Regulator tells Tameside Hospital NHS Foundation Trust to make further improvements

5 May 2011

The Care Quality Commission (CQC) has told Tameside Hospital NHS Foundation Trust that, despite improvements since the last review and inspection on 16th June 2010, it must do more to comply fully with three essential standards of quality and safety.

CQC reviewed information it held about the trust for sixteen essential standards, surveyed people who use services, carried out a visit on 9 March 2011, observed how people were being cared for, talked to people who use services, talked to staff, checked the trust’s records, and looked at records of people who use services.

CQC inspectors found that although there was evidence of improvement and compliance with regulations, care is falling short of the essential standards of quality and safety people should be able to expect in three areas:

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

Feedback from patients and observations of staff provided positive evidence of the care provided but risk assessments were not consistently completed and were not always accurate, particularly in respect of assessing the risk of falls. It was also not clear how the trust might consistently share learning from incidents across the organisation.

Food and drink should meet people’s individual dietary needs

People who needed support with eating were helped promptly and appropriately by staff when meals arrived. Records were kept of what people had eaten and drunk where it was necessary. People were weighed regularly and this was being recorded. However, we found some delays in completing nutritional assessments and referral to a dietician.

The trust does not employ a dedicated nutrition support nurse. National Institute for Health and Clinical Excellence (NICE) guidance for nutrition support says that an acute trust should employ a specialist nutrition nurse.

The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care

There is a culture of risk management and quality improvement, but there are inconsistencies in the documentation and management of action plans.

Failure to have robust systems in place for identifying risks potentially puts patients at risk

CQC Regional Director Sue McMillan said: “Although we welcome the improvements made by Tameside at ward level, the quality and safety of care we observed at the trust was not yet up to the required standard. CQC is requiring Tameside Hospital NHS Foundation Trust to take action to comply with essential standards

“We will continue to monitor the trust closely to ensure that it has taken all necessary steps to meet the required standards. We are already reviewing additional evidence that has been provided by the trust and received from other sources. We shall take further action if we are not satisfied that shortfalls are being addressed”.

Under the Health and Social Care Act 2008, the Care Quality Commission has a number of enforcement powers to deal with services that are not meeting essential standards of quality and safety. In the most serious cases, the Commission can prosecute or cancel registration.

Any regulatory decision that CQC takes is open to challenge by a registered person through a variety of internal and external appeal processes.

Ends

For further information please contact David Fryer, Regional Communications Manager, on 07901 514220 or the CQC press office on 0207 448 9239 or out of hours on 07917 232 143.

Notes to editors