Download George Eliot Hospital

Dignity and nutrition
for older people
Review of compliance
George Eliot Hospital NHS Trust
George Eliot Hospital
Region:
West Midlands
Location address:
Eliot Way
Nuneaton
CV10 7DJ
Type of service:
Acute Services
Publication date:
July 2011
Overview of the service:
The George Eliot Hospital NHS Trust is a single
site hospital and serves a population of
approximately 250,000 from North
Warwickshire, South West Leicestershire and
North Coventry. The trust provides core
services which include accident and
emergency, maternity and children’s services.
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Summary of our findings
for the essential standards of quality and safety
What we found overall
We found that George Eliot Hospital NHS 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, carried out a visit on 19
April 2011 to Felix Holt ward and Dolly Winthrop ward, observed how people were
being cared for, talked with people who use services, talked with staff, checked the
provider’s records, and looked at records of people who use services.
The inspection teams were led by CQC inspectors joined by a practising,
experienced nurse. 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. During the course of the day, the team spoke
with twelve patients, two relatives and nine staff from different disciplines.
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What people told us
Patients we spoke with confirmed that they were listened to and were given the
opportunity to express their views about their care, support and treatment. They said
they were given clear information and had been involved in decisions about their
care. Some patients told us that they often experienced delays in getting help from
staff when they pressed their call bell for help, whilst others said staff responded
promptly.
Patients said that the staff always asked permission before carrying out any
examinations or care and also regularly asked if they had any concerns. They said
staff asked them how they wanted to be addressed, were respectful and always
maintained their privacy. All said they had never been embarrassed or felt
uncomfortable while care was being carried out.
Most of the patients we spoke with said there was a choice of meals and the food was
good. They said that they were given help to eat if they needed it and they had never
missed a meal.
What we found about the standards we reviewed and how well
George Eliot Hospital 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 George Eliot Hospital 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 George Eliot Hospital was meeting this essential standard.
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What we found
for each essential standard of quality
and safety we reviewed
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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.
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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
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
Overall, patients we spoke with during our visit were positive about their care,
treatment and support. They said they were happy about how they were treated and
listened to by staff. None of the patients on the wards we visited said they had been
made to feel embarrassed or left in discomfort. One person told us how they
receive personal care and said “staff are very good at minimising embarrassment,
they make me laugh.”
We asked patients on both wards how quickly staff respond to their individual
needs. Some patients told us that they often experienced delays in getting help
from staff when they pressed their call bell for help. Comments included, “I don’t like
to use the bell as staff might not come. They don’t always respond quickly enough
and I wouldn’t want to be a nuisance.” Other patients told us that staff responded
quickly to call bells, commenting, “Nurses are rushed off their feet. They usually
come fairly quickly, but always leave me with a bell.” and “Staff come quickly when I
ring the bell.” Observations of care across both wards showed that call bells were,
with two exceptions, within reach. They were usually answered promptly when
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rung, except during the lunch time period when patients had to wait longer for a
response from staff.
Patients said they get the information and explanations they need about their
treatment from the doctors and ward staff. They also confirmed that they had been
asked on admission how they would like to be addressed by staff and that this had
been respected during their stay.
We observed staff using bed curtains to protect patients’ privacy when receiving
treatment or assistance, although it is difficult in communal ward bays not to be
overheard. Staff were aware of the limitations and lowered their voices so that what
might be overheard was minimised.
Other evidence
Both of the wards we visited appeared calm, although busy with care practices. We
observed interactions between staff and patients and saw staff behaving in a way
that was respectful to patients. For example, we saw a nurse talking with a patient
who was disorientated following sleep. The nurse was speaking calmly and
reassured the patient. She explained that she was taking some observations such
as blood pressure and the patient visibly relaxed while she was talking to them. We
heard a ward hostess ask patients what they wanted to drink and observed her
chatting with patients as she gave out the drinks. We saw some very good
interaction and positive encouragement from two physiotherapists as they helped a
patient to walk.
We overheard a conversation between a patient and a doctor behind closed
curtains. Time was given to the patient to answer questions. When the patient
couldn’t understand another means of explaining was given. The doctor explained
who would be looking after them and what treatment they would be receiving. The
doctor then introduced the physiotherapist to the patient by full name. The patient
was assured throughout the conversation and their questions answered. The
physiotherapist introduced himself and was heard to ask permission to move the
patient’s body (for exercise),
Overall we observed staff promoting patients’ privacy and dignity across the two
wards we visited, for example timing of personal care, lowering their voices when
discussing sensitive issues or care with individuals, using curtains to ensure privacy
and adjusting their position to be level with the patients they care for. We observed
staff taking time to listen to patients and supporting the more frail patients and
involving them in their care routines. However, during our visit, we saw some
practices that compromised patients’ dignity. We saw some occasions where staff
practice was inappropriate. For example, we overheard two staff members
discussing other patients within earshot of patients on the ward. We also saw a
nurse approach a patient and ask in a loud voice “(patient’s name), have you got a
catheter in?” On another occasion we heard a staff member calling a patient
“darling”, instead of their preferred name.
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Staff told us that the trust provide training courses in promoting equality and
diversity which helped them promote patients individual needs. Promotion of dignity
is included in the induction training of new staff and is ‘refreshed’ annually as part of
their mandatory training. They have also had study days around the subjects of
‘privacy and dignity’ and ‘equality and diversity.’
Staff told us that overall, patients get the care they need in a dignified and respectful
way, but it can be frustrating when there are staff shortages or a busy period. They
said, at these times, it is difficult for them to have the time to sit with patients when
they need comfort or reassurance.
Each ward bay is restricted to single sex occupancy and the patients we spoke with
said they felt comfortable with this arrangement as they felt their dignity was less
likely to be compromised.
Staff ensure that patients understand the diagnosis assessment process. Reviews
are undertaken with input from the patient and their family, if applicable. Staff know
how to access specialist staff and other services such as translator services to
ensure they can meet the patient’s individual needs.
Therapy staff, including a physiotherapist and occupational therapist, was seen on
both wards, assisting with promoting patients’ independence. The therapy staff
engaged with patients appropriately and did not rush treatments.
The trust has a spiritual needs care plan used to record a person’s faith, spiritual
needs, special dietary requirements and special hygiene requirements linked to their
particular faith. One of the care plans we reviewed indicated that the patient
appeared to have religious and cultural needs as English is not their first language.
However, there was no reference in the care plan for ethnic needs for food and
drink.
On admission to wards staff ensure patients clearly understand their treatments by
discussing it with them and their families. For patients who were not capable to
making their own informed decisions, an assessment of each patient’s mental
capacity had been undertaken and appropriate processes put in place. We saw
information sheets about diagnoses displayed in a prominent position on one of the
wards we visited. These leaflets were accessible to patients and were tidy and well
stocked.
We were told that a multidisciplinary team meets weekly on Felix Holt ward, which is
the stroke ward in the hospital, with a view to enabling patients to regain their
abilities as quickly as possible. Patients’ assessments records were also reviewed
and found to be detailed and thorough.
The trust has a complaints procedure and on both wards we visited we saw
‘complaints, comments and compliment’ leaflets on display and readily accessible to
Patients visiting the wards. In addition to this there is Patient Advice and Liaison
service (PALs) and leaflets about this were also on display.
The trust also has a patient experience committee whose work includes the review
of dignity in care throughout the trust. The Patient Experience Group (PEG) meets
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monthly and receives reports / feedback from incidents, claims and complaints as
well as ‘Smiley Card’ feedback.
We were told that ward audits are also undertake by the Matron and the findings are
recorded and fed back to staff to inform practice. Senior staff also told us that they
observe practice on an ongoing basis and take action where they feel patients’
privacy and dignity needs are not being respected.
When we spoke with staff we asked how they get feedback from patients who use
the service. They explained the ‘Smiley Card’ system whereby staff ask a number of
patients on a weekly basis their experience of their care at the hospital. This is
collated by the trust and a recent analysis indicated that nearly 80% of patients were
satisfied with the quality of care, treatment and support they received during their
stay.
Annual PEAT (Patient Environment Action Team) inspections are carried out. When
compared to other NHS Trusts, the hospital scored ‘better than expected’ with
regard to privacy and dignity within this outcome area in 2010 which looked at
confidentiality. The trust scored 'better than expected ' for issues around modesty,
dignity and respect.
Our judgement
Patients were treated with respect and were involved in making decisions about
their care, treatment and support. They were able to give feedback about their
experiences.
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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 with Outcome 5: meeting nutritional needs
Our findings
What people who use the service experienced and told us
In general, patients told us that the food was good and it was reported in the NHS
Inpatient survey (2009/2010) that the George Eliot scored 5.4 out of 10 for the
quality of food which was similar to other hospital’s scores.
Data analysis on NHS Choices website rated the hospital as excellent for the overall
quality of its food.
Patients told us the food was enjoyable and they could choose what they liked from
the daily menu. Their comments included, “Food is quite good.”, “The beef in stout
was lovely yesterday,” and “We get a decent selection.”
Everyone we spoke with on the wards said they got enough to eat and drink. We
heard one patient tell a staff member that lunch was so nice they could have eaten
another one. A second helping was provided for the person.
Patients told us that if there was anyone in their bay who could not manage to eat or
drink staff were always on hand to help them.
There were general checks made to ensure patients were able to manage and help
was given where necessary. The mealtime did not appear to be hurried and patients
were given time to eat their meal.
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Other evidence
We observed the lunchtime routine on two wards. Both wards operate a ‘red tray’
system to identify those patients who may be at risk and need support with eating
and drinking. This was also indicated on the respective menu cards.
Information about patients nutritional needs was cascaded by staff at handover and
we saw an example of a handover record which shown the nutritional status of each
patient. For example whether they were nil by mouth or on a ‘soft fork mash’ diet.
On Felix Holt ward this also included details of the patient’s swallowing capabilities,
where applicable.
We spoke at length to a ward hostess and she demonstrated a clear understanding
of her role and responsibilities. We were shown copies of the menus that patients
choose from and advised that the trust has a four week rolling menu. Nursing staff
tell the hostess if patients are on a soft diet. They recommend what would be best
for patients when discussing their choice of meal. They are also told patients’ likes,
dislikes and allergies. We were told the quality of food is good but they have a few
problems with pureed food as there is not as much variety, for example one patient
had the same choice of dinner every day for a week.
Patients choose their meals from a menu card every morning. Staff told us that
there is access to hot and cold food for patients outside mealtimes, which patients
confirmed. There was evidence that a choice of food that meets a range of
individual needs is available. When choosing a meal patients are also able to select
a portion size, such as small, medium, or large. This means that patients with
different appetites are catered for and the patients we spoke to after lunch all said
the portion they got was what they preferred and had asked for.
Both of the wards had protected mealtimes which means that patients should be
free from interruptions and that sufficient numbers of staff are available to assist
patients. Patients’ relatives were allowed on the ward at mealtimes only if they were
helping a patient with their meal. The expectation is that patients will not be
interrupted during mealtimes unless an emergency arises. However, we observed a
doctor having a consultation about pressure area care with a patient behind curtains
in one bay whilst other patients were eating.
A range of supportive equipment is provided to assist patients eat and drink
including, for example, drinking beakers with lids, adapted cutlery and ‘lipped’
plates. We saw examples of these items being used on the wards.
During our observations we saw an example of patients experiencing difficulties with
their meals. A patient was lying flat in bed when the meal arrived. The person was
raised in bed, but the tray was still nearly level with their face. They had difficulty
eating and their meat had not been cut up into manageable portions. The person
slipped back down the bed whilst eating, but we did not see staff come and re-assist
the patient to a more comfortable eating position.
Staff have access to specialist staff such as dietitians, and speech and language
therapists (SALT). All patients are assessed on admission to the hospital with the
Malnutrition Universal Screening Tool (MUST). This tool helps to identify patients
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who are either at risk of malnutrition or obese or those that are malnourished. Staff
weighed patients on admission and then at intervals determined by the patient’s
risk. We saw patients had a MUST score in place and a care plan had been
developed to meet the patient’s needs. There was evidence that referrals are made
to nutritional and dietetic services for patients. Patients’ records reviewed
demonstrated specialist input from dietitians and nutritionists for patients who had
been assessed using the nutritional screening tool as medium or high risk.
We spoke with a dietitian who confirmed that special meals can be provided
following their assessment of a person’s particular dietary needs. We were told that
leaflets providing information on nutrition for various illnesses and treatments are
provided so that patients are kept fully informed. We were also told that all nurses
on Felix Holt, the stroke ward, are trained to ‘swallow screen’ patients to identify
their risk of choking.
Staff told us that if a patient misses a meal they could access food out of hours.
They also had facilities on the ward to make simple snacks such as beans on toast.
The ward hostess told us if a patient was admitted to the ward after the menu
choices had been made, they would still be able to offer them a choice of meal.
Food charts were located at each bedside and we were told that it was the
responsibility of ward staff to complete these prior to removing patients’ meal trays.
We observed staff completing these records, but one that we looked at had
recorded the patient had eaten their beef dinner, when in fact they had had turkey.
Patient Environment Action Teams (PEAT) rated the George Eliot Hospital as better
than other hospitals for food which included looking at the menu, choice, availability,
quality, portion sizes, temperature, presentation, service and beverages.
Our judgement
Patients were supported to have adequate nutrition and hydration and were given
choices to meet their needs. Patients received an assessment of their nutritional
state and if necessary assistance is requested from dietary specialists.
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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
Treatment of disease,
disorder or injury
Surgical procedures
Diagnostic or screening
procedures
Regulation
17
Outcome
1 – Respecting and
involving people who use
services
Why we have concerns:
On the basis of the evidence provided and observed,
there was a minor concern with this outcome. There
was evidence that patients were receiving
individualised care in practice however; in order to
maintain compliance, the trust needs to ensure that
patients’ dignity is respected and promoted. Although
patients reported they generally received assistance
in a timely manner, we observed that call bells were
not always easily accessible and some patients had
to wait longer for a response from staff during the
lunch time period.
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 2010.
The provider’s report should be sent within 28 days of this report being received.
CQC should be informed in writing when these improvement actions are complete.
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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.
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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.
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Information for the reader
Document purpose
Review of compliance report
Author
Care Quality Commission
Audience
The general public
Further copies from
03000 616161 / www.cqc.org.uk
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.
Care Quality Commission
Website
www.cqc.org.uk
Telephone
03000 616161
Email address
[email protected]
Postal address
Care Quality Commission
Citygate
Gallowgate
Newcastle upon Tyne
NE1 4PA
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