Vale of Leven Hospital | NHS Greater Glasgow and Clyde

Unannounced Inspection Report – Care for Older People in Acute Hospitals

23–24 June 2015

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First published August 2015

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Healthcare Improvement Scotland Unannounced Inspection Report (Vale of Leven Hospital, NHS Greater Glasgow and Clyde): 23–24 June 2015

2 Contents

1 Background 4

2 A summary of our inspection 6

3 What we found during this inspection 8

Appendix 1 – Areas for improvement 23 Appendix 2 – Details of inspection 26 Appendix 3 – List of national guidance 27 Appendix 4 – Inspection process flow chart 28 Appendix 5 – Terms we use in this report 29

Healthcare Improvement Scotland Unannounced Inspection Report (Vale of Leven Hospital, NHS Greater Glasgow and Clyde): 23–24 June 2015

3 1 Background

In June 2011, the Cabinet Secretary for Health, Wellbeing and Cities Strategy announced that Healthcare Improvement Scotland would carry out a new programme of inspections. These inspections are to provide assurance that the care of older people in acute hospitals is of a high standard. We measure NHS boards against a range of standards, best practice statements and other national documents relevant to the care of older people in acute hospitals, including the Clinical Standards Board for Scotland (CSBS) Clinical Standards for Older People in Acute Care (October 2002).

Our inspection process is focused on the three national quality ambitions for NHSScotland, which aim to ensure that all care is person-centred, safe and effective. The process includes a planned NHS board visit which allows them to highlight areas of good practice and also areas where improvements could be made. The NHS board visit is then followed up by an inspection to each acute hospital in the NHS board area. We also look at outcomes relating to one or more of the following areas on each inspection:

 treating people with compassion, dignity and respect  screening and initial assessment  person-centred care planning  safe and effective care  managing the return home, and  leadership and accountability.

We are working closely with improvement colleagues in Healthcare Improvement Scotland to ensure that NHS board teams are given appropriate support to deliver improvements locally and to share and learn from others.

During our inspections, we identify areas where NHS boards:

 must take action in a particular area, or  should take action in a particular area.

If we tell an NHS board that it must take action, this means the improvements we have identified are linked to national standards, other national guidance and best practice in healthcare. A list of relevant national standards, guidance and best practice can be found in Appendix 3.

If we tell an NHS board that it should take action, this means that, although the improvements are not directly linked to national standards, guidance or best practice, we consider the care that patients receive would be improved.

About this report This report sets out the findings from our unannounced inspection to Vale of Leven Hospital, NHS Greater Glasgow and Clyde from Tuesday 23 to Wednesday 24 June 2015.

This report summarises our inspection findings on page 6. Detailed findings from our inspection can be found on page 8.

Healthcare Improvement Scotland Unannounced Inspection Report (Vale of Leven Hospital, NHS Greater Glasgow and Clyde): 23–24 June 2015

4 The inspection team was made up of five inspectors and one public partner, with support from a project officer. One inspector led the team and was responsible for guiding them and ensuring the team members agreed about the findings reached. A key part of the role of the public partner is to talk with patients about their experience of staying in hospital and listen to what is important to them. Membership of the inspection team visiting Vale of Leven Hospital can be found in Appendix 2.

The report highlights areas of strength and areas for improvement. You can find all areas for improvement from this inspection in Appendix 1 on page 23.

The flow chart in Appendix 4 summarises our inspection process. More information about Healthcare Improvement Scotland, our inspections, methodology and inspection tools can be found at www.healthcareimprovementscotland.org/OPAH.aspx

Healthcare Improvement Scotland Unannounced Inspection Report (Vale of Leven Hospital, NHS Greater Glasgow and Clyde): 23–24 June 2015

5 2 A summary of our inspection

The Vale of Leven Hospital, Alexandria, serves the region of Dunbartonshire. The hospital has approximately 92 inpatient beds and provides a range of healthcare services.

We carried out an unannounced inspection to Vale of Leven Hospital from Tuesday 23 to Wednesday 24 June 2015.

We inspected the following areas:

 acute medical receiving unit (AMRU)  Lomond ward (general medicine)  ward 14 (elderly assessment/rehabilitation), and  ward 15 (elderly assessment/rehabilitation).

Before the inspection, we reviewed NHS Greater Glasgow and Clyde’s self-assessment and gathered information about Vale of Leven Hospital from other sources. This included Scotland’s Patient Experience Programme and other data that relate to the care of older people. We also carried out an NHS board visit to NHS Greater Glasgow and Clyde on Wednesday 29 October 2014. Based on our review of this information, we focused the inspection on the following outcomes:

On the inspection, we spoke with staff and used additional tools to gather more information. In all wards, we used a formal observation tool and the mealtime observation tool, where appropriate. We carried out 11 periods of observation during the inspection. In each instance, members of our team observed interactions between patients and staff in a set area of the ward for 20 minutes.

We also carried out patient interviews and used patient and carer questionnaires. We spoke with 14 patients during the inspection. We received completed questionnaires from 18 patients and 10 family members, carers or friends.

As part of the inspection, we reviewed 34 patient health records to check that the care we observed was informed by the outcomes of the assessments and as described in the care plans.

Areas of strength We noted areas where NHS Greater Glasgow and Clyde was performing well in relation to the care provided to older people in acute hospitals. This included the following.

 Good interactions between staff and patients, and patients were complimentary about the care and treatment they had received.

Healthcare Improvement Scotland Unannounced Inspection Report (Vale of Leven Hospital, NHS Greater Glasgow and Clyde): 23–24 June 2015

6  Mealtime co-ordinators and activities co-ordinators were in place to support staff and patients. Areas for improvement We found that further improvement is required in the following areas.

 Person-centred care plans should be in place for all identified care needs.  Appropriate assessments should be carried out in line with the relevant standards.

What action we expect the NHS board to take after our inspection This inspection resulted in six areas of strength and 12 areas for improvement. A full list of the areas for improvement can be found in Appendix 1 on page 23.

We expect NHS Greater Glasgow and Clyde to address all the areas for improvement. The NHS board must prioritise those areas where improvement is required to meet a national standard.

The NHS board has developed an improvement action plan, which is available to view on the Healthcare Improvement Scotland website and the NHS board website for 16 weeks. After this time, the action plan can be requested from Healthcare Improvement Scotland www.healthcareimprovementscotland.org/OPAH.aspx

We would like to thank NHS Greater Glasgow and Clyde and in particular all staff at the Vale of Leven Hospital for their assistance during the inspection.

Healthcare Improvement Scotland Unannounced Inspection Report (Vale of Leven Hospital, NHS Greater Glasgow and Clyde): 23–24 June 2015

7 3 What we found during this inspection

3.1 Treating older people with compassion, dignity and respect

All patients were cared for in either single rooms or single sex bays. The majority of rooms had ensuite toilet facilities and, where ensuite facilities were not available, patients had access to separate male and female toilets, bath and shower facilities.

The wards inspected were light, bright and fresh smelling. Wards were calm, quiet and uncluttered. Some wards benefited from having a patient day room, which could also be used as a dining area for patients and visitors.

All wards inspected had a nurse call system in use. We saw that the call buttons were placed near to patients to make them more accessible and requests for assistance were met promptly. We saw staff were proactive in anticipating patient care needs. Personal items, such as glasses and hearing aids, were easily accessible for patients. In some wards, we saw that patients had their own bed throws, blankets and photographs at their bedside. Familiar personal items can be comforting for patients when they are in a hospital setting.

We saw most patients wearing their own clothes or nightwear. However, during our mealtime observations, we noted that aprons were being put on some patients without staff being seen to obtain consent. This practice was not outlined in any of the patient care plans reviewed. While we acknowledge that staff may do this to protect patients’ clothing during mealtimes, it would be good practice to respect the individual’s choice and ensure the decision is recorded in the care plans, particularly where the individual cannot give verbal consent.

In the wards inspected, risk-based information was displayed above patient beds and was kept to a minimum to maintain patients’ privacy. This included the patient’s name and mobility risk information. Some wards also had ‘Who and what is important to me’ information displayed above the patient beds. Relatives and carers could use this as a way of informing ward staff about the patient’s personal information. In one ward, a large whiteboard was displayed in the main ward corridor which contained relevant key information for staff and symbols were used to denote individual patient needs. Some wards were starting to use electronic boards to display patient information. However, at the time of the inspection, these electronic boards were awaiting repair. Staff were still able to access patient information on the ward computers, but had to log-in in order to so this, defeating the purpose of having the screen visible to all to inform care and minimise risks.

Patient and relative comments Through our patient surveys and interviews, patients had the opportunity to give us their opinion about the care they received whilst in hospital. Overall, patients were complimentary about the care and treatment they had received from all members of staff. Most patients said they were included in conversations about their treatment and that questions were answered in terms they understood. Patients also stated that staff introduced themselves and were compassionate and considerate.

Of the 18 patients who completed our questionnaire:

 17 stated they had been given clear information about their condition and treatment  17 stated the quality of care they received was good, and  16 stated that they felt involved in their care.

Healthcare Improvement Scotland Unannounced Inspection Report (Vale of Leven Hospital, NHS Greater Glasgow and Clyde): 23–24 June 2015

8 Through our carer and visitor questionnaires, family members, carers and friends had the opportunity to give us their opinion of the hospital. Of the 10 people who completed our questionnaire:

 10 stated that: ‘Staff have taken the time to get to know the person I am visiting’  nine stated that: ‘The quality of care the person I am visiting receives is very good’, and  nine stated that: ‘Staff seem knowledgeable about the care and treatment of the person I am visiting.’

We received the following positive comments from patients, carers and visitors through our surveys and interviews.

 ‘Staff have been welcoming and informative, pleasant and cheerful.’  ‘In my opinion, all grades of staff have gone out of their way to make my stay in hospital very comfortable, pleasant and secure.’  ‘Staff are extremely kind and caring, providing all care that is required by my mother. They are polite and very helpful. Quality of care received has been second to none.’  ‘[I am] extremely grateful for the excellent care I have received. [I] would particularly like to mention the kindness, cheerfulness and cleanliness and all over well being I have experienced.’  ‘The nursing staff are so caring and kind and cannot be praised enough for the hard work that they do.’

Some patients, carers and visitors told us of some concerns and worries they had.

 ‘Not enough staff for the number of patients and their different needs, especially not weekends. Food isn't very appetising for patients who are trying to regain an appetite.’  ‘Food not very appetising. There should be more nursing staff on the ward.’  ‘When I first came to visit my dad I arrived early, not knowing what visiting hours were. The nurse wasn't as polite as she could have been when telling me I could see my dad for a few minutes but then had to come back later.’

Patient and staff interactions We used a formal observation tool in all wards inspected to observe interactions between staff and patients. From our observations, we saw that interactions with patients were positive, friendly and caring. We also found that staff were supportive, and talked to patients in a calming and respectful manner. We heard staff introduce themselves to patients and check that they were comfortable. We also observed positive attitudes and good team working amongst staff.

Activity co-ordinator We were told that wards 14 and 15 have activity co-ordinators. This service operates between Monday-Friday (10am–3pm), but this is flexible to cover evenings and weekends, if required. Ward 14 also has a volunteer. The activity co-ordinators and volunteer interact with patients, provide assistance at mealtimes and encourage patients to engage in activities. The activity co-ordinator can also assist family members and carers when completing documentation, such as the ‘Getting to know me’ document. Staff and patients spoke positively about these roles.

Healthcare Improvement Scotland Unannounced Inspection Report (Vale of Leven Hospital, NHS Greater Glasgow and Clyde): 23–24 June 2015

9 Patient flow and capacity Patient boarding is when patients are moved from one ward to another to meet the needs of the service and not the patient’s clinical needs. During this inspection, we found that no patients had been boarded in or out of the ward areas. At the time of the inspection, we were aware that a number of patients were medically fit for discharge, but were awaiting packages of care.

Area of good practice ■ Activity co-ordinators and volunteers support patients to engage in activities.

3.2 Screening and initial assessment

Outcome 1: The patient is supported to return home (or to a homely setting or care service) or if necessary admitted directly to the correct ward (in this or other appropriate hospital). Ensuring older people are screened and assessed appropriately on arrival at hospital, including medicines reconciliation. Where initial assessment and screening identifies care needs, a multidisciplinary team completes a detailed assessment without delay. Once the assessments are completed, admission or discharge occurs promptly.

Dementia and cognitive impairment Cognitive assessment is carried out using the AMT4 cognitive assessment tool. This is included in the medical and nursing documentation. Of the 20 patient health records reviewed for dementia and cognitive impairment, 19 had a completed cognitive assessment using the AMT4. Where the assessment score indicates a possible impairment, a more detailed cognitive assessment should be carried out, including screening for delirium. However, from the patient health records reviewed, it was not clear that this was carried out for all patients who needed it.

Delirium Delirium (sometimes called acute confusional state) is a common, serious condition for older people and is the most common complication of hospitalisation in the elderly population. This medical emergency is often under-recognised and poorly managed. The incidence is also higher in those with a pre-existing cognitive impairment.

We found that there is currently no routine assessment carried out for delirium at the Vale of Leven Hospital. However, medical staff stated that they will assess a patient using the confusional assessment method (CAM), if they have concerns. From the patient health records reviewed, we found the following.

 A CAM had been completed for a patient, but had not been dated or signed.  A CAM had not been completed for a patient with a diagnosis of dementia who was non- compliant with the AMT4 on admission. However, as the patient’s usual level of cognitive function was not established, it was unclear if this patient had a possible delirium.  Two patients were identified as being acutely confused. No formal assessment tool to identify delirium was used for these patients. However, their health records documented that delirium was being considered and detailed the treatment to resolve.

Healthcare Improvement Scotland Unannounced Inspection Report (Vale of Leven Hospital, NHS Greater Glasgow and Clyde): 23–24 June 2015

10 We found no consistent, reliable approach for the assessment of patients who may have a delirium. This can result in the appropriate care or treatment being delayed. We are aware that NHS Greater Glasgow and Clyde has a plan to spread the delirium work that is currently being tested at various other sites. As patients with a known cognitive impairment are at high risk of delirium, it is essential that staff establish what the patient’s normal cognitive function is and are aware of how to recognise and manage delirium.

Nutritional care and hydration Nutritional screening is carried out using the Malnutrition Universal Screening Tool (MUST). This tool calculates the risk of malnutrition and should be completed within 24 hours of admission. During the inspection, we reviewed 20 patient health records for nutritional care and found that all patients had a MUST in place.

From the patient health records reviewed, it was not clear how the patient’s height and weights had been measured. The MUST in use does not contain a place to record the patient’s usual weight or if staff have asked the patient or relative about weight loss. Therefore, it was unclear how the weight loss score was obtained.

The body mass index (BMI) is a measure of relative weight based on an individual's mass and height. An accurate BMI is needed to calculate the MUST score. There are factors which can increase or decrease a person’s weight, such as fluid overload or amputation. In these circumstances, another calculation needs to be carried out to obtain the BMI. NHS Greater Glasgow and Clyde’s nutrition manual contains information to support these types of calculations and, from a patient health record reviewed, we saw that this had been accurately applied. This demonstrates good practice.

MUST rescreening is required to be carried out weekly to highlight any changes in the patient’s nutritional needs during their stay in hospital. We found that the majority of wards carry out weekly MUST rescreening.

Nutritional assessment We saw all patients had a nutritional assessment completed. This document details any special dietary requirements, religious or cultural dietary needs, likes or dislikes or any assistance the patient needed. However, we saw that one nutritional assessment did not indicate, in the appropriate section, that a patient had a swallowing problem. One nutritional assessment did not reflect that a patient required a diabetic diet. Staff stated that the correct information was on the ward handover sheet and staff knew the patient was diabetic and had been receiving the correct diet. They did acknowledge that the information should have been included in the nutritional assessment and took action to rectify this.

Falls assessment During the inspection, we reviewed 20 patient health records for falls. All patients had been assessed for their risk of falls on admission, using the Cannard falls assessment pack. There was also evidence of assessment by occupational therapy and physiotherapy, to ensure the assessment was multidisciplinary. It also prompted completion of the safe use of bedrails assessment as a falls prevention measure.

Preventing and managing pressure ulcers During the NHS board visit to NHS Greater Glasgow and Clyde in October 2014, we were told that an adapted Waterlow risk assessment tool is used as the primary risk assessment tool. During the inspection, we reviewed 20 patient health records for pressure area care and found that all patients had an assessment completed within 6 hours of admission.

Healthcare Improvement Scotland Unannounced Inspection Report (Vale of Leven Hospital, NHS Greater Glasgow and Clyde): 23–24 June 2015

11 We were told that two wards were trialling the use of a new pressure ulcer risk assessment (PURA) tool in place of the Waterlow risk assessment tool. This tool should be completed daily for each patient. Two patient health records reviewed showed that the PURA had been completed within 24 hours of admission and on an ongoing daily basis. In another ward, which was trialling the PURA tool, we saw that Waterlow charts were still present in the patient health records. This could be confusing for staff to know which assessment to use.

Medicines reconciliation The Chief Medical Officer (CMO) (2013)18 states that, when a patient is admitted to hospital for more than 24 hours, medicines reconciliation should take place. This should include a documented record of the patient’s details and whether they have any allergies. Any medicines prescribed to the patient should only be listed after checking with two or more sources. This can be the patient, a carer, GP, pharmacy or a printed GP letter. There should also be a medicines plan for each medicine to indicate if the medication is to ‘continue’, ‘stop’ or ‘be withheld’. It should be clear who has completed the form and there should also be evidence of a pharmacist review.

NHS Greater Glasgow and Clyde’s self-assessment states that the majority of patient admissions to hospital are through the medical admission units and these have been the focus of medicines reconciliation work to date.

During the inspection, we reviewed 20 patient health records for medicines reconciliation and found that 13 patients had this in place. However, only five medicines reconciliation forms had been completed correctly. We found that patients within ward 15 had been transferred from the Royal Alexandra Hospital, Paisley, for rehabilitation and therefore an admission booklet, which includes the medicines reconciliation form, had not been completed. From the 13 medicines reconciliation forms seen:

 three did not have a medicines plan, for example whether the medicine was to continue, be withheld or stopped  three had no patient demographics recorded  three had no signature of the person who completed the form, and  seven had not been reviewed or signed by a pharmacist.

Do not attempt cardiopulmonary resuscitation Do not attempt cardiopulmonary resuscitation (DNACPR) relates to the emergency treatment given when a patient’s heart stops or they stop breathing. Sometimes medical staff will make a decision that they will not attempt to resuscitate a patient. This is because they are as sure as they can be that resuscitation will not benefit the patient. For example, this could be when a patient has an underlying disease or condition and death is expected. When this decision is made, opportunities should be taken to have honest and open communication to ensure patients and their families are made aware of the patient’s condition. However, in some cases, clinical staff may decide not to share this information as they feel it may cause too much distress for the patient and their families. This decision should be clearly documented in the patient notes.

During the inspection, we reviewed nine DNACPR forms and found that two had been fully completed. Of the remaining seven forms, three did not indicate if discussions had taken place with the patient, or their family, or why these discussions had not taken place. Seven forms did not have review dates documented. We also saw five other patient health records which clearly documented that the patient was to be resuscitated in the event of a cardiac arrest. This demonstrates that the medical staff have considered and clearly communicated the decision to remove any doubt or uncertainty.

Healthcare Improvement Scotland Unannounced Inspection Report (Vale of Leven Hospital, NHS Greater Glasgow and Clyde): 23–24 June 2015

12 Documentation Care needs are identified for all patients using a structured assessment tool which is contained within the nursing assessment book. This is based on the activities of daily living (ADL) such as eating and drinking, mobility, maintaining a safe environment and washing and dressing. We saw examples of this tool in the patient health records reviewed. The tool highlighted the needs to be addressed on the care plan template which uses the same ADL headings.

The nursing admission booklet contains a prompt question to establish if a person has a power or attorney or guardianship in place. This will be carried out as part of the admission process for all patients. This ensures that, should a person lose the capacity to consent to treatment, legal proxy decision makers are identified and can be consulted about care and treatment decisions.

Areas for improvement 1. NHS Greater Glasgow and Clyde should continue to spread the improvement work about detection and management of delirium. 2. NHS Greater Glasgow and Clyde must ensure that the nutritional care assessment accurately identifies and records any therapeutic dietary needs. 3. NHS Greater Glasgow and Clyde must ensure that the nutritional care assessment accurately identifies and records measured height and weight, with the date and time that these measurements were taken (if estimates are used, this should be stated and a rationale provided). 4. NHS Greater Glasgow and Clyde must ensure that medicines reconciliation is fully completed within 24 hours of admission. 5. NHS Greater Glasgow and Clyde must ensure clinical staff consistently comply with the national policy on do not attempt cardiopulmonary resuscitation (DNACPR).

3.3 Person-centred care planning

Outcome 2: The patient (and their carer, if appropriate) is consulted and involved in decisions about their care. Ensuring that all care is person-centred and that care plans are developed with the involvement of the patient and their carer, if appropriate.

NHS Greater Glasgow and Clyde’s self-assessment states that a generic core care plan has been recently developed and now covers the acute sector across NHS Greater Glasgow and Clyde. This contains mandatory and optional care interventions and space to record specialist interventions so that individualised care plans can be developed.

During the inspection, we found that the generic core care plan was not in use at the Vale of Leven Hospital. The care plan in use was based on the ADL and provided basic information to guide care, for example, if walking or hearing aids were needed or if the patient wore spectacles. However, care plans did not reflect the information obtained from ‘Who and what matters to me’ or ‘Getting to know me’. Some care plans did not demonstrate patient or relative involvement or person-centredness. There was evidence of ongoing review, but there was limited space on the document to provide any in-depth personalised information.

Healthcare Improvement Scotland Unannounced Inspection Report (Vale of Leven Hospital, NHS Greater Glasgow and Clyde): 23–24 June 2015

13 The care plans in place did not provide sufficient amount of detail to inform care for people with dementia and cognitive impairment. NHS Greater Glasgow and Clyde is using the ‘Getting to know me’ booklet. This is used for patients and their carers to highlight personal information to staff such as habits, background, likes and dislikes and things that are important to them. We saw that this was not well competed across the wards inspected.

NHS Greater Glasgow and Clyde’s self-assessment states that active care is the process of delivering individualised clinical care in prescribed intervals of time. Active care is about promoting person centred care, enhancing communication and improving outcomes in relation to nutrition, hydration, falls and tissue viability. During the inspection, we saw that active care rounding sheets were well completed over a 24-hour period. Most detailed the mattress in use and the prescribed time of care delivery. Where there were changes or concerns, these were clearly documented on the reverse of the document. However, it was not clear how the assessment or care planning informed the frequency of care delivery.

NHS Greater Glasgow and Clyde’s self-assessment states that when the care of an older patient is being planned, carers are encouraged to be involved in decision-making in a variety of ways. We were told that patients and their carers can contribute to care planning and this would be recorded in the patient health record.

During the inspection, all patient health records reviewed had a communication sheet to record the conversations with relatives and carers and these were well completed.

The falls care plan within the Cannard falls risk assessment includes a list of nursing actions which staff tick if they are applicable to the individual. However, it did not provide detailed information for the individual’s needs. For example:

 there was limited space at the end of the list for staff to add additional interventions  the assessment stated ‘requires assistance with mobilisation’, but did not state what type of assistance was needed, and  whilst the care plan prompted staff to carry out a bedrail assessment, it did not prompt staff to consider further assessment before using high/low beds or one-to-one observation.

Area of good practice ■ Documented evidence of good communication with relatives and carers to ensure they were involved in and informed about the patient’s care.

Areas for improvement 6. NHS Greater Glasgow and Clyde must ensure that patients have person-centred care plans in place for all identified care needs. These should evidence patient and carer involvement and be regularly evaluated and updated to reflect changes in the patient’s condition or needs. 7. NHS Greater Glasgow and Clyde must ensure systems are in place to record key personal information about people with dementia or other cognitive impairments. Patients and their families should be given clear guidance on the purpose of this information when they are completing the documentation. This information should be used and shared with staff involved in the care of the patient.

Healthcare Improvement Scotland Unannounced Inspection Report (Vale of Leven Hospital, NHS Greater Glasgow and Clyde): 23–24 June 2015

14 3.4 Safe and effective care

Outcome 5: The patient, with dementia (or cognitive impairment), experiences care that is tailored to meet their individual needs and promotes their mental wellbeing. Ensuring that:  care for older people with dementia (or cognitive impairment) meets the Scottish Government Standards of Care for Dementia in Scotland, and  guidelines on use of medication for the behavioural and psychological symptoms of people with dementia and/or delirium are available to all staff.

Adults with incapacity The adults with incapacity (AWI) certificate is used to authorise treatment for patients who are unable to consent to treatment themselves. When people who have lost the capacity to make decisions about their welfare are admitted to hospital, it is important to know if they have an appointed power of attorney or guardian.

From the patient health records reviewed, we saw some good examples of completed AWI certificates with treatment plans in place. For example, one patient health record contained a detailed assessment by a psychiatrist of the patient’s capacity to consent to treatment which recognised the ability to make some decisions’ but not more complex ones. This was then reflected on the AWI treatment plan. In other patient health records reviewed, we saw partially-completed AWI certificates and out-of-date forms which did not include evidence of discussions with family members or carers. Not all AWI certificates specified the exact care and treatment authorised. It is recognised good practice to complete an accompanying treatment plan so that all foreseeable care and treatment needs are identified. We did not see completed treatment plans for all the AWI certificates in place.

Power of attorney A power or attorney or guardian, is someone who is appointed to make decisions on another person’s behalf when they are unable to do so themselves. NHS Greater Glasgow and Clyde’s nursing documentation contains a prompt to establish if a power of attorney or guardianship order is held.

From the patient health records reviewed, we noted that the prompt was not always completed. Where a power of attorney or guardianship order is in place, staff should obtain a copy to verify what decisions can be made on behalf of the individual. This was seen in two patient health records reviewed. In one patient health record, it was documented that there was a power of attorney in place, but there was no copy of this available to detail what powers were held.

Environment for people with dementia and cognitive impairment NHS Greater Glasgow and Clyde’s self-assessment states that a person-centered environmental strategy has been developed by the acute dementia group, from improvements identified by the dementia champions, to ensure a prioritised, phased approach to environmental changes.

During the inspection, we saw that few changes had been made to improve the environment and, as a result, the wards were not dementia friendly. However, we acknowledge that the age and design of the hospital has an impact on the number of changes which can be made.

Healthcare Improvement Scotland Unannounced Inspection Report (Vale of Leven Hospital, NHS Greater Glasgow and Clyde): 23–24 June 2015

15 Each patient room and ward area had wall clocks and dementia-friendly signage to indicate where the toilet or showers were located. There was little use of contrasting colours to help patients with dementia find their way round the ward. Senior charge nurses, spoken with during the inspection, were aware that the ward environments could be improved and were working with the dementia champions to carry out an environmental audit using a recognised audit tool.

Dementia champions The role of a dementia champion is to advocate for patients with dementia at every appropriate opportunity. NHS Greater Glasgow and Clyde’s self-assessment states that dementia champions are in place and cover a wide variety of clinical areas and disciplines, including nursing, physiotherapy, occupational therapy and pharmacy. During the inspection, we saw that dementia champions were in place in each ward and a number of staff were undertaking the training programme.

Older people’s mental liaison team NHS Greater Glasgow and Clyde’s self-assessment states that, as part of the initial assessment process, patients may be referred for psychiatric evaluation through the older people’s mental liaison team. We were told that liaison services were in place across all acute sites and were closely linked to the community older people’s mental health teams. Liaison staff can carry out mental health assessments, provide advice and guidance, including diagnosis, make recommendations about regarding appropriate medications and link patients to community services on discharge, as appropriate.

During the inspection, staff stated that they could easily access the older people’s mental liaison team for guidance and advice. From one patient health record reviewed, we saw good documented evidence of input from the liaison team for a complex capacity assessment.

Area of good practice ■ The older people’s mental health liaison team works with medical staff and community mental health teams to enhance the care of patients with cognitive impairment.

Area for improvement 8. NHS Greater Glasgow and Clyde must carry out improvements to the ward environment, where possible, to make it more suitable for people with dementia and cognitive impairment.

Outcome 6: The patient’s status is maintained or improved and appropriate food, fluid and nutrition is provided in a way that meets their individual needs. Ensuring care for older people meets the NHS Quality Improvement Scotland Clinical Standards for Food, Fluid and Nutritional Care in Hospital.

NHS Greater Glasgow and Clyde’s self-assessment states that every adult acute ward has access to the nutrition resource manual. The manual includes policies, guidelines and best practice on providing safe, effective, evidenced-based nutritional care to patients. It also

Healthcare Improvement Scotland Unannounced Inspection Report (Vale of Leven Hospital, NHS Greater Glasgow and Clyde): 23–24 June 2015

16 contains referral pathways for dietetics, speech and language therapy, occupational therapy and the dental service, in addition to nil by mouth guidance. A screening tool for oropharygeal swallow symptoms (STOPSS) was developed to assist healthcare staff to assess and manage patients with suspected swallowing difficulties. It supports the safe initiation of oral hydration, nutrition and medication.

During the inspection, we found that staff knew how to access resource manuals and tools and could make referrals to speech and language therapists and dietetics. We were told not all staff are trained to carry out STOPSS but there is good guidance available. Staff stated that a speech and language therapy referral would only be accepted if the STOPSS had been completed.

Patient weighing equipment Accurate weights are required for the safe and effective prescribing of some medications and to monitor any patient weight loss. All wards stated that they had access to a range of patient weighing scales and equipment, for example hoist scales, sit on scales and stand on scales.

In one ward, we were told that the sit on scales were broken and staff were borrowing scales from another area. However, in another ward, we were told that the hoist scales were broken as they were waiting for a replacement part. NHS Greater Glasgow and Clyde told us that wards did have access to other working weighing equipment. However, ward staff told us that they were unclear what interim measures were being put in place to weigh patients in the absence of these scales. This was brought to the attention of senior management during the inspection.

Management and provision of nutrition and hydration Each ward had a nutrition board which detailed special diets and patients requiring assistance. This information was also communicated during ward handovers and ward safety briefs. Wards also had the red mat system in place to highlight any patients who would benefit from assistance during their meal. However, this appeared to be inconsistent as some patients who required assistance did not receive their meal on a red tray. We saw that some water jugs were also colour-coded. However, some staff spoken with during the inspection could not state why some water jugs had a red lid and some had a green lid.

From our observations, the majority of patients were suitably prepared before mealtimes. However, it was not clear if patients were prompted to wash their hands or use hand wipes before their meal. Mealtimes appeared to be well organised, with all members of staff being involved. Mealtime co-ordinators were in place in all wards to ensure that meals were given out on a timely manner and at the correct temperature.

All patients were given appropriate assistance, where required. We observed members of staff sitting at the patient’s level to provide such assistance. This was done in a caring and compassionate manner. Staff stated that adapted cutlery was also available from the occupational therapy department, when needed.

Some patients are prescribed nutritional supplements by the dietician to increase their nutritional intake. During the inspection, we noted that there had been no supplement drinks in the hospital for a 5-day period. This meant that some patients would be unable to meet their identified dietary needs. This was brought to the attention of senior management and we are assured that action was taken to rectify this.

Healthcare Improvement Scotland Unannounced Inspection Report (Vale of Leven Hospital, NHS Greater Glasgow and Clyde): 23–24 June 2015

17 Protected mealtimes During the inspection, we saw that protected mealtimes were in place to reduce non- essential interruptions during mealtimes. This is to ensure that eating and drinking are the focus for patients without unnecessary distractions. Staff stated that, whilst protected mealtimes are adhered to, they would encourage family members and carers to assist the patient with their meal, if they wished.

Menu and provision of snacks Vale of Leven Hospital has a wide range of menus available for patients to meet their dietary needs. A ‘light bites’ menu is also available, which contains smaller snack-type foods. This can be useful for patients who only want a small snack or for patients who find it easier to eat with their hands. We were told that ward staff can offer this menu to patients without having to go through a dietician.

In all wards inspected, staff stated that they could access hot meals for patients who had missed their meal. There were also supplies of sandwiches for patients who would prefer a smaller meal. All wards had a good range and supply of snacks, including biscuits, yoghurts, cheese and crackers, plus additional milk and bread, if needed. Each ward was also able to make toast for patients each evening and also offered patients toast with their breakfast.

Fluid balance charts Food and fluid balance charts are used to record how much patients are eating and drinking when there are concerns about their intake and output. These charts may be requested by medical staff, dieticians, speech and language therapists or started by nursing staff.

During the inspection, we found that the completion of fluid balance charts was inconsistent. We saw some good examples where charts had been completed throughout the day, with totals calculated and carried forward to the next day. However, in the majority of charts reviewed, we noted that outputs were not recorded and no explanation was given for this decision. Therefore, there were no output totals, no balances recorded and no carry forward to inform the next day’s care and treatment. In some charts, we saw ‘IC’ had been written in the output column, meaning the patient was incontinent. However, urine output was not being measured or monitored.

NHS Greater Glasgow and Clyde’s fluid chart provides a space to document why the chart is in use. Some charts had ‘poor fluid intake’ written as the reason for the chart being in place, but on others this was blank. Therefore, we were unsure why the fluid balance chart is needed. We were told that, on occasion, fluid balance charts are only used to record intake. However, the reason for this was not clearly documented in the patient health record.

In ward 14, we reviewed a health record for a patient who was receiving artificial nutrition through a tube and was also nil by mouth. There was a dietetic feeding regime chart in place, stating the required feed and what water flushes were needed. However, there was no feed intake chart in place to record the actual amount of feed given or the amount of water flushes given. There was also no fluid balance chart in place to monitor intake and output to inform future decision-making. For the same patient, there was no evidence of any mouth care being provided, including how often it should be offered or how often it was provided. One nurse thought this would be recorded on the active care checklist, but the checklist had nothing related to mouth care.

Healthcare Improvement Scotland Unannounced Inspection Report (Vale of Leven Hospital, NHS Greater Glasgow and Clyde): 23–24 June 2015

18 Area of good practice ■ Mealtime co-ordinators are in place to ensure that meals are given out in a timely manner.

Areas for improvement 9. NHS Greater Glasgow and Clyde must ensure there is access to appropriate patient weighing equipment.

10. NHS Greater Glasgow and Clyde must ensure that fluid balance charts are commenced and accurately completed for patients who require them and appropriate action is taken in relation to intake or output, as required. 11. NHS Greater Glasgow and Clyde should ensure that nutritional supplements are available for patients and accessible to staff at all times.

Outcome 7: Where avoidable, the patient does not fall during their stay in hospital. Ensuring a systematic process is in place to assess older people for the risk of falling (which includes medication review) and individualised controls are implemented to prevent falls or reduce any risk to a minimum.

NHS Greater Glasgow and Clyde’s self-assessment states that there are five hospital falls prevention co-ordinators covering all NHS Greater Glasgow and Clyde acute hospital wards. The falls prevention co-ordinators provide in-service education, support and advice to clinical teams on falls prevention and management. During the inspection, we were told that all wards have good access to a falls prevention co-ordinator.

We saw that all wards use the Cannard falls risk assessment pack to assess patients at risk of falls and for falls care planning. We were told that any patient scoring 18 or above on the risk assessment would be referred to the falls service.

All Cannard packs reviewed during the inspection were well completed, with evidence of referral to both an occupational therapist and a physiotherapist. Patients who had been in hospital for longer than a week had all been reassessed on a weekly basis. We saw evidence of multidisciplinary team working, including the involvement of family and carers.

Patients at risk of falls are highlighted on the ward safety brief and on the nursing handover sheet. Individual risks for mobility were clearly highlighted at the patient’s bedside. All wards had access to pressure mats, which alert staff when a patient has moved off their chair or bed, and there was clear evidence of bedrail risk assessments for patients.

A falls safety cross was seen in all wards inspected. This is a daily record of any falls which have occurred within the ward. If a fall has occurred, this will trigger a review of patient care to identify any learning for ward staff. Incidents are also recorded on the hospitals electronic incident reporting system.

Area of good practice ■ Falls co-ordinators are in place to support staff and provide advice.

Healthcare Improvement Scotland Unannounced Inspection Report (Vale of Leven Hospital, NHS Greater Glasgow and Clyde): 23–24 June 2015

19 Outcome 8: Where avoidable, the patient does not acquire a pressure ulcer during their stay in hospital. If they are admitted with a pressure ulcer their care is tailored to their needs. Ensuring care for older people is delivered in line with the NHS Quality Improvement Scotland Best Practice Statement for the Prevention and Management of Pressure Ulcers, so patients can be identified as being at risk of a pressure ulcer and receive care to minimise the risk, including access to a local wound care formulary.

Active patient care checklist Active patient care is carried out within the hospital. This is where staff actively check patients at pre-determined intervals. The active patient care checklist contains all elements of the skin, surface, keep moving, incontinence, nutrition (SSKIN) bundle and ensures that factors contributing to pressure damage are addressed. This includes, what surface is in place for the patient, the frequency of interventions and any changes in the patients’ skin condition.

During the inspection, we saw that the majority of checklists reviewed were well completed and up to date. There was also evidence of a separate active care checklist being used for each day and care being recorded throughout the 24-hour period. However, we also saw some examples where time frequencies had not been recorded. It was also difficult to establish from the documentation how the frequency of the active care was determined.

Specialist pressure relieving equipment NHS Greater Glasgow and Clyde’s self-assessment states that all patients are nursed on, as a minimum, a dynamic pressure relieving surface. This type of mattress is designed to cope with patients who have pressure damage. If a patient is in need of an upgraded dynamic surface, there is guidance available for staff to assess which equipment would be suitable and how to order the equipment required.

During the inspection, we saw pressure relieving equipment was in use in all wards inspected. Staff could access guidance on equipment selection and knew how to access additional equipment, if required. We were told that the AMRU can access equipment from either Lomond ward or ward 14, when needed.

Tissue viability service Ward staff were aware of how to refer patients to the tissue viability service, and when it would be appropriate to do so. Staff also stated that they felt well supported by the service. Tissue viability link nurses were identified within the wards inspected and patient information leaflets were available for patients identified as being at risk of pressure ulcers.

Pressure ulcer safety cross Each ward had a pressure ulcer safety cross in place to show when a pressure ulcer had occurred. When a pressure ulcer occurs, it is investigated using a formal investigation tool. Incidents are also recorded on the hospitals electronic incident reporting system. We were told that learning is shared with staff through the ward safety briefs, staff meetings, a communication folder and through immediate discussions.

During the inspection, we saw one patient who had been admitted to the hospital with small pressure sores. There was a wound chart in place for this patient and clear, up-to-date evidence of wound management and review.

Healthcare Improvement Scotland Unannounced Inspection Report (Vale of Leven Hospital, NHS Greater Glasgow and Clyde): 23–24 June 2015

20 3.5 Managing the return home

Outcome 9: The patient is able to return home (or to a homely setting or care service) as soon as they are well enough to do so. Any additional support that they require at home is in place at the time of discharge. Ensuring that:  older people are discharged from hospital in a planned way and without delay  partnerships between acute care settings and community care services support a co-ordinated approach to discharge, and  medicines are reconciled as part of the discharge process.

NHS Greater Glasgow and Clyde’s self-assessment states that a board-wide discharge document, policy and patient information have been rolled out. The self-assessment also states that this has allowed NHS Greater Glasgow and Clyde to set a consistent standard across all acute areas and ensure the role and responsibility of all disciplines involved in multidisciplinary assessment and the discharge process are captured.

The discharge policy states that all patients, except those who are critically ill, will have an estimated discharge date (EDD) within 24 hours of admission. All EDDs will be reviewed on a daily basis following ward reviews and records should be updated accordingly. We noted that there was an inconsistent approach to the completion of EDDs with subsequent interventions not taking place.

While we saw some examples of discharge checklists being partially completed and evidence of arrangements being made for discharge, such as transportation, care home facilities and medication, there was no evidence of discharge planning being considered as a core part of the patient’s care.

A daily discharge huddle takes place every morning within the hospital to identify the number of beds available in each ward. A ‘discharge safety proforma’ should be completed for each ward before attending this meeting. This includes information on how many patients are due to be discharged that day and if there are any delayed discharges.

In ward 15, it was evident that there is a multidisciplinary team approach to patient care. This includes weekly meetings attended by all disciplines, including social work representatives. We were told that, where complex needs were identified, patients could be referred to the discharge support team.

Area of good practice ■ A discharge safety proforma is used to identify which patients are due to be discharged and if there are any delayed discharges.

Area for improvement 12. NHS Greater Glasgow and Clyde must ensure effective discharge planning begins when, or shortly after, a patient is admitted to hospital.

Healthcare Improvement Scotland Unannounced Inspection Report (Vale of Leven Hospital, NHS Greater Glasgow and Clyde): 23–24 June 2015

21 3.6 Leadership and accountability

Outcome 10: The patient is cared for by staff who are knowledgeable, competent and accountable for the care they deliver. A clinical and care governance framework is in place which will underpin the quality improvement agenda and safeguard high standards of care. Staff are aware of relevant legislation, national standards and key strategies which support this framework.

During the inspection, we saw clear leadership from the senior charge nurses and nurses in charge. We were told that all nursing staff have access to e-KSF and have a personal development plan in place. Learning is available online and some topics, including the completion of MUST are mandatory.

We were told that a plan is in place to ensure all staff complete dementia training, in line with the Promoting Excellence framework, contained within the dementia strategy. However, the NHS board acknowledged that staff do not have protected time to complete online training and attendance at face-to-face training sessions can be difficult due to workload.

We noted that link nurses were identified for a number of topics, but not all have clear role descriptors or protected time to attend meetings. The NHS board anticipates that this will be addressed through the introduction of the care assurance and accreditation system.

Outcome 11: The patient is cared for by staff who are led and supported by effective managers and leadership at every level (from line manager to executive team and NHS Board members). The NHS board is able to demonstrate that there is strong leadership from the Board downwards throughout the whole organisation. The management structure of the NHS board can be clearly articulated and evidence is available to show it is being put into practice at ward level, for the benefit of patients.

During the inspection, we saw that all levels of staff were enthusiastic and motivated. All senior charge nurses had a clear presence in the ward areas and were greatly involved in patient care. There were good examples of effective team working and communication across all wards, which support the delivery of patient care.

In ward 15, we saw that staff were actively gathering feedback from patients by using postcard questionnaires, given to patients on discharge from the ward, and from patient experience feedback. The ward could demonstrate learning and was open to testing new ideas using improvement methodology.

Healthcare Improvement Scotland Unannounced Inspection Report (Vale of Leven Hospital, NHS Greater Glasgow and Clyde): 23–24 June 2015

22 Appendix 1 – Areas for improvement

Areas for improvement are linked to national standards published by Healthcare Improvement Scotland, its predecessors and the Scottish Government. They also take into consideration other national guidance and best practice. We will state that an NHS board must take action when they are not meeting the recognised standard. Where improvements cannot be directly linked to the recognised standard, but where these improvements will lead to better outcomes for patients, we will state that the NHS board should take action. The list of national standards, guidance and best practice can be found in Appendix 3.

Screening and initial assessment Outcome 1

NHS Greater Glasgow and Clyde: 1 should continue to spread the improvement work about detection and management of delirium (see page 13).

2 must ensure that the nutritional care assessment accurately identifies and records any therapeutic dietary needs (see page 13).

This is to comply with Standards for Food, Fluid and Nutritional Care, Criterion 2.2d (2014).

3 must ensure that the nutritional care assessment accurately identifies and records measured height and weight, with the date and time that these measurements were taken (if estimates are used, this should be stated and a rationale provided) (see page 13).

This is to comply with Standards for Food, Fluid and Nutritional Care, Criterion 2.2a (2014).

4 must ensure that medicines reconciliation is fully completed within 24 hours of admission (see page 13).

This is to comply with Scottish Government Health Directorate, Chief Medical Officer (CMO)(2013)18.

5 must ensure clinical staff consistently comply with the national policy on do not attempt cardiopulmonary resuscitation (DNACPR) (see page 13).

This is to comply with Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Integrated Adult Policy – Decision Making and Communication (Scottish Government, May 2010) and SGHD/CMO(2014)17.

Healthcare Improvement Scotland Unannounced Inspection Report (Vale of Leven Hospital, NHS Greater Glasgow and Clyde): 23–24 June 2015

23 Person-centred care planning Outcome 2

NHS Greater Glasgow and Clyde: 6 must ensure that patients have person-centred care plans in place for all identified care needs. These should evidence patient and carer involvement and be regularly evaluated and updated to reflect changes in the patient’s condition or needs (see page 14).

This is to comply with Standards of Care for Dementia in Scotland, Standards for Food, Fluid and Nutritional Care, Criterion 2.9. and Best Practice Statement for the Prevention and Management of Pressure Ulcers, Section 4.

7 must ensure systems are in place to record key personal information about people with dementia or other cognitive impairments. Patients and their families should be given clear guidance on the purpose of this information when they are completing the documentation. This information should be used and shared with staff involved in the care of the patient (see page 14).

This is to comply with Standards of Care for Dementia in Scotland, page 26.

Safe and effective care Outcome 5

NHS Greater Glasgow and Clyde: 8 must carry out improvements to the ward environment, where possible, to make it more suitable for people with dementia and cognitive impairment (see page 16).

This is to comply with Standards of Care for Dementia in Scotland page 26.

Outcome 6

NHS Greater Glasgow and Clyde: 9 must ensure that fluid balance charts are commenced and accurately completed for patients who require them and appropriate action is taken in relation to intake or output, as required (see page 18).

This is to comply with Standards for Food, Fluid and Nutritional Care Criteria 4.1 (g).

10 must ensure there is access to appropriate patient weighing equipment (see page 19).

This is to comply with Standards for Food, Fluid and Nutritional Care Criteria 2.2 (a).

11 should ensure that nutritional supplements are available for patients and accessible to staff at all times (see page 19).

Healthcare Improvement Scotland Unannounced Inspection Report (Vale of Leven Hospital, NHS Greater Glasgow and Clyde): 23–24 June 2015

24 Managing the return home Outcome 9

NHS Greater Glasgow and Clyde: 12 must ensure effective discharge planning begins when, or shortly after, a patient is admitted to hospital (see page 21).

This is to comply with Clinical Standards for Older People in Acute Care, Standard 5c.

Healthcare Improvement Scotland Unannounced Inspection Report (Vale of Leven Hospital, NHS Greater Glasgow and Clyde): 23–24 June 2015

25 Appendix 2 – Details of inspection

The inspection to Vale of Leven Hospital, NHS Greater Glasgow and Clyde was conducted from Tuesday 23 to Wednesday 24 June 2015.

The inspection team consisted of the following members:

Ian Smith Senior Inspector

Claire Blackwood Inspector

Kenneth Crosbie Inspector

Julie Miller Inspector

Irene Robertson Inspector

Marguerite Robertson Public Partner

Supported by:

Jill Sands Project Officer

Healthcare Improvement Scotland Unannounced Inspection Report (Vale of Leven Hospital, NHS Greater Glasgow and Clyde): 23–24 June 2015

26 Appendix 3 – List of national guidance

The following national standards, guidance and best practice are relevant to the inspection of the care provided to older people in acute care.

 Best Practice Statement for Prevention and Management of Pressure Ulcers (NHS Quality Improvement Scotland, March 2009)  Standards for Food, Fluid and Nutritional Care in Hospitals (Healthcare Improvement Scotland, October 2014)  Care of Older People in Hospital: Standards (Healthcare Improvement Scotland, June 2015)  Clinical Standards for Older People in Acute Care (Clinical Standards Board for Scotland, October 2002)  Dementia: decisions for dignity (Mental Welfare Commission, March 2011)  Health Department Letter (HDL) (2007)13: Delivery Framework for Adult Rehabilitation - Prevention of Falls in Older People (Scottish Executive, February 2007)  National Standards for Clinical Governance and Risk Management (NHS Quality Improvement Scotland, October 2005)  Scottish Intercollegiate Guidelines Network (SIGN) Guideline 86 – Management of Patients with Dementia (SIGN, February 2006)  SIGN Guideline 111 – Management of Hip Fracture in Older People (SIGN, June 2009)  Standards of Care for Dementia in Scotland (Scottish Government, June 2011)  The Code (Nursing and Midwifery Council, January 2015)

Healthcare Improvement Scotland Unannounced Inspection Report (Vale of Leven Hospital, NHS Greater Glasgow and Clyde): 23–24 June 2015

27 Appendix 4 – Inspection process flow chart

This process is the same for both announced and unannounced inspections.

Healthcare Improvement Scotland Unannounced Inspection Report (Vale of Leven Hospital, NHS Greater Glasgow and Clyde): 23–24 June 2015

Appendix 5 – Terms we use in this report

Terms and abbreviations

ADL activities of daily living

AMRU acute medical receiving unit

AWI adults with incapacity

BMI body mass index

CAM confusional assessment method

CMO Chief Medical Officer

CSBS Clinical Standards Board for Scotland

DNACPR do not attempt cardiopulmonary resuscitation

EDD estimated discharge date

HDL Health Department Letter

MUST Malnutrition Universal Screening Tool

PURA pressure ulcer risk assessment

SIGN Scottish Intercollegiate Guidelines Network

SSKIN skin, surface, keep moving, incontinence, nutrition

STOPSS screening tool for oropharygeal swallow symptoms

Healthcare Improvement Scotland Unannounced Inspection Report (Vale of Leven Hospital, NHS Greater Glasgow and Clyde): 23–24 June 2015

How to contact us

You can contact us by letter, telephone or email to:

 find out more about our inspections, and  raise any concerns you have about care for older people in an acute hospital or NHS board.

Edinburgh Office | Gyle Square | 1 South Gyle Crescent | Edinburgh | EH12 9EB Telephone 0131 623 4300

Email [email protected]

www.healthcareimprovementscotland.org

The Healthcare Environment Inspectorate, the Scottish Health Council, the Scottish Health Technologies Group, the Scottish Medicines Consortium (SMC) and the Scottish Intercollegiate Guidelines Network (SIGN) are part of our organisation.