Page 1 of 38

Review ofcompliance

Blackpool Teaching Hospitals NHS Foundation TrustBlackpool Victoria Hospital

Region: North West

Location address: Whinney Heys Road

BlackpoolLancashireFY3 8NR

Type of service: Acute services with overnight beds

Rehabilitation services

Diagnostic and/or screening service

Blood and Transplant service

Date of Publication: January 2012

Overview of the service: The Blackpool Teaching Hospital NHS Foundation Trust (the trust) provides acute health services in Blackpool. The trust has six sites across the area. The main site is Blackpool Victoria Hospital, an 850 bedded hospital that provides a

Page 2 of 38

wide range of acute services. The trust also provides specialist cardiac and non acute services, rehabilitation and respitecare for those with long-term conditions,care of children physical or learning needs.

Page 3 of 38

Our current overall judgement

Blackpool Victoria Hospital was not meeting one or more essential standards. Improvements are 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 because concerns were identified in relation to:

Outcome 01 - Respecting and involving people who use servicesOutcome 02 - Consent to care and treatmentOutcome 04 - Care and welfare of people who use servicesOutcome 07 - Safeguarding people who use services from abuseOutcome 08 - Cleanliness and infection controlOutcome 10 - Safety and suitability of premisesOutcome 13 - StaffingOutcome 14 - Supporting staffOutcome 16 - Assessing and monitoring the quality of service provision

How we carried out this review

We reviewed all the information we hold about this provider, carried out a visit on 27 September 2011, observed how people were being cared for, talked to staff, reviewed information from stakeholders and talked to people who use services.

What people told us

Patients we spoke with during our inspection were very positive about the information they had received prior to under going surgery. All confirmed they had received information about what to expect during their stay in hospital and about the treatment they were to receive.

Patients told us that they felt fully informed about their care and treatment and that alldoctors had taken the time to answer any questions they had. Patients said that their pre-operative assessment and physical examinations were carried out in private and helped them understand the surgical procedure they were being admitted to hospital for and were positive about their experiences.

Patients said that the new building was relaxing and clean but some did not like the lay outof the four bedded bays. However patients told us there was insufficient natural light in the bay and the lighting provided was insufficient that in the for the bathroom there were no electric shaver points.

for the essential standards of quality and safetySummary of our findings

Page 4 of 38

Patients said that staff were available when needed and had a relaxed and professionalapproach to their jobs which put them at ease. They told us that they were supported by staff who were helpful and recognised if they had anxieties about their treatment. They confirmed that staff helped them understand their treatment and allay their anxieties.

Patients said that staff were attentive and were readily available to provide care andsupport when needed.

"Everybody has been brilliant; they have told me everything I wanted to know"

"I thought the information I had was good".

"The leaflets were helpful, but then the staff explained everything I needed to know".

"They went through all the forms again so I understood what was happening and I hadalready agreed to have the operation. They treat you really well in that way and I knew what to expect"

"The wards are new and clean – it's very comfortable in here."

"The staff are excellent; they do speak to people in a respectful way".

"Night staff are friendlier, the day staff seem to be a bit rushed to spend too long a time with you"

"The nurses have explained everything and carried out the procedure very well, they are all very caring".

What we found about the standards we reviewed and how well Blackpool Victoria 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

Patients were positive about their experiences of care and treatment at BlackpoolVictoria Hospital. They told us their individual needs had been recognised, that theyhad been respected, and that they were well-informed about their care and treatmentarrangements.

Outcome 02: Before people are given any examination, care, treatment or support, they should be asked if they agree to it

People are able to decide upon examination, care and treatment because their consentis sought and the information provided to them explains the risks and benefits in a waythey can understand.

However people's rights could be compromised as staff do not have a full understanding ofmanaging the Mental Health Capacity Act 2005 when seeking consent as not all staff had received training on this Act.

Page 5 of 38

Outcome 04: People should get safe and appropriate care that meets their needs and supports their rights

People receive safe and appropriate care, treatment and support that meet their needs.

Outcome 07: People should be protected from abuse and staff should respect their human rights

People are protected by staff that understand the indicators of abuse and raise theirconcerns with the right people so action is taken to ensure they are safe.

However there is a risk that patient's human rights will always not be protected as not all staff had received training in the Mental Health Capacity Act 2005. The trust does not havea consistent approach to offering feedback to staff who had raised concerns.

Outcome 08: People should be cared for in a clean environment and protected from the risk of infection

The trust has appropriate policies and procedures in place which staff were seen toadhere to. Staff are trained in infection control procedures to ensure that patients wereadequately protected from the risk of infection. The trust takes its responsibility forpreventing and controlling infections seriously by providing staff, patients and visitorswith information about preventing infection from spreading by using best practiceguidance, infection control products and personal protective clothing.

Outcome 10: People should be cared for in safe and accessible surroundings that support their health and welfare

Patients are cared for in safe accessible surroundings that promotes their well being.

Outcome 13: There should be enough members of staff to keep people safe and meet their health and welfare needs

Patients did have a sufficient number of suitably qualified, skilled and experienced staffto assist them at all times. The numbers of qualified and non qualified staff and mix ofskills and experience provided appropriate levels of care and support.

Outcome 14: Staff should be properly trained and supervised, and have the chance to develop and improve their skills

Patients are cared for, supported and their health and welfare promoted by competentstaff that are appropriately trained, supervised and appraised. However somedepartments and staff would benefit from strengthening the appraisal and supervisiondelivery.

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 trust has developed new policies and procedures for dealing with seriousuntoward incidents and there is a system in place to monitor the quality of treatment and

Page 6 of 38

care.

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 to improve. We will check to make sure that the improvements have been made.

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.

Other information

Please see previous reports for more information about previous reviews.

Page 7 of 38

What we foundfor each essential standard of qualityand safety we reviewed

Page 8 of 38

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 tothe 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 outcomesrelating 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 9 of 38

Outcome 01:Respecting and involving people who use services

What the outcome saysThis 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 usPatients we spoke to during our inspection were positive about the information they hadreceived prior to under going surgery. Patients confirmed they had received pamphlets and adequate information about what to expect during their stay in hospital and about the treatment they were to receive.

They told us that they felt fully informed about their care and treatment and that alldoctors had taken the time to answer any questions they had.

"Everybody has been brilliant, they have told me everything I wanted to know""I thought the information I had was good".

"The leaflets were helpful, but then the staff explained everything I needed to know"

"The staff are excellent; they do speak to people in a respectful way".

"I think they do a great job".

"The information thoroughly put me at ease and told me what I needed to know. I was given a lot of leaflets which were colourful and nice. They were easy to read and told

Page 10 of 38

me what to expect. Before I came here I had lots of anxieties but talking to the nursehas allayed a lot of my fears. I have other medical conditions which worried me that mysurgery would be delayed but we talked about that. She was very thorough andexplained everything. I feel better having had the assessment with the nursepractitioner".

"I was given all the booklets and read them all. The information was what I wouldexpect to see. The booklets were informative and told me about consent and the choiceof anaesthetic I could have. The booklet said that I can elect to stop the procedure atany time. I'm ok with that".

Other evidenceIn the areas we visited on the day of our inspection we found that staff maintainedpeople's dignity and respect. We saw that patients had opportunities to express theirviews and wishes. This first started with the initial consultation, through the preassessment clinic, admission and post operatively.

We found that staff took time to listen to patients and discuss their care options withthem. During the pre-assessment clinics and in the admissions unit we observed thatconsultants explained the possible risks and side effects of treatment before patientssigned the consent to treatment form.

In most cases we observed that consultants, anaesthetists and nursing staff explainedto patients in a way they could understand however we did see one occasion when theanaesthetist used medical terms which the patient found hard to grasp. The nurse didexplain to the patient afterwards in a more simple language. One patient complained tous that they could not understand some doctors due to their language and dialect.

Before patients were admitted for surgery they attended a pre-operative assessmentclinic. This was so a patient's health status could be assessed for surgery. Staff andpatients all told us that through this pathway patients were involved in their surgerydecisions from their first outpatient appointment.

We were told by patients they were able to discuss the type of surgery they were being assessed for and given specific information about this at the pre-assessment clinics. Patients said they felt informed about their surgery, given relevant information and had the opportunity to discuss any issues they may have concerns about. It was at the preoperative assessment that relevant medical history, physical examinations andinvestigations were undertaken. Any mobility problems were also noted so appropriatearrangements could be put into place when the patient was first admitted to thehospital.

We spoke to several pre-operative assessment nurses who described the interpretationservice they use and they provided examples of how they provide support and respectfor religious beliefs. One person explained how they understood that peoples' religiousand cultural beliefs and practices. They described an occasion when they weregathering information from a patient whose religious beliefs were important to them andthey needed to pray several times a day. As the person would have reduced mobility after the operation they would contact the ward the person was to be transferred to after the operation and arranged a single room so the person could have privacy.

Page 11 of 38

When the nurses and doctors are undertaking an admission into the unit we saw thatstaff took time to discuss all care and treatment with the patient and their understandingof what this entailed. Staff told us that if they found an error in the case notes or patient expectation this would be documented and discussed with the consultant.

In all the areas we looked at in the surgical unit we saw that the hospital conformed tothe single sex accommodation policy. Although the wards were of mixed sex the layoutmeant that it was easy to segregate male and female bays. Each bay had en-suitefacilities. Single side rooms all had en-suites and were used for either sex. In theadmissions unit there was a separate waiting area for theatre for each sex thisenhanced and supported dignity in care provision.

During the inspection we spent time on the day surgical unit. We spoke to a number ofpatients who all said they were happy with the amount of information given to them,prior to their procedure. Patients said that staff explained what was going to happen ina way that was easy to understand. All the patients felt comfortable about how theywere treated.

Staff were observed speaking to patients and relatives in a professional and respectful manner. Staff were also observed to making appropriate adjustments for patients who had disabilities, which ensured that procedures were fully understood. One patient commented that within the letter informing them of their admission date and time, a sentence could be added to explain that once admitted there could be some time to wait before the procedure was completed. It was felt it was quite reasonable tohave to wait, but as long as patients were kept fully informed this was acceptable.We observed 'How to make suggestions and complaint' information was available in allthe areas we inspected and patients were encouraged to make comments on the service they received.

There were sufficient areas for private consultations or confidential discussion and staffwere observed to make appropriate provision for patients.

Our judgementPatients were positive about their experiences of care and treatment at BlackpoolVictoria Hospital. They told us their individual needs had been recognised, that theyhad been respected, and that they were well-informed about their care and treatmentarrangements.

Page 12 of 38

Outcome 02:Consent to care and treatment

What the outcome saysThis is what people who use services should expect.

People who use services:* Where they are able, give valid consent to the examination, care, treatment and support they receive.* Understand and know how to change any decisions about examination, care, treatment and support that has been previously agreed.* Can be confident that their human rights are respected and taken into account.

What we found

Our judgement

There are moderate concerns with Outcome 02: Consent to care and treatment

Our findings

What people who use the service experienced and told usPatients that we spoke with during our inspection told us that they felt fully informedabout their surgery and treatment options. One patient told us "I was given the choice ofan epidural or a general anaesthetic. When the risks and benefits were explained to meI decided to agree to the epidural."

"The doctor didn't explain who she was and then asked me to sign a consent for surgery form. I declined as I didn't realise that I needed surgery as that wasn't explainedto me so was quite shocked when asked to sign the consent form. She asked me lots ofquestions and was not wearing a badge. She did try to get further information or someone to speak to me but the person was unavailable. The doctor said that everything would be explained at the pre operative assessment which it was"

"I have been told exactly what's going to happen".

"I fully understand the procedure I am having. The consultant and the staff today haveexplained everything".

"I saw the surgeon and he explained it all the same as the nurse practitioner. I understood it all and have signed the consent forms. I understood what they both explained to me and that I can change my mind".

Page 13 of 38

In 2010 we were notified that the trust had reported several 'never' events for wrong sitesurgery. The trust had an improvement plan in place to ensure safe practice wasdelivered.

A 'never' event is an incident what is reportable to commissioners, the National PatientSafety Agency and Care Quality Commission. It is an incident that is deemed aspreventable. More information can be found at;http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_124552

At this time we were also informed by people who had used the services at the trustthat they were unsatisfied with the delivery of consent to treatment.

Other evidenceOn the day of our inspection we saw that patients who required admission to hospitalwere always admitted via the admissions unit before they went to theatre. Day carepatients were admitted through the day care unit and emergency admissions usuallycame direct to theatre from the Accident and Emergency department.

When we spoke to patients they told us that they had signed a consent form and feltinformed about the care and treatment they expected to receive. We saw that consentforms were either completed at the initial consultation with the consultant within the preassessment clinic or on admission. Where patients had signed consent before the day of admission we saw that consultants spent time to repeat all information and asked the patient to resign the form.

In the admissions unit we found all patients were seen by the anaesthetist before they went to theatre, when consent for anaesthetic was sought. In the day unit we also saw signed forms and patients commented they could see the anaesthetist prior to consent forms being signed. Patients were asked if they wanted a copy of their consent form.

We saw that consultants took the time to explain the risk and benefits which wererecorded on the consent form. The hospital had introduced new pre-printed forms forindividual operations which included all information regarding risk. We were told thatsite for the operation was marked in the admissions unit and that this was doublechecked with patients to ensure the procedure they expected, was the same as whatthe consultant was to undertake.

We were told by staff that it was the responsibility of the consultants and theanaesthetists to gain consent from patients and to complete the consent form. Nursingstaff told us they never undertook this for the medical staff, however they would act as an advocate if this was required. To advocate for a patients means that staff act as a person who speaks or writes in support of that patient if there were any concerns about the patients capacity to understand their treatment.

The trust had implemented a new consent policy this year and this was issued to staffin September 2011. This policy was specific about the responsibility and accountabilityfor assessing and determination of capacity and staff demonstrated an understandingof their role in ensuring that issues of the capacity of patients to understand their careand sign the consent form were highlighted to the responsible clinician.

Page 14 of 38

We saw that information provided to patients was specific to their type of surgery andgiven to them before they had a pre operative assessment so they had the opportunityto ask questions. Information was available in a range of different languages and wewere told that the trust was in the process of the information being available on thetrust's intranet. If a patient's first language was not English then there were interpreterservices available as well as the trust having a contract with language line. Staff withinthe trust who could act as interpreters were on the interpreter list.

The trust was able to provide information to learning disabled patients in the form of aneasy to read and understand format, which used pictures and symbols. This wasprovided so people could take this home and with the help of their family, carer,supporter or advocate could provide information about their individualised needs. Theinformation was clear on what processes to be referred to and followed if the personcould not understand the consent to treatment process.

We saw examples where pre- operative information clarifyed information about what toexpect after surgery. In critical care, a ward where patients have a high level of careneed, patients were provided with patient diaries so they could record informationbefore and after surgery and information they had sought themselves. The trust told us that patients could visit the operating theatres as well as the post operative wards prior to them being admitted to the hospital.

Within the pre-operative clinic and on the admissions unit we observed that physicalexaminations were done in individual consultation rooms and completed by nursingstaff. The patient's weight, body mass index, information about any risks known to theperson were confirmed and if they had any specific wishes in case of an emergency.

Staff on the post operative wards confirmed to us that they always explained to patientswhat procedure they were going to undertake and make sure that the patientsunderstand and verbally agreed before they start. When we talked to patients they told us that staff always discussed care and treatments with them prior to undertaking any care.

We talked to staff about their training on the Mental Capacity Act 2005 (MCA). Thislegislation protects people who lack mental capacity to make important decisions ortake important actions. Staff confirmed they had not received training on the Act butgave us good examples of the circumstances concerning its use. As an example a staffnurse described to us an incident where a patient was confused post operatively and asa result they had been advised to follow the safeguarding adults' process as they wereconcerned about the patient's welfare.

When we reviewed the mandatory training programme for 2011 we saw that only 20 minutes of the training was utilised to cover safeguarding vulnerable adults, Deprivationof Liberites and the MCA. The staff nurse recognised there were issues about the patient's ability to make decisions. On making further enquiries they discovered that theperson was known to the community mental health services and home discharge team and an investigation commenced as to why this information was not known to the ward staff. The positive outcome was that the staff nurse recognised the person could not make decisions in their best interest and acted up it.

Some staff said that consultant surgeons would 'consent' people for treatment if

Page 15 of 38

patients lacked capacity. We clarified that this was a staff perception that consultantsurgeons could make these decisions when they cannot. We advised the trust board ofthe need for staff to access training and guidance on the MCA so there would be nomisperceptions of staff about their responsibility and accountability under thislegislation.

On review of three case files in the pre operative assessment unit and on the surgicalwards we found that no issues of capacity had been identified during pre and postoperative assessment or care.

Our judgementPeople are able to decide upon examination, care and treatment because their consentis sought and the information provided to them explains the risks and benefits in a waythey can understand.

However people's rights could be compromised as staff do not have a full understanding of managing the Mental Health Capacity Act 2005 when seeking consentas not all staff had received training on this Act.

Page 16 of 38

Outcome 04:Care and welfare of people who use services

What the outcome saysThis 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 compliant with Outcome 04: Care and welfare of people who use services

Our findings

What people who use the service experienced and told usOne patient confirmed to us that they knew they would be going to the critical carefollowing their operation. Patients said that their pre operative assessment andphysical examinations were carried out in private. They told us that as part of the preoperative assessment they had a range of tests of their physical well being whichincluded a range of blood tests, heart monitoring and weight being assessed.

People said that the pre operative assessment helped them understand the surgical procedure they were being admitted to hospital for and were positive about their experiences.

We were also told that:"I had two telephone calls the day before I was due to come into hospital just to check Iwas okay and understood the admission procedure and operation"

"The staff have been great; they have looked after my elderly father very well".

"They went through all the forms again so I understood what was happening and I hadalready agreed to have the operation. They treat you really well in that way and I knew what to expect"

"The nurses have explained everything and carried out the procedure very well, theyare all very caring".

Page 17 of 38

" I have been impressed ; The NHS always gets a bad press but the doctor and all the staff have looked after me great"

"I have no complaints, I have been looked after well, my operation has been done andI'm going home now: I am very happy."

"They kept an eye on me and checked me every half hour. They gave me pain killerswhen I needed. They advised me to drink and made sure I had plenty of water".

"I'm waiting to go home as I'm ready. They've said I'll be given more information aboutwhat I'll have to do at home and that district nurses will be visiting me. Staff have beenlovely and checked on me all the time. I needed a bit of help to get dressed that was alland they made sure the curtains and the door was closed. That showed respect".

"The physiotherapist has seen me each day and I know when to expect them. They'vehad me standing and walking a bit already. They have speeded up my recovery, nowI'm waiting to be discharged and the physiotherapist is agreeing this with the doctor".

Other evidencePatients who were having surgery were seen within the pre assessment clinic. This wasthe time when staff would identify any concerns about high risk patients to enable theircare to be individualised. Staff told us that patients were contacted on the day beforetheir admission to check they were physically well making sure they had no signs of illhealth or with their skin integrity. They also discussed when patients should stop eatingand drinking. They have found that in doing this they have reduced the number ofpeople who do not attend for their surgery.

We reviewed three medical records of patients who had a pre operative assessment.We found that their health was assessed by the senior nurse practitioner and they hadexplained the procedure to the patient. We saw that patients had been seen by a doctorwhen completing a consent form. The doctor and patient had both signed the consent form to confirm that they understood the risks and benefits of the procedures they were having.

We could see that patients were offered and agreed to having blood transfusions if needed or additional surgical repairs. We could see that patients were also able to choose the type of anaesthetic they wanted.

We observed that on admission patients were reassessed within the admissions unit bynursing staff. Both the consultant and the anaesthetist spoke to the patients to ensurethey knew what to expect and consented to surgery. Staff were able to spend time with patients to explain and discuss any concerns. We saw that all staff updated the medicalrecords during this consultation. Patients were prepared for theatre in the admissions unit and were escorted to theatre direct from the unit.

During the inspection we were able to spend time both in the day surgery unit and themain theatre suite. We observed that patients had identity and procedural safety checksundertaken and documentation was completed as required. Consent forms werechecked and the proposed procedures confirmed with the patient before being takeninto the anaesthetic room. The patient's observations were appropriately monitored andstaff constantly assured patients during the administration of the anaesthetic.

Page 18 of 38

Patients were safely and effectively transferred throughout all areas of theatre. Swab,needle and instrument checks were undertaken and documented as required. Time out to undertake the checks was observed as required within the World Health Organisation(WHO) surgical safety guidance. It was evident that learning from previous incidentshad been disseminated and put into clinical practice.

The operating session observed was conducted in an organised and professionalmanner throughout. Patients were seen to be safely transferred back to the care of the ward staff and all relevant information was appropriately cascaded to staff, withoutcompromising confidentiality.

All the areas we inspected were designed to promote dignity and privacy for patients.The hospital maintained single sex bays and theatre waiting areas. Staff we spoke toconfirmed that single sex accommodation was maintained by moving patients aroundwithin ward areas as required. All patients stay in the surgical unit and we were told thatbeds were protected so they cannot be used by other departments in the hospital.

We saw that care for patients was multi-disciplinary to ensure that each patient receivedthe best outcome from their surgery. Physiotherapists were available in ward areas throughout the day and there was a designated therapy room available. Patients'records were seen to be multidisciplinary with all practitioners recording the care andtreatment they have given to patients.

Discharge procedures for patients were commenced in the pre-operative clinic. We sawthat time was taken to assess if a patient would be safe to go home and if there wascare and help at home for them. Staff told us that they would access support fromsocial services if the patient lived alone and needed help.

Our judgementPeople receive safe and appropriate care, treatment and support that meet their needs.

Page 19 of 38

Outcome 07:Safeguarding people who use services from abuse

What the outcome saysThis 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

There are minor concerns with Outcome 07: Safeguarding people who use services from abuse

Our findings

What people who use the service experienced and told usWe did not receive any specific comments about this outcome.

Other evidenceThe hospital had procedures in place for dealing with allegations of abuse. Staffconfirmed they had access to these and told us they had read and understood them.They told us they had received training in the protection of vulnerable adults andchildren and showed a good understanding of the procedures to be followed in theevent of any allegations or suspicion of abuse or neglect. We were told that as part ofstaff supervision safeguard training was assessed and reviewed.

Staff training on safeguarding was provided by the safeguarding lead on the ward usinga DVD presentation and the safeguarding work book. There was also a safeguarding e-learning module for staff. We were told that the safeguarding process had been revised and was available on the trust's intranet. However we saw that the mandatory training programme only included a 20 minute session on safeguarding vulnerable adults, Deprivation of Liberties and the Mental Capacity Act.

Staff members spoken to said they would not hesitate to report any concerns they hadabout care practices to ensure people were protected from potential harm or abuse.Staff were aware of the 'Gillick competencies' when dealing with older children. Gillickcompetence is a term used in medical law to decide whether a child (16 years oryounger) is able to consent to his or her own medical treatment, without the need for parental permission or knowledge.

Page 20 of 38

Some members of staff were able to describe incidents they witnessed and explainedhow they dealt with the situation adhering to hospital guidelines. It was clear from discussions with staff of various designations, that they had a good understanding of safeguarding. They commented that they had confidence in the process they would follow if they had concerns about clinical practice or if issues had been disclosed to them. However we were told that on occasions when referrals had been made to the safeguarding team, staff making the referral were not informed of the outcome.

Throughout observation of practice within the surgical unit it was evident that staffprovided care in a manner that protected patients both from physical and physiologicalharm. The pre operative assessment senior practitioner in the pre operative assessment clinic was trained on the Mental Capacity Act 2005 but said this needed refreshing. They were very clear that it was the consultant's responsibility for assessing capacity and this was supported by the trust's consent policy issued in September 2011.

We spoke with three members of staff about safeguarding and they were able to describe the trust's process on referrals. Two members of staff had used the safeguarding referral process successfully but had not received any feed back on the outcome.

We spoke to two members of staff about Deprivation of Liberties (DoL's); theyunderstood the principle but had not experienced this in the surgical ward. However wefound that a ward manager understood DoL's and there was a policy stemming from theconsent policy. Both indicated that if the MCA or DoL's were to be used then they wouldbe aware of this or any restrictions prior to admission.

Our judgementPeople are protected by staff that understand the indicators of abuse and raise theirconcerns with the right people so action is taken to ensure they are safe.

However there is a risk that patient's human rights will always not be protected as not all staff had received training in the Mental Health Capacity Act 2005. The trust does not have a consistent approach to offering feedback to staff who had raised concerns.

Page 21 of 38

Outcome 08:Cleanliness and infection control

What the outcome saysProviders of services comply with the requirements of regulation 12, with regard to the Code of Practice for health and adult social care on the prevention and control of infectionsand related guidance.

What we found

Our judgement

The provider is compliant with Outcome 08: Cleanliness and infection control

Our findings

What people who use the service experienced and told usPeople told us that they found the new surgical unit nice and bright, clean and comfortable.

Other evidenceThe surgical unit of the hospital has recently been built and opened in July 2011. Onthe day of our inspection we found the unit met infection control guidelines forcleanliness and infection control.

Prior to this inspection we had received some concerning information about the way thehospital managed one patient who may have had an infectious disease. As part of ourinvestigation into these concerns we asked the trust to provide us with their selfassessment documentation for this outcome.They told us, and were able to demonstrate that, they monitored their infection rates and reported the outcomes to the trust board.

The trust had an infection control strategy in place which has resulted in the reduction in Methicillin Resistant Staphylococcus Aureus (MRSA) bacteria by 85%when compared to 2007/08 rates. There has also been a reduction in the number of cases of Clostridium Difficile (C. Diff.) by 68.73% for the last four years. The trust told us that thiswas as a result of clinical engagement, new ways of working and the commitment of all staff to make improvements in this area.

We saw that the trust also had a plan to manage influenza (flu) outbreaks. On review ofthe pandemic influenza plan we found that the trust had mechanisms and a deliveryplan in place to support people suffering from influenza and to prevent the spread of the

Page 22 of 38

infection throughout their hospitals. This plan confirmed that patients admitted who had suspicion of 'flu were tested for the disease. A consultant told us it was not routinepractice to test all patients on admission due to number of patients within the hospital.

Advice was available to patients regarding infections. Specific pamphlets had beenproduced and information was available on the trust's internet. If a patient who had, ordeveloped an infectious disease, was admitted to the hospital there were procedures inplace to care for them.

The hospital had an isolation policy. On inspection of the post operative wards we saw that there were single rooms available in all areas and staff explained to us that patientswould be nursed in isolation as required. The pandemic influenza plan described a clear strategy for caring for patients and preventing the spread of infection.

When we asked commissioners about the trust's policy on the control of infectionsassociated with a specific disease we were told that they were satisfied with the trust'sprocedures. The commissioners provided us with details regarding the trusts handlingof last year 'swine flu' epidemic. They demonstrated to us that daily meetings took placeto discus patient infection. Patients arriving via the clinical decisions unit (CDU) wereautomatically swabbed when symptomatic of flu. Patients were referred to CDU by adoctor who had made an assessment of their condition and who confirmed that CDUwas the best place to investigate the problem further.

Within the pandemic strategy it stated that an executive decision would be made withregards to the suspending of all planned activity throughout the trust. Microbiologists inthe trust were included on Department of Health's distribution list when updatedguidance received. They further confirmed that the hospital had sufficient supplies ofthe flu vaccine.

A hygiene code inspection of the hospital was undertaken in November 2009 which didnot identify any concerns with the hospital at the time. The trust told us that the hygienecode was complied with and ongoing compliance was monitored at hospital infection prevention and control committee. We saw that quarterly infection prevention reports were submitted to the board for their ongoing monitoring and information. These reportscontained monthly national and local monitoring of infection targets.

We saw that the infection prevention standards had been re-issued and all staff were required to sign to demonstrate commitment to infection prevention practices. We saw that staff had access to the trust's intranet and that the front page and screen saver on the computer gave staff information about infection control rates.

During our inspection we saw that all staff conformed with the trust's uniform policy andthe dress code was adhered to which ensured that clothing worn by staff when carrying out their duties was clean, fit for purpose and prevented the possibility of spreading infection. Staff told us that there was a zero tolerance to staff not following the policy; however they identified the junior doctors as the worst culprits for not following the procedure.

We saw that there were hand dispensers at various points around the ward areas andcorridors containing an antibacterial hand wash. There were signs prominentlydisplayed requesting people to follow the hand washing procedure. We saw staff

Page 23 of 38

regularly use antibacterial hand wash before entering and when leaving bedrooms orward areas after contact with patients. We saw staff used personal protective clothing when providing care to patients.

There was information to staff and visitors about how infection control was monitored in the ward areas with the results of hand washing audits and audit of cleanliness of the ward area displayed.

We were told that infection prevention training was provided at induction and ongoingtraining was implemented on mandatory training days and contained with the learningworkbook. Staff we spoke to confirmed they understood the principles of infectionprevention and had received up to date training. Practices observed on our visitdemonstrated that staff provided care in a manner that protected patients from crossinfection.

Our judgementThe trust has appropriate policies and procedures in place which staff were seen toadhere to. Staff are trained in infection control procedures to ensure that patients wereadequately protected from the risk of infection. The trust takes its responsibility forpreventing and controlling infections seriously by providing staff, patients and visitorswith information about preventing infection from spreading by using best practiceguidance, infection control products and personal protective clothing.

Page 24 of 38

Outcome 10:Safety and suitability of premises

What the outcome saysThis is what people should expect.

People who use services and people who work in or visit the premises:* Are in safe, accessible surroundings that promote their wellbeing.

What we found

Our judgement

The provider is compliant with Outcome 10: Safety and suitability of premises

Our findings

What people who use the service experienced and told usPatients said that the new building was relaxing and clean but some did not like the layout of the four bedded bays. We were told there was insufficient natural light in the bayand the lighting provided was insufficient and had to be on all day and that in the bathroom there were no electric shaver points.

"The wards are new and clean – it's very comfortable in here."

"For a new building they have got a lot of the basic things wrong. When I used the toiletafter having an operation I had to wriggle about to reach the toilet roll which is behindyou. That's just not sensible".

Other evidenceThe surgical unit of the hospital has recently been built and opened in July 2011. Theenvironment was clean and bright in all of the units, with sufficient rooms and spacethat enabled confidential discussions with staff when appropriate. Reception and waiting areas were large and able to accommodate patients with relatives or friends.Cubicle curtains were antimicrobial treated. There were sufficient hand wash facilities,with non touch tap systems. Hand towels were available at each sink.

Staff said the new surgical unit was a positive place to work and they were still settlingin after the recent move from the previous facilities. Staff said the pre operative facilitiesand post operative wards were more relaxed and comfortable. A staff member said, "Patients seem more relaxed when they come in for their assessments and have said how relaxing it is in comparison to what we had. Patients have said how relaxing it is

Page 25 of 38

coming in for their pre-operative assessment and then going into surgery. I haven't had any negative comments yet".

In all the areas we looked at in the surgical unit conformed to the single sexaccommodation policy. Although the wards were of mixed sex, the layout meant that itwas easy to segregate male and female bays. Each bay and single side rooms all haden-suites and were used for either sex. In the admissions unit there was a separatewaiting area for theatre for each sex.

On our inspection we found that the main theatres, as with all other areas in the unit,were fit for purpose and were clean and well organised. The theatres complied withcurrent health building and technical guidance. We inspected equipment within the theatres and found that it was either newly purchased or had been transferred from the old unit. All equipment was seen to have been portable appliance tested and serviced as appropriate, either by the internal electrical engineering department or via service level agreements with the manufacturer. Equipment for patient use that was transferredto ward areas had been standardised across the trust. This included the patient controlled analgesia pumps. There was a current asset register in place for all equipment within the theatre unit.

All patient areas were suitable for use. However we did note that in some areas the callbells in toilet did not reach the floor and some fire doors were not closing correctly. Wewere informed that there was a 'snagging' visit scheduled for the following day by thebuilder's representative and we were assured that these issues would be addressed.We were told that the fire evacuation policy had only just been approved and that fireevacuation drills had not been undertaken since the unit had opened in August. Seniorstaff confirmed that a drill was arranged in October.

Our judgementPatients are cared for in safe accessible surroundings that promotes their well being.

Page 26 of 38

Outcome 13:Staffing

What the outcome saysThis is what people who use services should expect.

People who use services:* Are safe and their health and welfare needs are met by sufficient numbers of appropriate staff.

What we found

Our judgement

The provider is compliant with Outcome 13: Staffing

Our findings

What people who use the service experienced and told usPatients said that staff were attentive and were readily available to provide care andsupport when needed.

"Fantastic, can't do enough for you. If you ask for something it's done. If I press the callbell they're there within four beeps, I can't fault them".

"They kept an eye on me and checked me every half hour".

"The staff are excellent; they do speak to people in a respectful way".

"I think they do a great job".

"Night staff are more friendly, the day staff seem to be a bit rushed to spend too long atime with you"

"The day staff are perfect, they have been wonderful. I feel there may be a shortage of night staff as I usually have to wait for my medication until after 11.30pm. Night staff can also be noisy as they talk in normal voices and seem to forget people are trying to sleep"

Other evidenceWe discussed staffing levels and were informed there was only one staff vacancy onone of the two wards we visited. One of the wards offered varied post operative surgical

Page 27 of 38

care to patients offering urology, ear, nose and throat and ophthalmology services. Staffon the ward said there had been an integration of three different wards and staff were learning new skills from one another but difficulties arose if there was not someone withthe appropriate specialist skills on duty. This was not raised as a concern as the staff member said it was "More of a teething problem when you move to a new unit and integrate services".

We were told on another ward that through integration the staffing levels were felt to be inadequate due to the types of patients and the lay out of the ward. There wereconcerns raised that there was no nurse bank to support unexpected sickness so it wasexpected that staff would be shared between wards and sometimes wards did have tomanage short staffed. On the day of our site inspection we did found people's needswere being met by the level of staff on duty however the trust must keep this underreview to ensure the staff concerns are listened to and fluctuations in needs are met.

Senior staff confirmed during the visit that the staffing establishment for the theatreswas under review. Guidance from professional bodies had been considered during thereview. It was explained that a number of staff worked over their contracted hours inorder to complete operating sessions on a regular basis. Staff told us that they do feelunder pressure; however they were aware that vacancies were being reviewed.

The trust's staff rotas have been managed electronically for the past 18 months. Wereviewed past staffing rotas for August and found that these met the staffingrequirements apart from one day. We found that the day had been covered but hoursand allocation had not been transferred from a paper based rota still used on the wardsto the electronic system. Staffing levels were supported in times of sickness, from staffeither working overtime or from the 48 hour capacity.

Our judgementPatients did have a sufficient number of suitably qualified, skilled and experienced staffto assist them at all times. The numbers of qualified and non qualified staff and mix ofskills and experience provided appropriate levels of care and support.

Page 28 of 38

Outcome 14:Supporting staff

What the outcome saysThis 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

There are minor concerns with Outcome 14: Supporting staff

Our findings

What people who use the service experienced and told usPatients said that staff were available when needed and had a relaxed and professionalapproach to their jobs which put them at ease. They told us that they were supported bystaff who were helpful and recognised if they had anxieties about their treatment. Theyconfirmed that staff helped them understand their treatment and allay their anxieties.

Other evidenceThe trust reconfigured the surgical division when they opened the new unit and therehave been some large changes across the general hospital. The executive team told usthey have undertaken investment in the previous 12 months to improve staff moraleand productivity. This includes development of the 'Blackpool Way', an ethos and values base plan introduced through the vision and values road shows started in 2011 and included within the suite of mandatory training.

We talked to staff about their access to and opportunities for training. A health careassistant said that they had achieved a nationally recognised qualification called aNational Vocational Qualification at level 3 which supported them to do their job. Theyalso told us that they had additional training so they had developed different skills suchas taking blood from patients.

We were told that the trust provided training that staff had to complete at least annually for some courses. This training included moving and handling, first aid, health and safety at work, equality and diversity, depravation of liberty safeguards and emergency life aid. We saw that staff had access to the trust's intranet for training on line. We saw how the front page and screen saver on the computer gave staff up and coming

Page 29 of 38

information about forthcoming training events. However staff said they hadopportunities to do training during their working hours but training opportunities couldbe limited if the wards were busy. They also told us that training could also be cancelled.

Staff showed us how they accessed their own individual learning information. We talkedabout training on the Mental Capacity Act 2005. The staff based on the surgical wardswe visited confirmed that they had not undertaken this training but were aware thedoctors had. Staff also discussed with us their training and professional development inline with clinical procedures they needed to undertake. There is more informationregarding this within the evidence of outcomes 2 and 7.

All staff members can view their training and attendance record on the front of their newfor 2011 intranet page. We saw that the hospital had 17 specific training eventsconsidered mandatory, these include clinical governance, risk management,safeguarding vulnerable adults and information governance which are all completedannually via a work book. Courses ranged in both their frequency of requiredattendance and their method of delivery, including e-learning which was new for 2011.

Attendance on training was led by the individual with their intranet page alerting them ofrequired attendance and due date. Staff that missed courses were sent a letterrequesting attendance at the next session, details were also given of the time framethey had left to complete the training. The completion of mandatory training was linkedto the appraisal system and non attendance resulted in issues for appraisal completion.However in May 2011 it was acknowledged that medical staff had a low completion ratefor e-learning and a memo was sent to all medical staff to encourage participation

Corporate inductions were held on a monthly basis and 80% of staff attended within 3 months of commencing their employment. Corporate induction for medical trainees wastwice yearly as the majority of new trainees join the trust in February and August, however specialist trainees, on a rolling programme, join the trust throughout the year and attend the corporate induction sessions.

As part of each staff members induction they completed a one day course on all mandatory training courses they needed to attend specific to their job role/grade. All staff have a basic introductory induction including a first day /first week checklist; this included familiarisation with facilities and introduction to policies and procedures within their workplace. The full three day course included the attendance at the vision and values road show, the expected employment and health and safety policy overviews, aswell as introductions to reporting and investigating incidents complaints and all aspects of safeguarding.

We found that the appraisal of staff within the trust changed from paper based to anelectronic system in April 2011. The appraisal consisted of 6 vision statements andidentified the breakthrough objective for its completion. These included quality, safety(including safeguarding), people, delivery, environment and cost. The content had notbeen changed since 2010.

When we inspected the appraisal process we saw that the intranet home page showedthe staff's progress through the appraisal process. The process involved the appraisedself assessing their achievements which is then submitted on line to the appraiser. The

Page 30 of 38

line manager and staff member then meet together to complete the electronic final appraisal assessment, add comments and set objectives for the following year. The electronic appraisal can not be submitted until all elements are completed.

Also included in the 2011 appraisal was a specific question on the usefulness of the medical devices training and a personal development plan. This also included questions on how the appraised was planning on meeting their mandatory training requirements and if there are any potential issues or risks for non-attendance.

When we spoke to staff they said they were supported by their managers and hadopportunities to discuss their professional development and training and this wascomplemented by an annual appraisal. We were told that the ward managers appraisethe staff on the ward and they were appraised by the matrons on the unit. One staffmember told us that they "had a great job – I feel very well supported."

In the theatre suite concerns were expressed about staffing levels which impacted on the availability of staff to undertake appraisals and clinical supervision adequately. Moststaff confirmed that they had completed their appraisals but senior staff expressedconcerns about the quality of appraisals due to time constraints. It was explained thatmore staff were to undertake appraiser training in the near future to improve theprocess.

Some clinical supervision had taken place but it was felt due to time restraints that mostsupervision was informal and not documented. It was felt this reflected the "open doorpolicy" of the line managers and senior staff. Staff meetings had not taken place on aregular basis since the unit had opened, however some staff had been able to meet onthe day of the inspection.

In the trust's surgery department response within the staff satisfaction survey 2010,most responded negatively to all questions related to immediate line manger supportand significantly worse in all aspects of appraisal. Specifically that the appraisal processwas not helpful in improving how they did the job.

Staff were spoke to during our inspection told us however:"I do feel supported by my manager, but still feel under pressure at all times due to thestaffing situation".

"Staff support each other well here".

"I really do feel part of a team".

"This is my first placement, it's been great: all the staff have been very supportive".

Our judgementPatients are cared for, supported and their health and welfare promoted by competentstaff that are appropriately trained, supervised and appraised. However somedepartments and staff would benefit from strengthening the appraisal and supervisiondelivery.

Page 31 of 38

Outcome 16:Assessing and monitoring the quality of service provision

What the outcome saysThis 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

There are minor concerns with Outcome 16: Assessing and monitoring the quality of service provision

Our findings

What people who use the service experienced and told usWe did not receive any specific comments about this outcome.

Other evidenceAudits undertaken at Blackpool Victoria Hospital were agreed in line with national andlocal priorities and ratified by the Board of Directors. Staff time for the inclusion in auditswas allocated within their work plan and support was offered via a lead auditor.Additional audit support was provided at division level if required.

The 2011/12 audit work plan consisted of 402 audits which the trust was to undertake.Samples of 43 of these were taken at the inspection which included 12 audit's relatingspecifically to surgery related activity. Reviewing these audits we found that there were 13 audits ongoing of which 4 were relating specifically to surgery related activity.

The lead auditor was usually a consultant who supervises junior doctors undertakingthe audit and ensured continuity if any of the doctors left before the audit wascompleted. Junior doctors and nursing and support staff had time allocated in their workplans for education and participation in audit.

A recent WHO surgical safety checklist audit was completed in July 2011 on Elective,Day Surgery unit (DSU) and emergency surgery departments. The results of thisdemonstrated that there were some concerns over the adherence to this process. InApril 2011 the WHO checklist was included in the newly implemented ways of workingcalled Standard Operating Procedures (SOP).

Page 32 of 38

Blackpool Victoria Hospital had a number of serious untoward incidents (SUI's) andnear misses in the last half of 2010. We saw that following these incidents a workingparty was developed, supported by the clinical improvement committee and learningfrom incidents and risks committee. A surgeon was appointed to the working group inJanuary 2011. However we saw that concerns were noted that improvements topractice following SUI's were not being made quickly enough.

We were told that the SOP was expected to be implemented in February 2011 with theresponsibilities from the SOP to be drawn into job descriptions. Failure to comply withthe SOP would result in disciplinary action. However we found that these were notfinalised and issued to staff until April 2011; this had resulted in many of the detailswithin the procedure not being adhered to. Policy, procedure and board ratification of actions to be taken has been slow and minutes of a governance meeting show that some surgeons were reluctant to 'buy in' to the procedure.

It was clear that many new procedures and systems had recently been developed andimplemented. These included a monthly lessons learnt newsletter, the inclusion of alesson learnt section on the incident records and the review and closure ofcomprehensive SUI files by commissioners. It was not clear if these systems andprocedures were embedded and actioned by all departments and indeed how theywere to compliment and support procedures already in place. The current process forproducing and circulating a lessons learnt log did not allow the sharing of these lessonsto be completed as long as four months after the incident. There was also evidence thatmany intended recipients were not receiving the newsletter including surgery teams.

We found that the lessons learnt newsletter was distributed via email to key staff. Aread receipt was requested for the email and the newsletter was then filed on theintranet. When we reviewed the audit of this distribution we found that there wasapproximately 30% failed delivery of the email with its newsletter attachment, includingthe delivery to the cardiac surgery and day case theatre email address'. This had failedin the three months October 2010, February 2011 and September 2011. As these werethe only logs viewed it was unclear if it was successful at any other time. The trustexplained to us that this occurred because within the past 12 months the trust hasundergone restructuring within the divisions and a reduction in employees. This hasresulted in individuals listed on the mailing list no longer being employed by the trustand therefore these e-mails will be returned as failed delivery.

The lessons learned newsletters, red alert newsletters and the anonymised StEIS/SUIreports included actions taken. We were also told that the electronic incident reportingsystem included a lessons learned mandatory field for staff to complete and followingthe closure of the investigation the investigation report was returned back to thereporter for all levels of incidents.

When reviewing information and discussing incidents with a member of staff, we foundthat the untoward incident and serious incident reporting policy and the SOP policywere not available in a hard copy on the ward. We were told that staff did howeverknow how to access them from the intranet. The Knowledge Management websiteincluded lessons learnt newsletters, improvement initiatives and risk reduction measureinitiatives. The trust told us that web page had received over 5500 hits since January 2011

Page 33 of 38

Staff demonstrated that they knew about marking the site of surgery and identify anyhigh risks with the patient prior to surgery onto the WHO checklist. We were told thatstaff had completed root cause analysis training and understood their responsibilitiesfor reporting incidents.

We were informed by the trust that the executive team undertook planned monthly patient safety walkabouts and weekly unplanned patient safety walkabouts in which best practice and areas for improvement were identified and followed up to ensure improvements were made and published on the Patient Safety Walkabout Web Page and reported to the board.

Our judgementThe trust has developed new policies and procedures for dealing with seriousuntoward incidents and there is a system in place to monitor the quality of treatment and care.

Page 34 of 38

Improvement actions

The table below shows where improvements should be made so that the service provider maintains compliance with the essential standards of quality and safety.

Regulated activity Regulation Outcome

Surgical procedures Regulation 11 HSCA 2008 (Regulated Activities) Regulations 2010

Outcome 07: Safeguarding people who use services fromabuse

Why we have concerns:People are protected by staff that understand the indicators of abuse and raise their concerns with the right people so action is taken to ensure they are safe.

However there is a risk that patient's human rights will always not be protected as not all staff hadreceived training in the Mental Health Capacity Act 2005. The trust does not have a consistent approach tooffering feedback to staff who had raised concerns.

Surgical procedures Regulation 23 HSCA 2008 (Regulated Activities) Regulations 2010

Outcome 14: Supporting staff

Why we have concerns:Patients are cared for, supported and their health and welfare promoted by competent staff that are appropriately trained, supervised and appraised.

However some departments and staff would benefit from strengthening the appraisal and supervision delivery.

Surgical procedures Regulation 10 HSCA 2008 (Regulated Activities) Regulations 2010

Outcome 16: Assessing and monitoring the quality of service provision

Why we have concerns:The trust has developed new policies and procedures

Actionwe have asked the provider to take

Page 35 of 38

for dealing with serious untoward incidents and there isa system in place to monitor the quality of treatment and care.

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 to us within 14 days of the date that the final review of compliance report is sent to them.

CQC should be informed in writing when these improvement actions are complete.

Page 36 of 38

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

Surgical procedures Regulation 18 HSCA 2008 (Regulated Activities) Regulations 2010

Outcome 02: Consent to care and treatment

How the regulation is not being met:People are able to decide upon examination, care and treatment because their consentis sought and the information provided to them explains the risks and benefits in a waythey can understand.

However people's rights could be compromised as staff do not have a fullunderstanding of managing the Mental HealthCapacity Act 2005 when seeking consentas not all staff had received training on this Act

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 2010.

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 37 of 38

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 actionsor 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 proceduresin 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 38 of 38

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 © (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 www.cqc.org.uk

Telephone 03000 616161

Email address enquiries@cqc.org.uk

Postal address Care Quality CommissionCitygateGallowgateNewcastle upon TyneNE1 4PA