CQC calls for action to improve care for older people

By on October 13th, 2011

CQC today publishes a report into the standards of care that elderly people receive in hospital – and calls for a system-wide response to combat the failings identified.

(Download the Dignity and nutrition inspection Report)

This report summarises the findings of 100 unannounced inspections of NHS acute hospitals which took place between March and June, looking at whether the essential standards of dignity and nutrition were being met on wards caring for elderly people.

Around half of the hospitals needed to do more to ensure that they were meeting people’s needs – with twenty of the hospitals visited failing to meet essential standards required by law.

Of the 100 hospitals inspected:

  • 45 hospitals were fully compliant – meeting the essential standards relating to both dignity and nutrition.
  • 35 met both standards but still needed to make improvements in one or both
  • 20 hospitals did not meet one or both standards – with major concerns identified in two cases.

CQC inspectors have since returned to hospitals where concerns were identified to check that improvements have been delivered.

During the initial inspections, two hospitals were identified as having major concerns – Sandwell General Hospital, in West Bromwich, and Alexandra Hospital in Worcestershire.

A follow-up unannounced inspection to Alexandra Hospital found that action has been taken to address CQC concerns and the hospital is now meeting essential standards.

However, when CQC inspectors returned to Sandwell General, they found that, although standards around meeting people’s nutritional needs had improved, people’s dignity was not always respected. Inspectors visited two wards; the Emergency Assessment Unit (EAU) and Newton 4. Patients spoke highly of the care they received in EAU, but on Newton 4, inspectors observed incidents including a person who had been incontinent remaining unwashed for an hour and a half, despite asking staff for help.

Following this inspection, continuing concerns about the care provided on Newton 4 were raised with the Trust.  In response, the Trust has subsequently closed Newton 4 and replaced it with two separate units for acute stroke and stroke rehabilitation.  General medical admissions to the ward also ceased immediately. As a result, CQC have not taken immediate enforcement action, although inspectors will be making another unannounced visit to check that this action has had a real impact on improving care and that problems do not emerge elsewhere.

CQC inspectors also revisited James Paget University Hospitals NHS Foundation Trust in September – having originally identified moderate concerns around both dignity and nutrition. They found people not being given appropriate support to eat and drink, and that people in need of intravenous fluids did not have infusions.   As a result, a warning notice has been issued to James Paget which demands that the Trust make swift improvement or face serious consequences, which could include prosecution or restriction of services.

The key themes observed in hospitals that were failing to meet the essential standard relating to dignity (‘respecting and involving people who use services’) were:

  • Call bells put out of people’s reach or not responded to in a reasonable time
  • Staff speaking to people in a condescending or dismissive way
  • Curtains not properly closed when personal care was given to people in bed
  • Comments from patients and staff that there were not enough staff with the right training on duty to spend time giving care

The key themes observed in hospitals that were failing to meet the essential standard relating to nutrition (‘meeting nutritional needs’) were:

  • People not given the help they needed to eat, meaning they struggled to eat or were physically unable to eat meals
  • People interrupted during meals and having to leave their food unfinished
  • People’s needs not assessed properly, which meant they didn’t always get the care they needed – for example, specialist diets
  • Records of food and drink not kept accurately so progress was not monitored
  • Patients not able to clean their hands before meals

Commenting on the report, Dame Jo Williams, Chair of the CQC said:

“Too often, our inspectors saw the delivery of care treated as a task that needed to be completed. Those responsible for the training and development of staff, particularly in nursing, need to look long and hard at why the focus has become the unit of work, rather than the person who needs to be looked after – and how this can be changed.

“Care professionals need to strike the right balance between ensuring that people get the care they need in a safe way – recording how much they have eaten and drunk, what medications they have taken and when – while not prioritising processes over people. Task-focused care is not person-centred care. Often, what is needed is kindness and compassion…which cost nothing.”

The report identifies three underlying conditions that can lead to poor care:

Leadership. It was clear that in some hospitals unacceptable care had been allowed to become the norm. Leaders in hospitals must create a culture in which good care can flourish; boards of governors, chief executives, senior managers, health professionals and those who manage teams of nurses and healthcare assistants should foster an environment in which care staff understand the importance of dignity and good nutrition, and are supported to deliver this.

Staff attitudes – and the training and management that nurture these attitudes – are critical. CQC inspectors saw too many cases where patients were treated by staff in a way that stripped them of their dignity and respect. People were spoken over, or not spoken to; people were left without call bells, ignored for hours on end, or not given assistance to do very basic things – to eat, drink, or go to the toilet.

Resources: Having plenty of staff does not guarantee good care – inspectors saw unacceptable care on well-staffed wards, and excellent care on understaffed ones – but not having enough staff increases the risk of poor care.  The best nurses and doctors can find themselves delivering care that falls below essential standards because they are overstretched. Staff must have the right support if they are to deliver high-quality care that is clinically effective. In the current economic climate this is harder to deliver; but hospital management must ensure that budgets are used wisely to support front line care staff.

Dame Jo Williams concluded:

“The fact that over half of hospitals were falling short to some degree in the basic care they provided to elderly people is truly alarming, and deeply disappointing.

“This report must result in action. CQC will play its part by holding hospitals to account for poor care when we find it – our survey of trusts suggests many are already responding. But the system as a whole – those who are responsible for making sure care meets essential standards, and those who commission that care – must respond if we are not to find ourselves here, yet again, a few years down the line.”

The 100 inspections employed a collaborative approach, with CQC inspectors accompanied by a practising nurse and an ‘expert by experience’ (a person with direct experience of care services).CQC also worked closely with an external advisory group of key stakeholders throughout the process.

CQC sent a short survey to the Trusts we visited as part of the inspection programme to evaluate the impact of the process. Three-quarters of them responded saying they had made changes to the way they looked at dignity and nutrition as a result of the inspection programme. Impressively, 74% agreed that the judgements were fair – despite many of the judgments being negative – and only six per cent disagreed.

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Individual reports can be found at http://www.cqc.org.uk/reviewsandstudies/inspectionprogramme-dignityandnutritionforolderpeople/inspectionreports.cfm

Download the Dignity and nutrition inspection Report