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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. Page 1 of 16 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. Page 2 of 16 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. Page 3 of 16 What we found for each essential standard of quality and safety we reviewed Page 4 of 16 The following pages detail our findings and our regulatory judgement for each essential standard and outcome that we reviewed, linked to specific regulated activities where appropriate. We will have reached one of the following judgements for each essential standard. Compliant means that people who use services are experiencing the outcomes relating to the essential standard. A minor concern means that people who use services are safe but are not always experiencing the outcomes relating to this essential standard. A moderate concern means that people who use services are safe but are not always experiencing the outcomes relating to this essential standard and there is an impact on their health and wellbeing because of this. A major concern means that people who use services are not experiencing the outcomes relating to this essential standard and are not protected from unsafe or inappropriate care, treatment and support. Where we identify compliance, no further action is taken. Where we have concerns, the most appropriate action is taken to ensure that the necessary improvements are made. Where there are a number of concerns, we may look at them together to decide the level of action to take. More information about each of the outcomes can be found in the Guidance about compliance: Essential standards of quality and safety. Page 5 of 16 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 Page 6 of 16 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. Page 7 of 16 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 Page 8 of 16 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. Page 9 of 16 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. Page 10 of 16 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 Page 11 of 16 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. Page 12 of 16 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. Page 13 of 16 What is a review of compliance? By law, providers of certain adult social care and health care services have a legal responsibility to make sure they are meeting essential standards of quality and safety. These are the standards everyone should be able to expect when they receive care. The Care Quality Commission (CQC) has written guidance about what people who use services should experience when providers are meeting essential standards, called Guidance about compliance: Essential standards of quality and safety. CQC licenses services if they meet essential standards and will constantly monitor whether they continue to do so. We formally review services when we receive information that is of concern and as a result decide we need to check whether a service is still meeting one or more of the essential standards. We also formally review them at least every two years to check whether a service is meeting all of the essential standards in each of their locations. Our reviews include checking all available information and intelligence we hold about a provider. We may seek further information by contacting people who use services, public representative groups and organisations such as other regulators. We may also ask for further information from the provider and carry out a visit with direct observations of care. When making our judgements about whether services are meeting essential standards, we decide whether we need to take further regulatory action. This might include discussions with the provider about how they could improve. We only use this approach where issues can be resolved quickly, easily and where there is no immediate risk of serious harm to people. Where we have concerns that providers are not meeting essential standards, or where we judge that they are not going to keep meeting them, we may also set improvement actions or compliance actions, or take enforcement action: Improvement actions: These are actions a provider should take so that they maintain continuous compliance with essential standards. Where a provider is complying with essential standards, but we are concerned that they will not be able to maintain this, we ask them to send us a report describing the improvements they will make to enable them to do so. Compliance actions: These are actions a provider must take so that they achieve compliance with the essential standards. Where a provider is not meeting the essential standards but people are not at immediate risk of serious harm, we ask them to send us a report that says what they will do to make sure they comply. We monitor the implementation of action plans in these reports and, if necessary, take further action to make sure that essential standards are met. Enforcement action: These are actions we take using the criminal and/or civil procedures in the Health and Adult Social Care Act 2008 and relevant regulations. These enforcement powers are set out in the law and mean that we can take swift, targeted action where services are failing people. Page 14 of 16 Dignity and nutrition reviews of compliance The Secretary of State for Health proposed a review of the quality of care for older people in the NHS, to be delivered by CQC. A targeted inspection programme has been developed to take place in acute NHS hospitals, assessing how well older people are treated during their hospital stay. In particular, we focus on whether they are treated with dignity and respect and whether their nutritional needs are met. The inspection teams are led by CQC inspectors joined by a practising, experienced nurse. The inspection team also includes an ‘expert by experience’ – a person who has experience of using services (either first hand or as a carer) and who can provide the patient perspective. This review involves the inspection of selected wards in 100 acute NHS hospitals. We have chosen the hospitals to visit partly on a risk assessment using the information we already hold on organisations. Some trusts have also been selected at random. The inspection programme follows the existing CQC methods and systems for compliance reviews of organisations using specific interview and observation tools. These have been developed to gain an in-depth understanding of how care is delivered to patients during their hospital stay. The reviews focus on two main outcomes of the essential standards of quality and safety: Outcome 1 - Respecting and involving people who use the services Outcome 5 - Meeting nutritional needs. Page 15 of 16 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 Page 16 of 16