Acute services with overnight beds Rehabilitation services Date of Publication: October 2012

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1 Review of compliance East Sussex Healthcare NHS Trust Irvine Unit Bexhill Hospital Region: Location address: Type of service: South East Holliers Hill Bexhill-on-Sea East Sussex TN40 2DZ Acute services with overnight beds Rehabilitation services Date of Publication: October 2012 Overview of the service: The Irvine Unit has 42 inpatient beds (for intermediate care), palliative care and rehabilitation services. 12 beds were allocated for stroke rehabilitation Services for the community and inpatients include community stroke rehabilitation, the Community Collaborative Rehabilitation Team, Page 1 of 23

2 occupational therapy and physiotherapy. The unit is also the base for the South East Health 'Out of Hours' GP service. Page 2 of 23

3 Summary of our findings for the essential standards of quality and safety Our current overall judgement Irvine Unit Bexhill Hospital was not meeting one or more essential standards. Action is needed. The summary below describes why we carried out this review, what we found and any action required. Why we carried out this review We carried out this review as part of our routine schedule of planned reviews. How we carried out this review We reviewed all the information we hold about this provider, carried out a visit on 28 September 2012, checked the provider's records, observed how people were being cared for, looked at records of people who use services, talked to staff and talked to people who use services. What people told us During our visit we met five patients and two sets of relatives. Three patients were able to engage in the inspection and commented positively about their care and the attitudes of staff at the unit. Two other patients had speech difficulties and were unable to vocalise at this time. We observed staff interactions with them during our visit. We also reviewed one patient who was asleep throughout our visit and whose health had deteriorated. The relatives commented that they found the general support provided by staff good. One relative felt fully involved in their family members care and treatment and was satisfied with progress to date. They thought that the unit was effective for people who had good potential for rehabilitation. However, one relative felt that for people with limited potential for further rehabilitation the unit was ineffective and did not fully communicate a true picture of what was achievable to families. What we found about the standards we reviewed and how well Irvine Unit Bexhill Hospital was meeting them Outcome 01: People should be treated with respect, involved in discussions about their care and treatment and able to influence how the service is run People's privacy, dignity and independence were respected. Page 3 of 23

4 The provider was meeting this standard. Outcome 04: People should get safe and appropriate care that meets their needs and supports their rights Although patient's needs were assessed and care and treatment was planned and delivered in line with their individual care, important omissions in recording placed patients at possible risk of care not fully meeting their needs. The provider was not meeting this standard. We judged that this had a minor impact on people using the service and action was needed for this essential standard. Outcome 07: People should be protected from abuse and staff should respect their human rights 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. The provider was meeting this standard Outcome 14: Staff should be properly trained and supervised, and have the chance to develop and improve their skills People were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard. The provider was meeting this standard. Outcome 16: The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care The provider had a system in place to regularly assess and monitor the quality of service that people received. Actions we have asked the service to take We have asked the provider to send us a report within 14 days of them receiving this report, setting out the action they will take. We will check to make sure that this action has been taken. Where we have concerns we have a range of enforcement powers we can use to protect the safety and welfare of people who use this service. When we propose to take enforcement action, our decision is open to challenge by a registered person through a variety of internal and external appeal processes. We will publish a further report on any action we have taken. Page 4 of 23

5 Other information Please see previous reports for more information about previous reviews. Page 5 of 23

6 What we found for each essential standard of quality and safety we reviewed Page 6 of 23

7 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. Where we judge that a provider is non-compliant with a standard, we make a judgement about whether the impact on people who use the service (or others) is minor, moderate or major: A minor impact means that 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. A moderate impact means that 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. A major impact means that 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. Where we identify compliance, no further action is taken. Where we have concerns, the most appropriate action is taken to ensure that the necessary changes are made. More information about each of the outcomes can be found in the Guidance about compliance: Essential standards of quality and safety Page 7 of 23

8 Outcome 01: 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 with Outcome 01: Respecting and involving people who use services Our findings What people who use the service experienced and told us During our visit we selected six patients whose notes we reviewed. We were able to speak with three of the patients and two sets of relatives. Patients able to engage in the inspection process told us that they felt informed about their care and treatment. People said that they found staff were helpful and friendly. They said that staff were always mindful of their privacy and dignity and closed curtains when undertaking personal care. One family member told us that they were satisfied with the way in which staff managed the personal care of their relative. They thought staff respected their privacy, and promoted their dignity and independence. They thought that they were kept informed by staff about their relatives care and treatment needs. Another family expressed disappointment at what they considered a lack of communication by staff about their relatives' rehabilitation and general lack of progress. They did not feel they had been kept informed about reasons why therapy input had ceased. They said they had raised concerns with the unit manager. They also felt their relatives' dignity had not been upheld on several occasions and they had to draw staff Page 8 of 23

9 attention to this. The unit manager said that they were looking into the families concerns. All the patients we observed during our visit were appropriately clothed or covered to protect their dignity. Patients said that staff were always checking on them, and one patient stated that staff responded quickly to the call bell. Other evidence During our visit we observed staff closed curtains when undertaking personal care. Conversations with patients were quiet and discreet. Patients seen were appropriately dressed. There were disclaimer forms in respect of patient's money and property and some files viewed contained a record of property brought into hospital. We noted completed consent to treatment forms in some files, but these were blank in other files viewed. When we raised this with managers there was no reason given as to why these had not been completed. When we reviewed records we found good evidence of staff listening to, and consulting with patients and seeking consent to provide personal care. We were satisfied that people expressed their views and were involved in making decisions about their care and treatment. There was good evidence that people had access to therapy assessments and input to help promote their independence and rehabilitation. All patients who were able to use their call bell were seen to have one in reach. We noted in meeting minutes that generic information used to inform patients about what they can expect in hospital was under redevelopment. We were informed that one specifically designed for the Irvine unit and the service was currently in the draft stage. Our judgement People's privacy, dignity and independence were respected. The provider was meeting this standard. Page 9 of 23

10 Outcome 04: Care and welfare of people who use services What the outcome says This is what people who use services should expect. People who use services: * Experience effective, safe and appropriate care, treatment and support that meets their needs and protects their rights. What we found Our judgement The provider is non-compliant with Outcome 04: Care and welfare of people who use services. We have judged that this has a minor impact on people who use the service. Our findings What people who use the service experienced and told us When we visited we reviewed five patient files, two from the stroke unit and three where patients had physical traumas as a result of falls. We were able to speak with three of the patients selected. We were also able to speak with two sets of relatives. Patients told us that they felt well cared for by staff who they felt couldn't do enough for them. They told us that staff were always willing to do extra tasks for them. They told us that staff checked on them regularly and also ensured they were not developing any problems with pressure areas. One patient told us she was regularly checked for sore areas and that staff applied cream daily to help keep her skin in good condition. The patient also told us that she always felt able to ask for drinks and if staff noticed her glass was empty they would top this up. The family of one patient we reviewed however were concerned that their relative who was unable to vocalise their needs was overlooked for drinks on occasion. They also were also concerned that physiotherapy had ceased with no explanation given to them for this. A patient who was vegetarian said that they felt their preference was generally supported but would on occasion be offered a meal that had meat in it. They were unclear why there was this occasional inconsistency. Page 10 of 23

11 Patients told us that pain relief was well managed and staff responded promptly to requests for medication. Other evidence We observed that staff were busy throughout our visit attending to patient care. We observed therapy staff working with patients. When we reviewed documentation there was good recording of therapy assessments and of therapy inputs when this was available. We were told that there had been reduced availability of therapies in all the community intermediate units and that this had impacted on the ability of patients to rehabilitate effectively. As a consequence complaints from relatives about lack of therapy input had increased. The trust had acknowledged that measures initially put in place to reduce the risk were inadequate and a planned review and consultation around therapy was underway. The trust had since assessed the risk as a level 4 major risk. We asked what the trust was doing about the heightened risk. Senior managers advised that recruitment had taken place to recruit to vacant therapy posts. When we spoke with staff they reported that things had improved and patients were only waiting one or two days before they had their initial therapy assessment. We looked at a patient's notes whose relatives had expressed concern at the lack of communication about access to physiotherapy and general progress. We found daily documenting of care delivery to the patient was good. However, we found no reference to discussions with the family in regard to the cessation of physiotherapy. When we spoke to the unit manager about this we were informed that they were aware of the family's concerns and was currently looking into this matter. Records of staff and management meetings viewed indicated that the trust was fully aware of staffing pressures within the Irvine unit. There had been a recent increase in dependency of patients on the stroke unit. Managers told us that they were aware that the unit had experienced some difficulties and as a result of these concerns an additional staff member had been agreed and was now in place for the evening shift. There was recorded evidence that patient feedback in regard to night time care was positive. We were told that from 6 August medical cover availability had improved. There was now with consultant input Monday to Friday 9am to 4 pm and regular consultant rounds. Middle grade medical staff cover was also available on the unit to provide medical cover primarily for stroke patients. Medical staff also provided clerking in of all patients, as well as assessment of patients who could wait until the GP arrived. GP's continued to provide cover for generic patients and out of hours cover. We reviewed a further five patient records, three of who we were also able to speak with. We found patient bed notes were indexed and information was easy to find. Each folder contained a summary care plan that reflected individual needs, and was supported by a range of risk assessments to support delivery of care. Risk assessments included moving and handling, continence, nutrition, tissue viability, falls and bed rail assessments. For the most part these were completed with evidence of review and dating. However in every file viewed we found omissions in recording. Some Page 11 of 23

12 documentation was left blank and it was unclear if this was meant to be used or not. When we raised this with senior managers they agreed if documentation was not applicable, it needed to be removed from the file as it gave the impression it had not been completed. However, they acknowledged that there were still omissions in recording. They said that they were seeking to address this through random sampling of patient notes for audit, and addressing the matter with staff. There was good evidence that appropriate screening was undertaken for infectious conditions, and measures implemented to mitigate risks. For those patients who were deemed at higher risk of developing pressure ulcers risk assessments were in place. There was evidence that pressure relieving equipment had been provided. We also noted that there were records of daily checks of pressure areas. However, when we checked records we found inconsistencies in the recording. We found that the frequency of checks varied between once and three times daily. Repositioning charts for those people unable to move themselves were not always completed. We checked essential rounds documentation and found this also did not record what repositioning may have taken place by staff. Essential rounds documentation had been introduced to ensure that staff undertook routine checks on patients. These were completed for each 24 hour shift. However, we sometimes noted gaps in checks of between two and six hours without any indication as to the reason for this. We asked a staff member why they thought there were gaps in recording, they told us that staff were doing the checks but did not have time to complete the documentation. In one patient's bedside notes we saw that fluid monitoring was in place as they were unable to access drinks for themselves. On the date of our visit no records of fluid taken had been recorded between 9am and 4:30pm that day. For another patient, similarly limited in their ability to access drinks, we observed small bottles of drink lined up on their table. There was no means for them to open the bottles or drink without support. We observed this patient to be dry mouthed, uncomfortable and flushed. Staff arrived soon after this to undertake personal care. Whilst there was evidence that daily observations were taking place there was inconsistency in the frequency of these being completed. We found that in two out of six files viewed, observations of temperature, pulse and blood pressure were not recorded daily. There was no pattern to the completion of these checks. For a patient who had suffered a serious fall prior to admission, a risk assessment had been completed. This highlighted that they were at a high risk, but made no reference to the fact they suffered seizures. There were no specific guidelines for staff in respect of this patient. In the bedside notes for another patient we found the personalised summary correctly recorded that they were diabetic. There was evidence that glucose monitoring was happening weekly. However, their summary plan made no reference to how their diabetes impacted on them and how their condition was controlled. For example, through medication or diet. We saw that the same patient was recorded in their mobility assessment as mobile and using a 'Zimmer'. Other notes viewed recorded that the Page 12 of 23

13 person was now being nursed in bed and required staff support to mobilise. For those patients with dietary or swallowing difficulties there was good evidence of referral to the speech and language therapist team and dietician and supporting plans and guidance in place. For a patient who indicated they had difficulty sleeping and usually requested medication at night to help this, the sleep section of their personalised plan was blank. For another patient whose personalised plan indicated the need for a pureed diet, this was not supported by the nutritional risk assessment which stated routine care should be provided. Whilst there was no evidence that the highlighted omissions had seriously impacted on the patients concerned, there was a potential risk that such routine omissions could place patients at risk by receiving inadequate or incorrect support. We viewed main patient file notes. These not easy to navigate and information was not easy to find. We noted that there was a clinical assessment in place but nursing assessments and discharge planning tools were not in place. Senior managers advised that nursing plans that reflected the rehabilitative nature of the unit were under development. Once finalised these would be introduced to enhance what is provided for patients requiring intermediate/rehabilitative care across all Intermediate care sites at the Trust. We found on all main patient files viewed that everyday recording was detailed and of a good standard. This detailed care and treatment tasks undertaken with patients. There was good evidence that best interest had been considered in one patient's case and a best interest meeting held. In another patients case there was evidence that discussions around discharge to a care home had been initiated. Our judgement Although patient's needs were assessed and care and treatment was planned and delivered in line with their individual care, important omissions in recording placed patients at possible risk of care not fully meeting their needs. The provider was not meeting this standard. We judged that this had a minor impact on people using the service and action was needed for this essential standard. Page 13 of 23

14 Outcome 07: Safeguarding people who use services from abuse What the outcome says This is what people who use services should expect. People who use services: * Are protected from abuse, or the risk of abuse, and their human rights are respected and upheld. What we found Our judgement The provider is compliant with Outcome 07: Safeguarding people who use services from abuse Our findings What people who use the service experienced and told us We spoke to people using this service but their feedback did not relate to this standard. Other evidence In discussion staff demonstrated a good understanding of safeguarding issues. Staff told us that training in safeguarding was mandatory and they competed this annually. Staff expressed confidence about raising alerts and gave examples of some they had raised. They knew how to escalate concerns. Staff said they sometimes received feedback about safeguarding alerts they had raised. The provider confirmed that all staff had updated their safeguarding training for this year and 95% of staff had undertaken mental capacity training. We viewed evidence of incidents raised and noted from meeting minutes that overall there was appropriate escalation of incidents and safeguarding issues. There was evidence of analysis of incidents and safeguarding alerts and actions highlighted as a result of investigations to improve staff practice. We were satisfied that the provider responded appropriately to any allegation of abuse. There was evidence on one patient's main file that a best interest meeting had taken place in respect of agreeing implementation of a Do Not Resuscitate (DNR) form. There was good evidence that relatives had been involved in the final decision. However, the DNR form had not been completed and added to the file. We highlighted this omission Page 14 of 23

15 to the unit manager. On a second patient file we noted that a DNR form had been completed. This stated the patient had no capacity. The part of the form to record discussions with family members was blank. There was no reference to discussions with relatives in regard to this decision within the daily notes. We highlighted our concerns about the poor completion of this form to the unit manager and were told that all DNR forms were to be reviewed and checked for accuracy and completion. Our judgement 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. The provider was meeting this standard Page 15 of 23

16 Outcome 14: Supporting workers What the outcome says This is what people who use services should expect. People who use services: * Are safe and their health and welfare needs are met by competent staff. What we found Our judgement The provider is compliant with Outcome 14: Supporting workers Our findings What people who use the service experienced and told us Three out of six patients who were able to engage in the inspection spoke positively about staff, commenting that they found them helpful, friendly, and always willing to do something for you. We spoke with two sets of relatives; both said they found staff helpful and friendly. One relative felt there were not enough staff to ensure patients were appropriately dressed at times, or to spend time with patients with more complex needs to help encourage drinking and eating. Other evidence When we spoke with staff they told us that they had access to mandatory training. They told us that they had attended additional workshops and specialist training, in some cases, to add credits to a degree course. We were satisfied that staff received appropriate professional development. We reviewed the staff training matrix which had not been recently updated. We noted a number of staff were overdue for some training. It was acknowledged that whilst staffing shortages had impacted on take up of training earlier in the year this was no longer the case. We were informed that the unit was now catching up in relation to some mandatory training. The provider was able to provide information subsequently that indicated that completion of mandatory training by all staff was well underway. Only fire and moving and handling training updates had been completed by less than 70% of the staff team. These were to attend training in the near future. Page 16 of 23

17 A newer staff member confirmed access to induction training which was class room based. They added that once on the ward they had been allocated a mentor and their skills were assessed and signed of when they were deemed competent. All three nursing staff spoken with confirmed that they had received an annual performance development review (PDR). Two staff confirmed that their PDR had highlighted training they needed or wanted. Records provided by the trust indicate that more than 95% of the staff team have received an annual appraisal this year. When we spoke with senior managers, they acknowledged that there had been a gap in the provision of clinical supervision to staff on a regular basis. They confirmed that group meetings took place with staff to talk about practice issues. The told us that operational supervision for staff was in place for all staff. When we spoke with staff they confirmed they were in receipt of supervision. However, the frequency of one to one meetings had drifted with the lack of senior nursing staff to undertake this earlier in the year. Recent recruitment of Band 6 and Band 5 nursing staff, and the development of a revised line management structure for supervision ensured that staff should now receive a minimum of six supervision meetings per year. Staff confirmed they had access to regular staff meetings and we were provided with copies of notes from recent meetings held. These were informative and made staff aware of new initiatives, outcomes from some incidents and recently highlighted concerns that reflected on staff practice. In discussion, all staff spoken with said they personally felt well supported. Our judgement People were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard. The provider was meeting this standard. Page 17 of 23

18 Outcome 16: Assessing and monitoring the quality of service provision What the outcome says This is what people who use services should expect. 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. What we found Our judgement The provider is compliant with Outcome 16: Assessing and monitoring the quality of service provision Our findings What people who use the service experienced and told us We spoke to people using this service but their feedback did not relate to this standard. Other evidence From our review of staff meetings, risk management meetings and quality review group meetings there was good evidence that some quality assurance audits were being undertaken. Staff meeting minutes indicated that hand washing audits were conducted. We found evidence of mini audits of patient end of bed notes for documentation relating to nutrition and hydration. Action plans related to what improvements were to be implemented and timescales for this were in place. Shortfalls highlighted by the audit were discussed at staff meetings and we saw evidence of this. It was evident from meeting records that patient documentation was under scrutiny. External staff were visiting the unit to undertake peer reviews and to feedback findings to staff. Minutes from meetings recorded that decontamination monitoring was in place. There was good evidence that incidents were being recorded and investigated, with analysis and findings informing discussions with staff around practice. Page 18 of 23

19 A detailed action plan for the governance and quality of the unit had been developed in This had been reviewed in June 2012 and highlighted a number of areas where the unit had achieved the identified improvements, or had made progress towards achieving them. The provider had a system in place to identify, assess and manage risks to the health, safety and welfare of people using the service and others. We saw evidence of a range of management meetings where the unit performance, in a number of areas, would be considered and escalated or acted upon where necessary. There was evidence in the unit action plan that patient questionnaires were under development. During our visit senior managers indicated these had been implemented but that feedback at this time was limited. Our judgement The provider had a system in place to regularly assess and monitor the quality of service that people received. Page 19 of 23

20 Action we have asked the provider to take Compliance actions The table below shows the essential standards of quality and safety that are not being met. Action must be taken to achieve compliance. Regulated activity Regulation Outcome Diagnostic and screening procedures Regulation 9 HSCA 2008 (Regulated Activities) Regulations 2010 Outcome 04: Care and welfare of people who use services How the regulation is not being met: Although patient's needs were assessed and care and treatment was planned and delivered in line with their individual care, important omissions in recording placed patients at possible risk of care not fully meeting their needs. The provider was not meeting this standard. We judged that this had a minor impact on people using the service and action was needed for this essential standard. Treatment of disease, disorder or injury Regulation 9 HSCA 2008 (Regulated Activities) Regulations 2010 Outcome 04: Care and welfare of people who use services How the regulation is not being met: Although patient's needs were assessed and care and treatment was planned and delivered in line with their individual care, important omissions in recording placed patients at possible risk of care not fully meeting their needs. The provider was not meeting this standard. We judged that this had a minor impact on people using the service and action was needed for this essential standard. Page 20 of 23

21 The provider must send CQC a report that says what action they are going to take to achieve 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 to us within 14 days of the date that the final review of compliance report is sent to them. Where a provider has already sent us a report about any of the above compliance actions, they do not need to include them in any new report sent to us after this review of compliance. CQC should be informed in writing when these compliance actions are complete. Page 21 of 23

22 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. Where we judge that providers are not meeting essential standards, we may set compliance actions or take enforcement action: Compliance actions: These are actions a provider must take so that they achieve compliance with the essential standards. 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 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 22 of 23

23 Information for the reader Document purpose Author Audience Further copies from Copyright Review of compliance report Care Quality Commission The general public / Copyright (2010) 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 23 of 23