The Care Quality Commission (CQC) today announced that Luton and Dunstable NHS Foundation Trust has addressed concerns linked to the trust’s clinical governance arrangements for infection prevention and control.
The regulator will now lift the remaining condition imposed on the trusts licence on 1 April 2010, when it introduced a tough new registration system for NHS trusts.
CQC ordered improvements to be made after concerns were identified requiring a review of the infection control governance arrangements across the trust to ensure that robust systems and processes were in place to protect people throughout all areas of the hospital.
As part of the review, CQC conducted an unannounced inspection on 1 July. During the visit CQC staff gathered information about improvements through discussions with front line staff and a review of care delivery systems to patients.
CQC also visited out-patient areas and reviewed the infection control clinical risk assessment documentation within this area.
The CQC review also noted that the trust had:
- Reviewed its infection control policy
- Set up weekly infection control task force meetings
- Changed its directorate structure and revised its clinical governance framework to ensure that monitoring and reporting systems were robust and accountable through line management responsibilities
- Carried out further Department of Health hygiene code audits “saving lives” to identify areas that the trusts infection control team should focus on
- Refurbished areas of the hospital, including replacing commodes and toilets
- Achieved an average score of four (out of a possible 5) from the Patient Environment Action Team which includes members of the public and carried out unannounced checks on the hospital environment
Frances Carey, CQC's east region director, said: "Catching a healthcare-associated infection, such as MRSA or Clostridium difficile, is a very real concern for some patients. That's why trusts must demonstrate that they are doing everything possible to minimise the risks.
"The trust has now introduced good processes that will help prevent and control infections. But, it must maintain vigilance on behalf of patients.
"We would like to thank all of the staff and patients who spoke with us during our inspections and gave us frank and honest accounts of patient care."
In April CQC also removed another of the conditions that it placed on the trust during registration. This condition linked to staffing issues (regulation 22).
Following an unannounced visit on the 30 April, CQC found evidence that the trust had taken necessary steps to review its processes for contracting with nurse agencies for the supply of temporary staff. This had addressed outcome 13 (regulation 22), which requires trusts to have sufficient numbers of staff with the right knowledge, experience and qualifications in place to meet patient needs.
The April CQC review report noted that the trust had addressed concerns linked to regulation 22 by:
- centralising its agency booking system
- reviewing the registration status of all nursing agencies
- reducing the number of nursing agencies used; by setting up a preferred provider list (of 5 providers)
- introducing an agency audit checklist which looks at agencies as a whole, and individual workers employed via agencies
The trust also reassured the regulator (CQC) that it had put plans in place to reduce dependency on agency/bank staff and to promote permanent staff recruitment.
Notes to Editor
Other areas of improvement for the trust:
The CQC's April unannounced inspection also revealed that the trust was able to provide evidence of progress in their maternity action plan around the areas of recruitment and retention of maternity service staff and in improvements to the built environment within the maternity department.The trust's updated action plan and their maternity dashboard a monthly performance update for the trust board demonstrated improved outcomes for people who use these services.This was supported by the tour of the department and discussions with front line staff and the people who were using the service.
The trust were found to be compliant with outcomes 10 (regulation 15) and 13 (regulation 22) in relation to progress on their maternity action plan.
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About the Care Quality Commission
The Care Quality Commission (CQC) is the independent regulator of all health and adult social care in England. We inspect all health and adult social care services in England, whether they're provided by the NHS, local authorities, private companies or voluntary organisations. We also seek to protect the interests of people whose rights are restricted under the Mental Health Act. We make sure that essential common standards of quality are met everywhere care is provided, from hospitals to private care homes, and we work towards their improvement. We promote the rights and interests of people who use services and we have a wide range of enforcement powers to take action on their behalf if services are unacceptably poor.
Our work brings together (for the first time) independent regulation of health, mental health and adult social care. Before 1 April 2009, this work was carried out by the Healthcare Commission, the Mental Health Act Commission and the Commission for Social Care Inspection.
Our aim is to make sure that better care is provided for everyone, whether it is in hospital, in care homes, in people's own homes, or anywhere else that care is provided.
Registration: The Health and Social Care Act 2008 introduced a new, single registration system that applies to both health and adult social care. The new system will make sure that people can expect services to meet new essential standards of quality and safety that respect their dignity and protect their rights. The new system is focused on outcomes, rather than systems and processes, and places the views and experiences of people who use services at its centre.
From April 2010, all health and adult social care providers will be required by law to be registered with CQC and must show that they are meeting the essential standards. Registration isn’t just about initial application for registration. We will continuously monitor compliance with the essential standards as part of a new, more dynamic, responsive and robust system of regulation.
Find out more
You can read the report on our Luton and Dunstable Hospital NHS Foundation Trust page.