food was not always as hot as they liked it." Patients we spoke with told us they were always asked for their permission before care or treatment was given. We found that the hospital had robust procedures in place to ensure that the rights of patient's who did not have capacity to make certain decisions for themselves were protected. Staff members were also aware of the action they would take if they suspected that someone was being abused. We looked at how the hospital managed medicines for patients and we found that they were managed safely and effectively. We also spoke with 10 staff members who told us that staffing levels were adequate as long as people arrived for their shifts. We looked at 18 sets of patient records during our visit and we found that they were not always accurate. Senior managers showed us the plans in place to deal with the shortfalls that the hospital had identified. We will check records again at our next visit. You can see our judgements on the front page of this report. Inspection Report Warrington Hospital March

5 More information about the provider Please see our website for more information, including our most recent judgements against the essential standards. You can contact us using the telephone number on the back of the report if you have additional questions. There is a glossary at the back of this report which has definitions for words and phrases we use in the report. Inspection Report Warrington Hospital March

6 Our judgements for each standard inspected Consent to care and treatment Before people are given any examination, care, treatment or support, they should be asked if they agree to it Our judgement The provider was meeting this standard. Before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. Reasons for our judgement The patients who we asked told us that staff asked for their permission before care or treatment was given. One patient told us "The staff explain what is happening to me and I am asked what I want to happen with my treatment." The patients also told us that they felt involved in their care and that decisions were not made without them. One patient who was going home told us that they had been involved in the plans for aspects of their care to be continued at home. Another patient told us that they were going to another care facility to continue with their rehabilitation after having a stroke. At first this person was not keen to go to this place but we were told that staff had persuaded them in a nice way that this was best. The patient was now in agreement with the staff and stated that they had not been forced to go. In patients' records we saw that consent was recorded for a wide range of interventions including the use of warning signs to alert staff that someone was at risk of falls. This was good example where the need for patients' confidentiality had been balanced with the need to make patients' safe. The Head of Governance told us that that the induction programme for all staff included a session on consent and capacity. We were also shown a list of on going sessions for consent and capacity to ensure that staff were able to update their knowledge. We saw that there was a record kept of all staff who were trained to obtain consent for procedures that they would not undertake themselves. For example a junior doctor would be trained in gaining consent for a procedure that a more senior doctor would carry out. This is referred to as delegated consent. The NHS Litigation Authority (NHSLA) is a Special Health Authority that handles negligence claims and works to improve risk management practices in the NHS. It manages a clinical negligence scheme for trusts, similar to that of a mutual insurer, and is funded by contributions paid by members of the scheme. NHS trusts can take part in an ongoing programme of assessments by the NHSLA, and progressing through three distinct Inspection Report Warrington Hospital March

7 levels allows the trust to have increasing financial discounts to their contributions. The trust had been assessed as being compliant for consent at level two by the NHSLA. This means that they provided evidence, such as their consent policy, to demonstrate that their processes for managing risks were being used by front line staff. The staff who we asked had a good understanding of consent and the need to ask for people's permission before carrying out care or treatment. One health care assistant told us "We need consent for everything; I ask and explain things fully to patients." Another junior staff member described appropriate strategies that would be used with patients who refused care such as personal hygiene. Inspection Report Warrington Hospital March

8 Care and welfare of people who use services People should get safe and appropriate care that meets their needs and supports their rights Our judgement The provider was meeting this standard. People experienced care, treatment and support that met their needs and protected their rights. Reasons for our judgement We observed medical, nursing, therapy and support staff delivering care and support in a confident and efficient manner. All staff members we observed interacted well with patients and were calm in their approach. We saw that when patients called for assistance, the staff responded quickly. The patients we spoke with were happy with their treatment. One patient who was going home told us "Staff have been good." We also heard comments such as "I give them 90%"; "staff are marvellous" and "I have been treated well." We spoke with relatives of five different patients who were all extremely satisfied with the way their family members were treated. We looked at a total of 17 patient records across the various wards that we visited and found that each person had an assessment of their needs completed. This included appropriate risk assessments for most people such as falls risk assessments, pressure ulcer risk assessments and risk assessment for bed rails. Whilst the care plans and risk assessments generally described the required information we found that they were not being completed or reviewed consistently. This meant that they did not always reflect the individual's current circumstances which could put them at risk. However, we did not find any evidence to show that people's needs were not being met. We have discussed the record keeping issues further in outcome 21. The staff we spoke with on the ward where patients who had had a stroke were cared for were positive about their roles. We saw evidence to confirm that there was good team working and staff from different professional backgrounds worked well particularly where patients had more complex needs. We saw many examples of staff working well with hospital teams. On one ward we heard a patient ask for an egg mayonnaise sandwich and approximately 10 minutes later, this was brought on to the ward from the kitchen. We saw the lunchtime meal being served on two wards and on most occasions patients who required support to eat were treated with dignity and respect. We observed one staff member standing over a patient to feed them. This can feel threatening towards patients and in most cases we would expect staff to sit down to feed people. Senior staff advised they would review the practice of staff supporting patients with their meals. Inspection Report Warrington Hospital March

9 Some patients had relatives assisting them with their lunch. The relatives we asked said they were visiting at lunchtime out of choice and not because they thought that their relative was at risk of not being fed if they were not present. Inspection Report Warrington Hospital March

10 Safeguarding people who use services from abuse People should be protected from abuse and staff should respect their human rights Our judgement The provider was meeting this standard. People who use the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. Reasons for our judgement The patients and relatives we spoke with told us that they had no concerns with the care on the wards. No-one had ever witnessed anything that gave them concerns about the safety of vulnerable patients being cared for on the wards. Most staff members we spoke with said they had received training about safeguarding vulnerable adults. One staff member told us that they had received this training in their previous employment with another Trust. All staff who we asked were aware of the procedures to follow if abuse was suspected and they were clear about the actions that would be considered to be abusive. One member of staff discussed us the actions they had taken in order to protect a vulnerable patient in their care. Within the medical records of some patient's who lacked capacity to make a specific decision for themselves, we saw that an assessment of capacity and a best interest review was fully recorded. This is important to ensure that the rights of people who cannot make certain decisions for themselves are fully protected. This is legal requirement that is set out in an Act of Parliament called The Mental Capacity Act (2005). Most of the staff we asked said that they had completed training regarding the Mental Capacity Act. We discussed the assessment of capacity and a best interest review form with Head of Governance. We saw that she received a carbonated copy of each form for review to ensure that the principles of the Mental Capacity Act were being followed by staff. If she identified any issues with the information recorded, the form was returned to the clinician who had completed the form. Overall all we found that clinical staff had a reasonable understanding of the Act and how it applied to their practice. Inspection Report Warrington Hospital March

11 Management of medicines People should be given the medicines they need when they need them, and in a safe way Our judgement The provider was meeting this standard. People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines. Reasons for our judgement We looked at how medicines were handled and saw appropriate arrangements for their prescribing, recording and administration. When patients were admitted to the hospital doctors recorded and prescribed their medicines following a standard procedure. This was then checked by the pharmacy team within 48 hours to make sure medicines were accurately prescribed and all the information was properly recorded. This helps to make sure patients receive the correct medicines. We looked at the prescription and medication records in detail for seven people on four wards. We found that appropriate arrangements were in place in relation to medicines administration and recording. One patient we spoke with confirmed that nurses and doctors "explained the changes" to their medicines and told us "the pain relief was very good". A second patient told us, "it's a good hospital, I don't do my own medicines at home, but I have my own inhaler. I've got it here so I can use it when I want it". A third person explained, "I do my own medicines at home but I'm fine with the nurses doing it here." I didn't want to take my water tablet this morning because I am travelling they (the nurses) were ok with it". The medicines records we checked were usually completed correctly and medicines were obtained promptly when patients were admitted to the hospital. However, one of the seven charts we looked at showed that doses of medication had been unnecessarily missed for one day. The ward pharmacist confirmed that two of the missed medicines were available as stock and that another medicine should have been brought with the patient when they transferred from another ward. We asked the chief pharmacist about the arrangements for auditing medicines handling and recording at the hospital. The programme of audit included checks of missed or omitted doses and the audits showed improvement in this area. We looked at how patients were supported to look after their own medicines. On one ward documents for assessing and supporting patients to self-administer medication were available and in use. However, the provider might like to note that nurses on a second ward we visited were not following the hospital self-administration policy. They told us they had not received training in its use. It is important that self-administration is assessed and recorded in line with hospital policy to help ensure patients are fully supported. Inspection Report Warrington Hospital March

12 Records of medicines given to people on discharge were clear. Patients were also given a card explaining how they could contact the pharmacy or ward if they needed advice about their medicines. We spoke with three patients who were getting ready for discharge from the hospital. Two of the patients we spoke with confirmed that nurses had explained the medicines they were going home with and how to take them. One person told us "I know about the medicines already, but they did come and tell me about them now I'm ready to go home." A third person explained that they were going to another healthcare setting and that staff there would administer their medicines for them. Inspection Report Warrington Hospital March

13 Staffing There should be enough members of staff to keep people safe and meet their health and welfare needs Our judgement The provider was meeting this standard. There were enough qualified, skilled and experienced staff to meet people's needs. Reasons for our judgement The patients we spoke with told us that staff were busy but they did not feel that their care was compromised in any way because of this. Patients and relatives told us that they had confidence in the ability of staff at all levels to look after them properly. Before our visit we received information that indicated that staffing levels on ward A8 were inadequate. During our inspection two inspectors spent three hours on this ward. We discussed staffing levels on this ward with the nurse in charge. We were informed that staffing levels were adequate if everyone arrived for their shifts. During our visit a member of the night staff for that evening rang in sick and we saw that the agreed procedure was followed. The staff we spoke with stated that this system worked well and that if it was not possible to cover the shift from within the hospital then an agency was requested to send a person to cover the shift. Although we could see that staff were busy on ward A8, the atmosphere was calm and patients were not rushed. During our visit we saw that call bells were answered quickly and staff had time to respond to patients' requests. We checked the staffing rotas for the days and weeks prior to our visit. We found that staffing levels were maintained at the same levels as on the day of our visit. On the other wards we visited, we found no evidence of inadequate staffing levels. On the other wards we visited some staff told us that staffing levels were not always ideal but that they could request extra support if this was needed. One staff member told us "When the ward is fully staffed its lovely; but it can be difficult when not." They said on occasions they had to manage because no-one was available from the agencies. We were shown evidence from September 2012 of a regional comparison of staff sickness levels and this Trust had the fourth lowest level of sickness in the North West region and was below the regional average for sickness. Staff were enthusiastic about ensuring high quality care was delivered to all patients within their wards. The staff we spoke with very also enthusiastic about their roles. One staff member told us "This is the nicest place I have ever worked. There is plenty of support and no little cliques or groups." Inspection Report Warrington Hospital March

14 Assessing and monitoring the quality of service provision The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care Our judgement The provider was meeting this standard. The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who use the service and others. Reasons for our judgement The evidence that we were shown demonstrated that the trust had a governance framework in place that involved staff from wards and departments through to the Board members. This is a complex system that monitors the quality of care and treatment delivered within an organisation and action is taken to ensure that the quality improves. At ward level we saw that some of the areas we visited had a board that displayed results of quality improvement work that had been completed. On the stoke unit we found that a significant amount of work had been completed to reduce the number of falls that occurred on the ward. Some of this work had been rolled out across the Trust and was staring to impact on the number of falls reported. We spent some time in the Clinical Audit Department and saw that there was a robust procedure in place for recording and monitoring the clinical audits that took place in the Trust. We found that action plans were implemented when any recommendations had been made following audits of practice. This showed that wards and departments were checking on aspects of the quality of care and identifying where the required standards were not met. We discussed the governance framework with the Head of Governance and we were told that incidents and accidents were recorded electronically and investigated by senior staff. All NHS organisations have to report accidents and incidents to an organisation called the National Learning and Reporting System (NLRS.) and we were shown evidence that this information was sent on a regular basis. The Trust had robust structures in place to ensure that areas of particular risk such as infection control and the management of medicines were handled effectively. The Head of Governance told us that there was a process in place to deal with issues that GPs had about the hospital. We saw that their issues of concern were dealt with and where required, systems were changed to prevent the same issues from occurring again. There was a regular newsletter that was sent to all wards and department across the Trust to inform them of incidents that had happened and what steps should be in place to prevent the same or a similar incident from happening again. This demonstrated that the Inspection Report Warrington Hospital March

15 organisation was leaning from incidents and taking appropriate action to prevent reoccurrence. There was evidence to show that systems and processes were changed following incidents that occurred. We were shown evidence that the Trust's compliance with guidance issued by the National Institute for Health and Clinical Excellence was monitored regularly. The government expects all NHS organisations to be fully compliant with guidance or to be working towards full compliance. We saw that there were action plans in place to achieve full compliance where this was not already in place. Inspection Report Warrington Hospital March

16 Records People's personal records, including medical records, should be accurate and kept safe and confidential Our judgement The provider was meeting this standard. People were protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained. Reasons for our judgement We checked a total of 17 care records and we found records were generally stored securely on each ward whilst still allowing staff to access them quickly. However we found that records were not always fully completed. We found that standard core care plans were in use for some people but on two occasions we found that these had not been signed and on another occasion they had not been dated or signed. We found that on three occasions a more in depth assessment had not been completed despite the records indicating that this should have been done. For example there was one section in the records that stated this must be completed if the person is aged 65 or over. On two occasions we found that this had not been completed. We did not find any evidence to suggest that people had received unsafe or inappropriate care because their records had not been fully completed. We were concerned about the issues that we had found in the records and we discussed this with the senior staff at the hospital. We were told that that the hospital quality monitoring system had already identified that there was an issue with record keeping and a plan was in place to meet the shortfalls that had been identified. The plan included a new record keeping format and it appeared that this may help to improve some of the issues that we noted. We were shown minutes of meetings that had taken place to plan the necessary improvements. We also saw evidence to confirm that action was taken when incidents regarding recording keeping errors were reported. The changes and improvements were not completed at the time of our visit and we could see that that there was still more to do. We will look at this outcome again at our next inspection. Inspection Report Warrington Hospital March

17 About CQC inspections We are the regulator of health and social care in England. All providers of regulated health and social 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 essential standards are described in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations We regulate against these standards, which we sometimes describe as "government standards". We carry out unannounced inspections of all care homes, acute hospitals and domiciliary care services in England at least once a year to judge whether or not the essential standards are being met. We carry out inspections of dentists and other services at least once every two years. All of our inspections are unannounced unless there is a good reason to let the provider know we are coming. There are 16 essential standards that relate most directly to the quality and safety of care and these are grouped into five key areas. When we inspect we could check all or part of any of the 16 standards at any time depending on the individual circumstances of the service. Because of this we often check different standards at different times but we always inspect at least one standard from each of the five key areas every year. We may check fewer key areas in the case of dentists and some other services. When we inspect, we always visit and we do things like observe how people are cared for, and we talk to people who use the service, to their carers and to staff. We also review information we have gathered about the provider, check the service's records and check whether the right systems and processes are in place. We focus on whether or not the provider is meeting the standards and we are guided by whether people are experiencing the outcomes they should be able to expect when the standards are being met. By outcomes we mean the impact care has on the health, safety and welfare of people who use the service, and the experience they have whilst receiving it. Our inspectors judge if any action is required by the provider of the service to improve the standard of care being provided. Where providers are non-compliant with the regulations, we take enforcement action against them. If we require a service to take action, or if we take enforcement action, we re-inspect it before its next routine inspection was due. This could mean we re-inspect a service several times in one year. We also might decide to reinspect a service if new concerns emerge about it before the next routine inspection. In between inspections we continually monitor information we have about providers. The information comes from the public, the provider, other organisations, and from care workers. You can tell us about your experience of this provider on our website. Inspection Report Warrington Hospital March

18 How we define our judgements The following pages show our findings and regulatory judgement for each essential standard or part of the standard that we inspected. Our judgements are based on the ongoing review and analysis of the information gathered by CQC about this provider and the evidence collected during this inspection. We reach one of the following judgements for each essential standard inspected. This means that the standard was being met in that the provider was compliant with the regulation. If we find that standards were met, we take no regulatory action but we may make comments that may be useful to the provider and to the public about minor improvements that could be made. Action needed This means that the standard was not being met in that the provider was non-compliant with the regulation. We may have set a compliance action requiring the provider to produce a report setting out how and by when changes will be made to make sure they comply with the standard. We monitor the implementation of action plans in these reports and, if necessary, take further action. We may have identified a breach of a regulation which is more serious, and we will make sure action is taken. We will report on this when it is complete. Enforcement action taken If the breach of the regulation was more serious, or there have been several or continual breaches, we have a range of actions we take using the criminal and/or civil procedures in the Health and Social Care Act 2008 and relevant regulations. These enforcement powers include issuing a warning notice; restricting or suspending the services a provider can offer, or the number of people it can care for; issuing fines and formal cautions; in extreme cases, cancelling a provider or managers registration or prosecuting a manager or provider. These enforcement powers are set out in law and mean that we can take swift, targeted action where services are failing people. Inspection Report Warrington Hospital March

19 How we define our judgements (continued) Where we find non-compliance with a regulation (or part of a regulation), we state which part of the regulation has been breached. We make a judgement about the level of impact on people who use the service (and others, if appropriate to the regulation) from the breach. This could be a minor, moderate or major impact. Minor impact people who use the service experienced poor care that had an impact on their health, safety or welfare or there was a risk of this happening. The impact was not significant and the matter could be managed or resolved quickly. Moderate impact people who use the service experienced poor care that had a significant effect on their health, safety or welfare or there was a risk of this happening. The matter may need to be resolved quickly. Major impact people who use the service experienced poor care that had a serious current or long term impact on their health, safety and welfare, or there was a risk of this happening. The matter needs to be resolved quickly We decide the most appropriate action to take to ensure that the necessary changes are made. We always follow up to check whether action has been taken to meet the standards. Inspection Report Warrington Hospital March

20 Glossary of terms we use in this report Essential standard The essential standards of quality and safety are described in our Guidance about compliance: Essential standards of quality and safety. They consist of a significant number of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations These regulations describe the essential standards of quality and safety that people who use health and adult social care services have a right to expect. A full list of the standards can be found within the Guidance about compliance. The 16 essential standards are: Respecting and involving people who use services - Outcome 1 (Regulation 17) Consent to care and treatment - Outcome 2 (Regulation 18) Care and welfare of people who use services - Outcome 4 (Regulation 9) Meeting Nutritional Needs - Outcome 5 (Regulation 14) Cooperating with other providers - Outcome 6 (Regulation 24) Safeguarding people who use services from abuse - Outcome 7 (Regulation 11) Cleanliness and infection control - Outcome 8 (Regulation 12) Management of medicines - Outcome 9 (Regulation 13) Safety and suitability of premises - Outcome 10 (Regulation 15) Safety, availability and suitability of equipment - Outcome 11 (Regulation 16) Requirements relating to workers - Outcome 12 (Regulation 21) Staffing - Outcome 13 (Regulation 22) Supporting Staff - Outcome 14 (Regulation 23) Assessing and monitoring the quality of service provision - Outcome 16 (Regulation 10) Complaints - Outcome 17 (Regulation 19) Records - Outcome 21 (Regulation 20) Regulated activity These are prescribed activities related to care and treatment that require registration with CQC. These are set out in legislation, and reflect the services provided. Inspection Report Warrington Hospital March

21 Glossary of terms we use in this report (continued) (Registered) Provider There are several legal terms relating to the providers of services. These include registered person, service provider and registered manager. The term 'provider' means anyone with a legal responsibility for ensuring that the requirements of the law are carried out. On our website we often refer to providers as a 'service'. Regulations We regulate against the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations Responsive inspection This is carried out at any time in relation to identified concerns. Routine inspection This is planned and could occur at any time. We sometimes describe this as a scheduled inspection. Themed inspection This is targeted to look at specific standards, sectors or types of care. Inspection Report Warrington Hospital March

22 Contact us Phone: Write to us at: Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA Website: Copyright 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. Inspection Report Warrington Hospital March