Safety improvements lead care regulator to lift one condition on Heatherwood and Wexham Park NHS Trust

29 September 2010

The Care Quality Commission has said that Heatherwood and Wexham Park Hospitals NHS Foundation Trust has taken action to address concerns about the safety of its medical equipment. As a result CQC is lifting a legal condition which had been placed on the trust’s licence.

But a second condition which required the trust to improve its process for monitoring the quality of its services will remain in place until the regulator is certain that the system is working properly.

Heatherwood and Wexham Park Hospitals NHS Foundation Trust had been told to make the improvements when CQC introduced a new registration system on 1 April. Inspectors were concerned that the trust was not meeting essential standards of quality and safety.

As a result, CQC imposed two conditions on its licence:

• The trust must ensure that all medical and non medical equipment has been risk assessed and that only equipment that has been fully maintained and assessed as safe to operate is in continued use. The original deadline of 30 April was previously extended to 30 June.
• The trust must ensure that proper systems are in place to assess and monitor the quality of services. The deadline was 30 April.

CQC has now published its findings on progress made by the trust. The regulator has found that significant improvements had been made in response to the first condition.

Inspectors visited the Ascot birthing centre at Heatherwood Hospital. At Wexham Park Hospital in Slough they visited the accident and emergency unit, the coronary care unit and a ward specialising in respiratory medicine.

They spoke to a range of staff, including nurses and midwives, and checked static and portable equipment on the wards, looking at maintenance records and other documents. Hospital Staff confirmed that there was enough equipment available to do their jobs safely.

In relation to the second condition, CQC said the trust had provided evidence of improvements in its processes for assessing the quality of services, but these systems needed more time to be fully embedded in the trust’s day-to-day working practices. CQC said it would extend the deadline for this condition to 30 October.

Roxy Boyce, Regional Director for the South East acknowledged the progress made by the trust.

She said: “Old or poorly maintained equipment can present risks to the safety of patients. It is the duty of every hospital trust to ensure that all its equipment is up to standard, to replace it if necessary and to keep it under constant review which is why we imposed this condition in the first place.

“CQC is now satisfied that the trust has introduced systems to repair or replace older or obsolete equipment. We now have clear evidence that the trust is doing all that is required to minimise those risks and that any old equipment will be replaced when it comes to the end of its life.”

She said: “As for the need to assess and monitor the quality of services – we recognise that the trust has undertaken a significant amount of work in delivering improvements which is why we have given them a little more time.

“We will return to the trust later in the year looking for evidence that the improvements have made a real difference and are working properly.”

Condition 1 – Safety, availability and suitability of equipment

The trust was required to ensure that all medical and non medical equipment has been risk assessed and that only equipment that had been fully maintained and assessed as safe to operate was in continued use. It was also required to keep a database on all equipment with appropriate maintenance and review dates for replacement or continued use.

In assessing this condition, CQC inspectors found the trust had revised their monitoring systems and established new committees and equipment coordinators to address the risks associated with equipment.

Evidence showed the trust was now fully compliant with this condition, with systems designed to ensure that people are not at risk from the use of unsafe equipment, and that equipment is appropriate to their needs.

Inspectors found good levels of equipment in each of the areas visited and staff confirmed that there was sufficient provision of equipment to enable their duties to be undertaken safely and effectively.

The trust’s medical devices database contained detailed information on each piece of equipment, its service history and its maintenance schedule, with systems to monitor the replacement, or repair of inadequate equipment. The trust has now met the condition which required that all equipment should be risk assessed and that only equipment that had been fully maintained and assessed as safe is in continued use.

Condition 2 – Assessing and monitoring the quality of service provision

The trust was required to ensure that governance and audit systems to assess and monitor the quality of service provision were in place across all services.

CQC inspectors found that the trust was able to demonstrate that it had established a new governance system in April 2010, establishing new committees with emphasis on patient safety, quality of care, governance and patient experience.

The trust had also arranged systems to ensure effective monitoring of the quality of service provision across all services; and it provided evidence of how it assesses quality of services and identifies the risk of inappropriate or unsafe care.

However, the trust still needs to demonstrate that the new governance committees are fully embedded across all departments and functioning under their new titles; So far the trust has not been able to provide enough information to show how the new systems are improving services and helping to reduce the risk of unsafe care or treatment.

Ends

For further information please contact the CQC press office on 0207 448 9401 (07917 232 143 out of hours).

Notes to editors