Unannounced Inspection Report – Care for Older People in Acute Hospitals

Aberdeen Royal Infirmary and Woodend Hospital | NHS Grampian

11–14 August 2015

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© Healthcare Improvement Scotland 2015

First published October 2015

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Healthcare Improvement Scotland Unannounced Inspection Report (Aberdeen Royal Infirmary and Woodend Hospital, NHS Grampian): 11–14 August 2015

2 Contents

1 Background 4

2 A summary of our inspection 6

3 What we found during this inspection 9

Appendix 1 – Areas for improvement 28 Appendix 2 – Details of inspection 31 Appendix 3 – List of national guidance 32 Appendix 4 – Inspection process flow chart 34 Appendix 5 – Terms we use in this report 35

Healthcare Improvement Scotland Unannounced Inspection Report (Aberdeen Royal Infirmary and Woodend Hospital, NHS Grampian): 11–14 August 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 Care of Older People in Hospital: Standards (Healthcare Improvement Scotland, June 2015).

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 an NHS board self-assessment and a planned Older People in Acute Hospitals (OPAH) board visit.

All NHS boards complete a self-assessment to outline their performance in relation to the key issues for the care of older people and any improvement activity. The planned OPAH board visit allows staff in each NHS board to meet with the inspection team and highlight areas of good practice and areas where improvements could be made. We use the self- assessment data and findings from the OPAH board visit to inform our inspections and identify the key areas of focus.

We 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.

Healthcare Improvement Scotland Unannounced Inspection Report (Aberdeen Royal Infirmary and Woodend Hospital, NHS Grampian): 11–14 August 2015

4 About this report This report sets out the findings from our unannounced inspection to Aberdeen Royal Infirmary and Woodend Hospital, NHS Grampian from Tuesday 11 August to Friday 14 August 2015.

This report summarises our inspection findings on page 6. Detailed findings from our inspection can be found on page 9.

The inspection team was made up of five inspectors and a 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 Aberdeen Royal Infirmary and Woodend 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 28.

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 http://www.healthcareimprovementscotland.org/OPAH.aspx

Healthcare Improvement Scotland Unannounced Inspection Report (Aberdeen Royal Infirmary and Woodend Hospital, NHS Grampian): 11–14 August 2015

5 2 A summary of our inspection

Aberdeen Royal Infirmary serves the Grampian region. It has approximately 900 staffed beds and a complete range of medical and clinical specialties. In November 2012, the new purpose-built Emergency Care Centre opened, bringing together emergency and urgent care facilities into one building. There are 353 inpatient and day beds in the Emergency Care Centre.

Woodend Hospital is a community hospital located in the Woodend area of Aberdeen. The hospital provides elective orthopaedic surgery, rehabilitation and care of the elderly services in conjunction with the other acute and community hospitals in the NHS Grampian area.

We carried out an unannounced inspection to Aberdeen Royal Infirmary and Woodend Hospital from Tuesday 11 August to Friday 14 August 2015.

We inspected the following areas:

Aberdeen Royal Infirmary • ward 101 (acute medical initial assessment, AMIA) • ward 102 (geriatric assessment unit) • ward 105 (general medicine) • ward 107 (respiratory medicine) • ward 110 (general medicine) • ward 204 (acute stroke) • ward 209 (urology) • ward 212 (orthopaedic trauma) • ward 303 (acute geriatric medicine), and • ward 306 (acute geriatric medicine).

Woodend Hospital • orthopaedic rehabilitation unit, and • stroke rehabilitation unit.

Before the inspection, we reviewed NHS Grampian’s self-assessment. We also gathered information about Aberdeen Royal Infirmary and Woodend Hospital from other sources, including Scotland’s Patient Experience Programme and other data that relates to the care of older people. We also carried out an OPAH board visit to NHS Grampian on Wednesday 20 May 2015. Based on our review of this information, we focused the inspection on the following outcomes:

• 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.

Healthcare Improvement Scotland Unannounced Inspection Report (Aberdeen Royal Infirmary and Woodend Hospital, NHS Grampian): 11–14 August 2015

6 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 15 periods of observation during the inspection. In each instance, members of our team observed interactions between patients and staff ward for 20 minutes.

We also carried out patient interviews and used patient and carer questionnaires. We spoke with 24 patients at Aberdeen Royal Infirmary and eight patients at Woodend Hospital. Across both hospitals, we received completed questionnaires from 46 patients and 20 family members, carers or friends.

As part of the inspection, we reviewed 56 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.

Documentation is an essential part of a patient’s care it is a legal requirement and ensures that patient care is safe. Throughout this report, we have identified areas of poor documentation. However, it is important to stress that poor documentation does not automatically mean that care is poor. We cannot say that care was poor, only that we could not be assured that care was safe and appropriate.

Progress since last inspection Following our previous inspection of Aberdeen Royal Infirmary and Woodend Hospital in October 2014, we have noted that improvements have been made as described in the report. NHS Grampian has acknowledged that work is ongoing to introduce improvements.

Areas of strength We noted areas where NHS Grampian was performing well in relation to the care provided to older people in acute hospitals.

• the daily huddle that all senior charge nurses and senior staff attend to identify and discuss any issues that affect patient care, patient flow and capacity, and • The older people acute liaison (OPAL) multidisciplinary team that has been introduced to review frail, elderly patients admitted to Aberdeen Royal Infirmary to ensure the correct care is in place for the patient.

Areas for improvement We found that further improvement is required in the following areas:

• improving the completion of documentation and record-keeping, and • ensuring appropriate systems are in place across NHS Grampian in order to support staff in the prevention and management of falls.

What action we expect the NHS board to take after our inspection This inspection resulted in 15 areas for improvement and six areas of strength. A full list of the areas for improvement can be found in Appendix 1 on page 28.

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

Healthcare Improvement Scotland Unannounced Inspection Report (Aberdeen Royal Infirmary and Woodend Hospital, NHS Grampian): 11–14 August 2015

7 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 http://www.healthcareimprovementscotland.org/OPAH.aspx

We would like to thank NHS Grampian and in particular all staff at Aberdeen Royal Infirmary and Woodend Hospital for their assistance during the inspection.

Healthcare Improvement Scotland Unannounced Inspection Report (Aberdeen Royal Infirmary and Woodend Hospital, NHS Grampian): 11–14 August 2015

8 3 What we found during this inspection

3.1 Treating older people with compassion, dignity and respect Across both hospitals, all patients were cared for in either single rooms or single sex bays. Designated male and female toilets and shower facilities were available where rooms did not have ensuite facilities. We saw some single patient rooms had frosted glass windows on the doors and curtains that could be pulled over to preserve dignity and privacy. Patients looked comfortable and wore their own clothes, appropriate nightwear or hospital pyjamas. We found instances where personal items, such as cushions and photographs, were at the patients’ bedside. This helps patients feel more at ease within the hospital setting.

We found the wards inspected were generally calm and uncluttered. We saw the majority of patients had a nurse call bell. With the exception of one ward, buzzers were answered promptly.

We observed several instances where the nursing staff ensured that those patients who were receiving end of life care could be supported by their relatives. Arrangements were made for the relatives to stay overnight in the hospital, if they wished. This demonstrates a person-centred approach to meeting the needs of the patient and their relatives.

We were told that volunteers were being used in some areas of Aberdeen Royal Infirmary and Woodend Hospital. For example, in the acute stroke ward, volunteers played board games and chatted with patients in the staff duty room.

At both hospitals, we saw that some of the wards organised themed events, such as fiddle and ceilidh parties, tea parties, tea and cake trolleys, fish ’n’ chips days and a tuck shop. This provided activities for patients who needed to stay in hospital for longer periods of time.

Patient and relative comments Through discussions with our public partner, patients were able to give their opinions about the care they received while in hospital.

At Aberdeen Royal Infirmary, patients told us:

• ‘I have been coming here for 5 months now, and it feels like I’m visiting friends. They always find time for a wee chat, and I feel well and truly looked after.’ • ‘Staff are 100%. They can’t do enough for you.’ • ‘I feel very well looked after.’ • ‘You can’t fault the staff.’ • ‘The staff are very efficient.’

At Aberdeen Royal Infirmary, patients told us about some concerns that they had:

• ‘For some patients (in the ward) the nurses put music on, and this can be annoying.’ • ‘[staff] can be a bit long in answering the buzzer.’ • ‘The toilet is too low in ward 212. And I have a leg injury.’ • ‘I can’t pull the TV screen forward myself.’

We also spoke with eight patients at Woodend Hospital. They told us:

Healthcare Improvement Scotland Unannounced Inspection Report (Aberdeen Royal Infirmary and Woodend Hospital, NHS Grampian): 11–14 August 2015

9

• ‘Staff are more like friends. They use our first names.’ • ‘On the whole, staff are very good.’ • ‘They look after you well.’

At Woodend Hospital, patients told us about some concerns they had.

• ‘The TV is on the ward all day long, from morning to evening.’ • ‘Night staff do not moderate their noise level.’ • ‘In contrast to weekdays, when there are a lot of therapy and social activities on the ward, the weekend can be very hard and there is very little staff and patient interaction.’ • ‘It can be a boring day, more stimulus is required.’

We received 46 completed patient questionnaires from Aberdeen Royal Infirmary and Woodend Hospital. Of the patients that completed our questionnaire:

• 40 stated they had been given clear information about their condition and treatment • 42 stated that ‘staff always respond quickly if i need help’, and • 41 stated that ‘staff check on me regularly to ask if I need anything’.

We received the following positive comments from patients in Aberdeen Royal Infirmary through our questionnaire:

• ‘My stay in hospital has been very good. The doctors and nurses are very kind and always looking for a way to help you. They are very friendly at all times and having a good joke with you.’ • ‘I have had a very comfortable stay in hospital - staff, doctors, nurses and domestic staff have been very kind and helpful.’ • ‘Staff are friendly and caring. They understand the difficulties faced by someone suffering a stroke. They are motivating and help me stay positive. They are supportive to my relatives - always find the time to talk things through. Staff take the time to phone my relatives and keep them updated on my progress - this is very much appreciated.’ • ‘The staff are caring and are always on hand to help out with my questions.’ • ‘I find the staff most pleasant and helpful with showers. The food is perfect and also variable and well served. Nursing staff always respond if you call them.’

Through our carer and visitor questionnaires, family members, carers and friends were able to give us their opinion of the hospitals. Fifteen people completed our questionnaire in Aberdeen Royal Infirmary, stating that:

• ‘Staff and support during my mum’s time in ARI has been amazing.’ • ‘Great staff.’ • ‘Doctor in A&E attended to [relative] and gave us clear information all the time and transferred to ward. At the ward they received special attention from the staff as soon as we arrived. We have been told who we need to contact and feel confident going forward. The attention and care of all the staff is genuine and exceptional, giving us a confidence going forward...’ Healthcare Improvement Scotland Unannounced Inspection Report (Aberdeen Royal Infirmary and Woodend Hospital, NHS Grampian): 11–14 August 2015

10

Some family members, carers and friend told us about some concerns and worries they had in Aberdeen Royal Infirmary.

• ‘Seem to be in a hurry to discharge patients. While staff may listen to family concerns, do not appear at times to action or take family wishes into consideration. Procedure to have care for elderly put in place at home on discharge appears very drawn out and takes forever to happen.’ • ‘I think my husband should be back in bed before I leave because he gets tired easily.’

At Woodend Hospital, patients told us:

• ‘I have been treated with kindness, care and respect.’ • ‘[I am] very pleased with the treatment I have received from all staff.’

Through our carer and visitor questionnaires, family members, carers and friends were able to give us their opinion of the hospitals. Five people completed our questionnaire in Woodend Hospital, stating that:

• ‘Thank you for all the care, we are very pleased with the progress we have seen.’ • ‘From the very start I have been made to feel very welcome by all the staff I have been involved with. If my wife is requiring treatment and it is better that I leave until they have finished I have been asked very pleasantly to go to the day room and I am always told immediately when they have finished. I cannot praise the staff highly enough for their hard work and the patience they show with different situations.’ • ‘The words ‘[registered] blind’ were put up on my husband's white board without informing me first. I know my husband’s eyesight was bad but to see it up on his board was both shocking and upsetting. If staff could make a simple call before putting this information up on his board it would have made a big difference. I have asked repeatedly for my husband to be dressed in a vest before shirt, however, this rarely happens.’

Patient and staff interactions We used a formal observation tool in the wards inspected to observe interactions between staff and patients. The majority of interactions with patients were positive.

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.

Following the previous inspection in October 2014, we recommended to NHS Grampian should:

ensure the management of patient flow in the hospital is fit for purpose, and maintains patient safety, care and dignity.

Since our previous inspection in October 2014, work has been carried out on patient flow and capacity. One of the most significant pieces of work has been the introduction of the ‘daily huddle’. All senior charge nurses and senior staff attend the daily huddle to identify and discuss any issues that affect patient care. This includes patient flow and capacity. We attended one of these meetings and found it to be an effective way to allow staff to bring any

Healthcare Improvement Scotland Unannounced Inspection Report (Aberdeen Royal Infirmary and Woodend Hospital, NHS Grampian): 11–14 August 2015

11 issues to the attention of senior management. Staff reported that they felt these meetings were effective.

Area of strength ■ In some ward areas, activities are provided for patients. We encourage NHS Grampian to roll this out across all ward areas.

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.

All older people admitted to hospital should have assessments carried out to identify any risks and care needs. This should include assessments of cognition, nutritional state, risk of falls and risk of developing pressure ulcers. Information gathered to complete the assessments should be accurately recorded and should indicate the date and time these assessments were undertaken. The accuracy of assessments and, where appropriate, the source of information is important as this can impact on other assessments and aspects of care. For example, accurate height and weight are required for both nutrition and pressure ulcer risk assessments.

Dementia and cognitive impairment Since our previous inspection, NHS Grampian’s dementia steering group has agreed that all patients over 65 years of age who are admitted to hospital are screened initially for cognitive impairment using the 4AT screening tool which screens for both delirium and cognitive impairment. An improvement advisor based within NHS Grampian is supporting staff through education sessions and training on local implementation of new assessment tools to identify patients with delirium. NHS Grampian has also developed a policy for assessment of patients with cognitive impairment. An education plan will be rolled out to all hospitals in NHS Grampian, to be implemented by December 2015.

During this inspection, cognitive assessment was being carried out using various assessment tools. Of the 56 patient health records we reviewed for dementia and cognitive impairment, 51 (91%) had a completed cognitive assessment.

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. It is important to have an accurate weight recorded as it may be required for other assessments or to calculate the dosage for certain drugs.

During the inspection, we reviewed 56 patient health records for nutritional care and found 27 patients (48%) had a MUST assessment completed within 24 hours. Although, some patients had a MUST assessment in place, no date or time was recorded, therefore it was unclear if they were completed within the national standard timeframe of 24 hours after Healthcare Improvement Scotland Unannounced Inspection Report (Aberdeen Royal Infirmary and Woodend Hospital, NHS Grampian): 11–14 August 2015

12 admission. From the patient health records reviewed, it was not clear if the patient’s height and weight had been accurately measured, reported or estimated.

The MUST assessment document in use does not contain a place to record the patient’s usual weight or recent unplanned weight loss, which is required to calculate the overall MUST score. Therefore, it was unclear how the weight loss score was obtained.

We found MUST assessments completed in the acute medical initial assessment (AMIA) unit did not include how staff calculated the MUST score as only the total score was recorded.

We also found:

• a patient’s MUST was not completed until 8 days after admission. • a patient’s MUST was completed 2 days after the initial admission using a hoist scale. • a patient’s MUST was not completed until 5 days after readmission showing the patient was at risk of malnutrition. The previous admission notes had not identified the risk of malnutrition as the notes stated the patient had not been weighed. • In one patient health record, it stated ‘unable to weigh patient’. No estimated weight or alternative measure had been documented to inform calculation of body mass index (BMI).

MUST rescreening MUST rescreening should take place weekly while the patient remains in hospital. It is also important that rescreening takes place so that any weight loss is identified and appropriate action taken, such as referral to a dietitian. We found 27 patients were eligible for repeat MUST screening and 21 had taken place.

Nutritional assessment We reviewed 56 patient health records for nutritional care and found 47 patients had a nutritional assessment completed. This assessment should include special dietary requirements, religious or cultural dietary needs, likes or dislikes or any assistance the patient needs. However, we found not all assessments recorded patients’ likes and dislikes.

Falls assessment NHS Grampian’s patient admission assessment document contains a section to screen for falls risks which may prompt a more detailed falls assessment. We reviewed various documents in use to identify if the patient was at risk of falls and saw there was no consistent approach being applied. For example, we saw a checklist, a falls indicator and a falls bundle in place across various wards.

We reviewed 56 patient health records for falls. Fifty (89%) patients were screened for their risk of falls.

We found 27 patients’ falls screening prompted a further assessment and 19 of these had been completed. We found patients transferred from Aberdeen Royal Infirmary to Woodend Hospital had falls screening reviewed. However, it was not clear from the documentation what had been completed at Aberdeen Royal Infirmary and what had been completed at Woodend Hospital. Therefore, it was unclear what the patient’s current level of risk of falls was. Preventing and managing pressure ulcers NHS Grampian uses an adapted Waterlow risk assessment tool. This assessment should be carried out within 6 hours of patient admission. We reviewed 56 patient health records for Healthcare Improvement Scotland Unannounced Inspection Report (Aberdeen Royal Infirmary and Woodend Hospital, NHS Grampian): 11–14 August 2015

13 pressure area care. Thirty four (61%) patients had an assessment completed within 6 hours of admission.

In AMIA, we found that the Waterlow assessments reviewed did not include an assessment to evidence how staff calculated the overall Waterlow score. We spoke with the nurse in charge who told us that staff refer to a laminated Waterlow sheet and mentally calculated the patient’s Waterlow score. This was then recorded as a total score in the patient’s admission assessment document.

We saw examples in some patients’ health records that showed different Waterlow scores recorded in AMIA, compared to the next ward to which the patient was transferred.

Waterlow reassessments NHS Grampian’s pressure ulcer management pathway states that Waterlow scores are to be reassessed on a daily basis for all patients. During the inspection, we found 50 patients who should have had a Waterlow reassessment undertaken on a daily basis. Of these, 37 patients had a daily reassessment completed.

Medicines reconciliation The Chief Medical Officer (CMO) (2013)18 guidance 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 for 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.

During the inspection, we found various documents in use to record medicines reconciliation in both hospitals.

Of the 56 patient healthcare records reviewed for medicines reconciliation, 47 (85%) patients had a medicines reconciliation form in place. However, due to the layout of the forms, the majority were not fully completed. We found the following:

• The documentation used in the emergency department does not contain a medicines reconciliation form and there was no separate form in use. • There was no space to record the patient’s name, date of birth or other details. • There is no column to record if medicines are to continue, therefore no clear instruction is being given. • There is no place for the person completing the information to provide the date, time and their signature. This is not good record keeping as it may not be the person completing the medical assessment that completes the medicines reconciliation form, or that it is completed at the point of admission.

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 Healthcare Improvement Scotland Unannounced Inspection Report (Aberdeen Royal Infirmary and Woodend Hospital, NHS Grampian): 11–14 August 2015

14 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 this inspection, we reviewed 21 DNACPR forms and found that four had been fully completed. Although most of the forms included the reason for the decision, we found:

• nine of the forms did not indicate if discussions had taken place with the patient, or their family. There was no evidence in the medical records why these discussions had not taken place. • 11 of the forms did not have review dates documented • one patient had two DNACPR forms in place. Only one form should be in place as this can be confusing for staff as it is unclear what the current form is.

Documentation During our inspection, we found documentation and its use across all wards inspected at both hospitals was inconsistent.

• Entries within the patient admission assessment document were not always dated or signed. • Some wards were using combined medical and nursing notes, where others were using separate medical and nursing notes. • Loose forms, such as comfort rounding and fluid balance sheets, only recorded the patient’s name rather than recording the patient’s unique identifiable number. This could result in confusion if there were two patients with the same name in the ward.

Area for improvement 1. NHS Grampian must ensure that all older people who are being treated in the emergency department or are admitted to hospital are assessed within the national standard recommended timescales. Assessments should be accurate and fully completed. This includes nutritional screening and assessment, falls management and pressure ulcer care. Where an assessment is not thought to be appropriate, the decision should be recorded within the patient’s care record. 2. NHS Grampian must ensure clinical staff consistently comply with the national policy on do not attempt cardiopulmonary resuscitation (DNACPR). 3. NHS Grampian must ensure that medicines reconciliation is fully completed within 24 hours of admission. 4. NHS Grampian must ensure all documentation, both nursing and medical, is legible, dated, timed and signed. It should provide details of any assessments and reviews undertaken, and provide clear evidence of the arrangements that have been made for future and ongoing care. It should also include details of information about care and treatment.

Healthcare Improvement Scotland Unannounced Inspection Report (Aberdeen Royal Infirmary and Woodend Hospital, NHS Grampian): 11–14 August 2015

15 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.

During the inspection, we found an inconsistent approach to care planning throughout the wards inspected in Aberdeen Royal Infirmary and Woodend Hospital.

The patient admission assessment document includes a section to record ‘5 Must Do With Me’. This should include information that is important to the patient during their stay in hospital. This should also inform interactions between the patient and staff, and link in to the patient’s care plan. However, we found that this information was not always completed.

On some wards, where consent had been given, we saw posters above patient’s beds to capture the ‘5 Must Do with Me’. However, this information was not documented in the nursing record and did not inform any care plans.

We reviewed a variety of pre-printed nursing care plans in use. However, these were checklists rather than a personalised plan to inform care. We found care plans did not evidence that the patient or the patient’s relatives or carers had been involved in, or agreed with, the plan of care.

Comfort rounding Comfort rounding is when staff check on individual patients at defined regular intervals to anticipate any care needs they may have, for example pain relief or needing the toilet. We found comfort care rounding was in place in some of the wards inspected.

Not all comfort rounding sheets had a prescribed frequency of intervention and it was not clear how the frequency was informed by care planning. For example:

• one ward carried out comfort rounding once a day • one ward carried out comfort rounding twice a day, and • other wards carried out comfort rounding every 2 hours.

When comfort rounding forms were in place, they were not completed consistently over a 24-hour period. For example:

• one patient had their form completed at 6.00am, 7.00am and 11.40am, with no other entries for that day or night • one patient had no entries from 9.00pm until 8.00am the following day, and • one patient had no entries recorded for an 8-day period.

This demonstrates an inconsistent approach to the completion of comfort rounding and delivery of care.

Healthcare Improvement Scotland Unannounced Inspection Report (Aberdeen Royal Infirmary and Woodend Hospital, NHS Grampian): 11–14 August 2015

16 Areas for improvement 5. NHS Grampian must ensure that patients have person-centred care plans in place for all identified care needs. These should evidence patient or carer involvement and be regularly evaluated and updated to reflect changes in the patient’s condition or needs. 6. NHS Grampian must ensure that the implementation of care rounding is supported by adequate individualised care planning and evaluation of the patient’s care.

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.

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.

Since our pervious inspection, Healthcare Improvement Scotland and NHS Grampian are working together to improve the outcomes for patients with delirium. An improvement advisor based within NHS Grampian is supporting staff through education sessions and training on local implementation of new assessment tools to identify patients with delirium. This forms part of a wider local improvement programme for the care of older people.

NHS Grampian is currently in the process of introducing the 4AT assessment tool. This assessment tool is used to identify both a cognitive impairment and delirium. We saw that the wards using the 4AT were working well. We also saw that some wards have introduced a daily single question known as SQiD which can be used to identify delirium. As a result of the improvement work being undertaken, we saw that staff were more aware of delirium since the previous inspection. Staff had information available to guide care and treatment, with the Scottish delirium guidelines available on some of the wards. Medical staff knew they were available and how to access them.

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.

The nursing record contains a prompt to establish if a person has an appointed power ff attorney. It is good practice to establish on admission if a power of attorney is held in case a

Healthcare Improvement Scotland Unannounced Inspection Report (Aberdeen Royal Infirmary and Woodend Hospital, NHS Grampian): 11–14 August 2015

17 person loses the capacity to consent to treatment while in hospital. We saw that this was not always completed.

From the patient health records reviewed, we saw 15 AWI certificates in place However, only 11 AWI certificates had an accompanying treatment plan in place.

In one ward, we found an AWI form was 11 days out of date. We raised this with staff who agreed to arrange a review of the patient. There was no power of attorney details entered on the form or documentation to evidence that they had been consulted and agreed to the decisions made.

We found variable completion of accompanying treatment plans. • In one ward the AWI form was accompanied by a well completed treatment plan. This covered all the proposed interventions for the patient. This included fundamental healthcare needs, management of existing long term conditions and allied healthcare professional (AHP) intervention. It also detailed interventions for the investigation, treatment and management of infection and constipation. • In one ward, an AWI was in place due to the patient refusing care and having delirium. A treatment plan accompanied the form, but it did not reflect all interventions proposed, such as interventions by the speech and language therapist, dietitian or nursing staff inserting a feeding tube or urinary catheter. There was no evidence of discussions with relatives or the patient. We raised this with ward staff and were told that the patient had consented to the insertion of the feeding tube that day and that the patient was now more orientated. They agreed to ask for a review of the patient’s capacity to establish if the AWI was still required.

Power of attorney During this inspection, in the patient health records reviewed, we identified five powers of attorney. It is good practice to see a copy of this document to verify the powers held, and clearly identifies what decisions the attorney can make on the patient’s behalf. Only three patient healthcare records reviewed included a photocopy of the power of attorney document.

We saw that one patient’s health record stated that the patient’s power of attorney had both financial and welfare powers. However, on viewing the power of attorney document, it stated that the attorney only had financial powers. This meant the attorney could not make decisions on care and treatment on behalf of the patient.

Capacity assessments During the inspection, we found an inconsistent approach to the assessment of patients’ capacity to consent to treatment. For example, not all patients with an AWI certificate in place had a documented capacity of assessment. Other patients, whose assessments should have prompted medical staff to consider their capacity to consent to treatment, did not have these in place.

Environment for people with dementia and cognitive impairment Since previous inspections to Aberdeen Royal Infirmary, we found that general way finding signage throughout the hospital had improved. This includes the use of colour coding signage to direct patients and visitors to different parts of the hospital.

During the inspection, we saw some wards were undertaking work to improve the environment for people with dementia by creating sitting rooms with a dining area.

Healthcare Improvement Scotland Unannounced Inspection Report (Aberdeen Royal Infirmary and Woodend Hospital, NHS Grampian): 11–14 August 2015

18 We saw signage in place for bathrooms and toilets and clocks were available in all rooms. In some wards, staff wrote the day and date on the whiteboards in individual rooms so they were visible to patients in bed.

We saw volunteers were being used in some areas and a library trolley also visited some wards. A range of information for relatives was available, which included sources of support and voluntary organisations which could be accessed by carers.

Older people acute liaison (OPAL) team NHS Grampian has introduced the older people acute liaison (OPAL) team, this multidisciplinary team consists of three consultant geriatricians, three occupation therapists and one physiotherapist. We were told that they hope to recruit more physiotherapists and nursing staff.

This team reviews frail, elderly patients who are not in the acute geriatric medicine wards to ensure they are being cared for appropriately. and when possible transferring the patient to one of those wards.

The OPAL team also review frail, elderly patients who are admitted through the emergency department. At the time of the inspection, the OPAL team had only been in place for 2 weeks and had already seen 12 patients. These patients did not subsequently require admission to the hospital who may have previously been admitted, but the team were able to discharge the patients and ensure the correct care was in place for the patient at home.

Areas of strength ■ NHS Grampian has worked to improve the care of patients with delirium through implementation of the 4AT and SQiD. Guidelines are available to guide staff. ■ The introduction of the OPAL team at Aberdeen Royal Infirmary.

Area for improvement 7. NHS Grampian must ensure that current legislation, which protects the rights of patients who lack capacity, is fully and appropriately implemented. When legislation is used, this must be fully documented in the patient health record, including any discussions with the patient or family. For example, establishing if a power of attorney is held, and the information shared with staff.

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 Healthcare Improvement Scotland Food, Fluid and Nutritional Care standards (2014).

Patient weighing equipment During the inspection, ward staff told us they had access to weighing scales, including hoist scales. One ward’s hoist scales were broken and waiting to be repaired. This had been discussed at the morning huddle and a replacement set was organised. However, the ward received a replacement hoist without any weighing scales attached. In Woodend Hospital, we saw that each set of sit-on scales was numbered and staff recorded which scales were Healthcare Improvement Scotland Unannounced Inspection Report (Aberdeen Royal Infirmary and Woodend Hospital, NHS Grampian): 11–14 August 2015

19 used. This is good practice and supports accurate weight recording. NHS Grampian should consider introducing this system across the NHS board area.

Dietetic and speech and language therapy cover During the inspection, we found inconsistencies with patient referrals. It was not always clear if or when a patient had been referred to dietetics or the speech and language therapist as there was no space in the patient health record to document details of the referral.

Where we found evidence of dietetic and speech and language input within the patient healthcare records, the outcomes of their assessments and advice to ward staff were clear and comprehensive. However, there was not always evidence that advice was being followed.

In one patient health record, there was no food record chart in place for a patient with dementia who the dietitian advised needed to increase their dietary intake. However, nursing staff did not have a food record chart to monitor what the patient was eating; therefore it was unknown what the patient had eaten.

We saw evidence in seven patient healthcare records of MUST scores triggering a referral for dietetic input. We saw that these patients were seen promptly by the dietitian and there was clear evidence of detailed nutrition care plans.

Identifying individual patient nutritional needs In Aberdeen Royal Infirmary, we reviewed the care of one patient who was to start naso-gastric feeding after an assessment by the speech and language therapist. However, nursing staff were unable to contact the dietitian to get a feeding regime prescribed. The senior charge nurse told us there was no ‘starter regime’ within the ward for staff to use until the patient had been assessed by a dietitian and that patients would only be given intravenous fluids until the dietitian prescribed the feeding regime. This could result in patients being left without any nutritional support over weekends and public holidays.

We saw nutritional whiteboards in ward kitchens, but these were blank containing no information on dietary needs. Staff told us they use the safety brief and ward handover to highlight patients needing a special diet, assistance with meals or those who were ‘nil by mouth’. In some wards, there were also signs at the back of the patient’s bed. Patients seen by a speech and language therapist had clear flood, fluid and nutrition risk-based information recorded on their individual whiteboards behind their beds.

We noted that in the AMIA, staff had tested the use of food, fluid and nutrition whiteboards, which are located outside patient rooms. These boards help inform ward assistants giving out meals. The senior charge nurse and ward assistants both said this had proved helpful.

Protected mealtimes Staff in all wards told us that protected mealtimes were in place to reduce non-essential interruptions during mealtimes. This makes sure that eating and drinking are the focus for patients without unnecessary distractions. We saw that protected mealtimes were adhered to.

During this inspection, we found mealtime management was variable across the wards inspected. In some wards, we found evidence of good co-ordination of mealtimes and patients were seen to have been positioned correctly and offered hand hygiene. Wards were using red meal trays to let staff know who needed support with eating. In one ward, we saw a knife and fork symbol above patients beds to show the patient needed help. The meals

Healthcare Improvement Scotland Unannounced Inspection Report (Aberdeen Royal Infirmary and Woodend Hospital, NHS Grampian): 11–14 August 2015

20 were served in a timely manner and necessary assistance was given to patients. We also saw medical staff not interrupting patients during mealtimes.

In some wards, we saw no trained nursing staff involved with the mealtime activity. In one ward, meals took over half an hour to be served from the trolley. We also heard patient buzzers ringing for 20 minutes before being answered by staff. In this ward, we also saw patients incorrectly positioned before meals were served. This resulted in meals being left at the patient’s bedside for up to 15 minutes before assistance was given.

During the distribution of meals, we found that not all patients were given their meal at the time of service. Sometimes, there was no one making sure that all patients who could eat had received a meal. When this was brought to the attention of staff, they obtained a meal for the patients.

Assistance with eating and drinking Where patients needed assistance to eat, we saw incidences of appropriate help being given in a dignified manner. For example:

• staff were sitting by the bedside, taking time and focusing on the patient • we saw some positive interactions during mealtimes, with staff opening packets and assisting patients in a dignified manner, and • we also saw some patients being assisted by relatives during mealtimes.

However, we also saw one patient in their bed who needed help to eat their breakfast. Staff put their meal on a red tray and a senior nurse went back later to help the patient with their meal. The nurse stood with the patient while they ate.

In Woodend Hospital, we found the dining room was well used. The majority of patients were able to sit and use the tables for meals. Patients were asked what they would like and food arrived in a timely manner. We also saw staff giving assistance when needed. Patients reported that they liked the dining room and we saw good interactions between staff and patients.

Eating and drinking equipment During the inspection, we found that not all wards had adapted eating and drinking equipment. One member of staff told us such equipment would be requested from the kitchen department, but another member of staff said they would speak with occupational therapy to access this.

Provision of fluids and snacks A range of snacks was available in both hospitals. Patients could have toast, yoghurts, cup a soups, rice puddings, custard pots, cheese and crackers, sandwiches, and ice cream.

In addition to fresh drinks being served with meals, we saw ‘juice rounds’ and ‘cake rounds’ being offered in some wards. For example, in Woodend Hospital we saw staff serving afternoon tea for patients offering a choice of sandwiches, biscuits, yoghurts, fruit and a choice of hot and cold drinks.

Food record and 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:

Healthcare Improvement Scotland Unannounced Inspection Report (Aberdeen Royal Infirmary and Woodend Hospital, NHS Grampian): 11–14 August 2015

21 • medical staff • dietitians • speech and language therapists, • or started by nursing staff.

During this inspection, we found variable completion of fluid balance charts. Some charts were completed appropriately, over the appropriate 24-hour period and documented fluid totals. Examples included:

• one patient had their artificial feeds, water flushes and urine outputs recorded clearly on the chart, and • one fluid balance chart documented a patient’s refusal for staff to monitor their urine output.

However, we found some charts were not fully completed. Some did not detail why the chart was in place and other charts did not detail how long they should be used for. During the inspection, we also saw examples of:

• staff not completing the fluid balance charts over the whole day or night for input and output, resulting in gaps of many hours with no entries, and • staff not calculating fluid totals to inform decision-making for subsequent care and treatment.

Some patients had well completed food record chart but the completion was variable.

• One patient’s medical notes stated that they were to be encouraged to eat and drink more. However, there was no food record chart in place for this patient to monitor what they were eating. • One patient’s food record chart had no evening meals recorded. • One fluid balance chart was used by staff to record porridge, ice cream and jelly. This did not demonstrate good staff understanding of food or fluid balance monitoring.

Ward resource folder During the inspection, we noted that wards had a new therapeutic diet folder listing all allergens and special diets. Ward staff use this diet folder to check ingredients of dishes for patients with a known food or fluid allergy. In one ward, a ward assistant told us that this was much easier than phoning the kitchen directly.

Improvement work for nutritional care Since the previous inspection, we saw a number of wards were implementing a variety of initiatives to improve nutritional care. For example:

• in AMIA, changing the time the meal trolley arrives to avoid the busy patient admission time • in AMIA, staff are trialling a 9.30pm snack round for patients, and • in some wards, staff have introduced cake bar snacks for patients.

During the inspection, senior management advised use that plans were underway to test the introduction of a robust link nurse role to support nutrition and hydration at ward level. A formal role description will be used to support this work. Subject to evaluation, it is

Healthcare Improvement Scotland Unannounced Inspection Report (Aberdeen Royal Infirmary and Woodend Hospital, NHS Grampian): 11–14 August 2015

22 anticipated that the revised link nurse model will be adopted across all aspects of older people’s standards.

Areas of strength ■ At Woodend Hospital each set of scales are numbered and the appropriate number recorded on the MUST chart. ■ The improvement work carried out in AMIA is focused on food, fluid and nutrition, including asking patients and staff for their input. These improvements should be shared across NHS Grampian so that other wards can consider what would work well in their own respective wards. ■ At Woodend Hospital, afternoon tea rounds provide opportunities for patients to eat and drink outwith set mealtimes.

Area for improvement 8. NHS Grampian must ensure where a patient’s requires nutritional support, this is provided immediately and a specialist assessment takes place within 72 hours. 9. NHS Grampian must ensure mealtimes are managed in a manner that ensures that patients are prepared for meals and get assistance in a timely manner. 10. NHS Grampian must ensure that food record and 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.

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.

During the inspection, we saw that patients at risk of falls are highlighted on the ward safety brief and on the nursing handover sheet. Where a patient is identified as at risk of a fall, a multi-factorial assessment should be carried out by the multidisciplinary team. However, we did not see this in all of the notes reviewed. Some factors contributing to falls were not always identified, for example a review of the patient’s medication. .

NHS Grampian has a post-fall checklist in use which should be completed after a patient has fallen in hospital. This includes a prompt that ensures the patient is seen by medical staff and their risk assessment is updated. During this inspection:

• we found a patient was noted to have fallen twice in hospital. The patient was seen by medical staff, but we found no evidence of staff using the post-fall checklist. • another patient had a post-fall checklist in place despite not falling in hospital.

Healthcare Improvement Scotland Unannounced Inspection Report (Aberdeen Royal Infirmary and Woodend Hospital, NHS Grampian): 11–14 August 2015

23 Bedrails Following the previous inspection, NHS Grampian had introduced a bedrail protocol. This included the consent to use bedrails and suggests alternatives to bedrails, such as high low beds, floor mats and sensor alarms. We saw bedrails were in use in all wards inspected. However, there was no evidence found in the care records to demonstrate that risk assessments had been carried out to ensure their safe use or that the patient’s consent had been obtained.

Improvement work for falls prevention NHS Grampian has a board-wide falls advisor based in Elgin. They work 1 day a week providing support to NHS Grampian staff. We were told that there are currently no falls co-ordinators in Aberdeen Royal Infirmary and Woodend Hospital.

We were provided with evidence that showed a rise in falls in the acute geriatric medicine wards.

During NHS Grampian’s board visit in May 2015, we were told that falls prevention has been identified as an area for improvement. NHS Grampian had introduced a falls group to take forward this work. During this inspection, we saw a number of initiatives to reduce the risks of patient falls in hospital.

• In Woodend Hospital, staff had implemented the use of the falls safety cross. A falls safety cross records when a fall occurs and enables staff to review the patient’s care and identify any learning from the incident. • In the orthopaedic rehabilitation ward, we saw a falls improvement board. We were told a member of staff is working with AHPs to take forward this work. The senior charge nurse also told us that they had seen a reduction in falls. • A number of wards had introduced non-slip socks to be used by patients who do not have access to appropriate footwear.

Area for improvement 11. NHS Grampian should ensure that where a falls risk has been identified, the patient should be offered a multi-factorial assessment and intervention. They should ensure that any intervention addresses the patient’s identified individual risk factors for falling in hospital and takes into account whether risk factors can be treated, improved or managed during the patient’s expected stay. 12. NHS Grampian should ensure bedrail assessments are carried out consistently. This will make sure that no patients are at risk of falling out of bed or that bedrails are not used unnecessarily on patients.

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.

Healthcare Improvement Scotland Unannounced Inspection Report (Aberdeen Royal Infirmary and Woodend Hospital, NHS Grampian): 11–14 August 2015

24

SSKIN bundles NHS Grampian’s pressure ulcer prevention pathway states that a SSKIN bundle (skin, surface, keep moving, incontinence and nutrition) should be put in place if the patient’s Waterlow score identifies them as being at high risk of developing pressure ulcers. This prompts staff to check patients’ skin more regularly and reduce variation in practice. By checking the skin more regularly, early signs of pressure damage will be identified sooner by staff.

Where SSKIN bundles were in place, it was not always clear how the decision for the frequency of intervention had been reached due to the lack of care planning. The SSKIN bundles themselves did not always state how often the intervention should take place.

In some wards, neither the SSKIN nor comfort rounding sheets were completed consistently over a 24-hour period. This made it difficult to evidence that preventative measures, such as repositioning the patient, had been carried out.

At Woodend Hospital, we saw that there was not a personalised approach to the use of the SSKIN bundle. The stroke ward recorded care as ‘once daily - AM’ for every patient. Ward 12 recorded care as ‘AM’ and ‘PM’ on every patient’s sheet. This was not always seen to be completed. This reflects care delivery to suit the ward’s routine rather than a person-centred approach. We discussed this with both nurses in charge and the clinical nurse manager.

During the inspection, from the patient health records reviewed, we indentified one patient who had a pressure ulcer. The patient had no wound treatment plan in place for the ulcer, and no care plan indicating what dressing was to be used. No assessment form was in use to record the size, depth or grade of the ulcer, and this patient had not been referred to the tissue viability service for advice.

Tissue viability service The tissue viability team in NHS Grampian provides a service to the acute sector, community and care homes. This includes seeing patients using an electronic service (e-service) which allows photographs to be uploaded to allow the tissue viability nurses to review the wound if they are unable to see the patient in person.

Two senior members of staff had left the tissue viability team and had not been replaced. This left one full-time and one part-time member of staff who were trying to maintain the same level of service. We spoke with the tissue viability staff who expressed concerns to us that they were no longer able to provide the same level of service which could impact on patient care. This meant that the team was having to prioritise their case load and was only able to see patients at highest risk.

NHS Grampian told us that due to this staff turnover, an expert external review of NHS Grampian’s tissue viability service has been undertaken. A report of those findings is due to be circulated.

Healthcare Improvement Scotland Unannounced Inspection Report (Aberdeen Royal Infirmary and Woodend Hospital, NHS Grampian): 11–14 August 2015

25 Area for improvement 13. NHS Grampian should ensure that where a patient is identified as being at risk a SSKIN bundle should be implemented; it should contain the frequency of planned intervention. The information gained from each element of the bundle should be used to inform other assessments to ensure appropriate care planning and delivery 14. NHS Grampian should ensure that all patients who have a pressure ulcer or other skin wound must have appropriate wound assessment charts completed, which include grading or ulcers and / or sites of wounds. Wound management documents must be completed and evaluated regularly. Advice must be sought from tissue viability specialist nurses as necessary and relevant information communicated if the patient transfers wards or is discharged from hospital. 15. NHS Grampian must ensure that the tissue viability team is able to provide a comprehensive service to meet the needs of the patients and staff, providing staff education and advice, as required.

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.

Effective discharge planning should begin at admission or shortly after admission to hospital. During the inspection, we found that, although the nursing notes did not evidence estimated dates of discharge planning, the dates were in place on the electronic record system. We found that these were reviewed on an ongoing basis.

The acute geriatric medicine wards also hold daily morning ‘board rounds’. These were attended by medical, nursing and AHP staff and allowed decisions to be made for every patient about their care and treatment and discharge planning. Staff told us that the board rounds help them to identify any barriers to patients being discharged and facilitated effective decision-making within the team.

Two of the wards inspected had a dedicated discharge nurse who co-ordinates care and liaises with relatives and external agencies to ensure effective discharge planning. Ward staff told us that they felt that this was a benefit.

Healthcare Improvement Scotland Unannounced Inspection Report (Aberdeen Royal Infirmary and Woodend Hospital, NHS Grampian): 11–14 August 2015

26 3.6 Leadership and accountability

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.

Since the previous inspection, there had been a significant change to the NHS Grampian senior management team. A new chief executive, medical director and director of nursing had been appointed. During the inspection, we spoke with senior management who told us:

• NHS Grampian’s board governance arrangements for care of older people in acute hospitals had been significantly strengthened to ensure board wide engagement across the multi- professional team and ward to board reporting • an experienced senior nurse had been recruited to NHS Grampian in April 2015, to drive professional development and improvement and oversee the implementation of the revised Older People’s standards (in line of the appointment to the post of the older people improvement advisor in September 2015.) • an improvement collaborative had been established involving 22 wards, and that the first learning session had taken place attended by over 200 staff in May 2015, • weekly OPAH improvement clinics had been put in place and were very well attended by staff, and • additional funding had been put in place to increase dementia support through the recruitment of an additional nurse consultant .

We believe that progress has been made since the last inspection. For example, senior charge nurses told us that there has been improved communication between ward staff and senior management, including the implementation of the daily huddle.

During the inspection, staff within the acute geriatric medicine wards raised concerns about patient safety, in particular with patient falls, which had been increasing. We were told that this was due to staffing levels. Senior charge nurses were covering weekends and night shifts, which was taking them away from the ward.

We spoke with senior management and they demonstrated to us that the wards have appropriate staffing, but they do have a high vacancy rate for staff nurses. In response to the concerns raised by staff about patient safety, NHS Grampian has indentified funding to ensure that senior charge nurses will no longer work evenings or weekend shifts. This will allow them to focus on the ward. Also, to address the safety issues, one ward has been closed in the acute geriatric medicine wards.

NHS Grampian told us that due to the issues with tissue viability staff turnover, interim staffing was put in place during this period. Staffing is being revised following the recommendations made at the expert review.

Healthcare Improvement Scotland Unannounced Inspection Report (Aberdeen Royal Infirmary and Woodend Hospital, NHS Grampian): 11–14 August 2015

27 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 Grampian 1 must ensure that all older people, who are being treated in the emergency department or are admitted to hospital, are assessed within the national standard recommended timescales. Assessments should be accurate and fully completed. This includes nutritional screening and assessment, falls management and pressure ulcer care. Where an assessment is not thought to be appropriate, the decision should be recorded within the patients care record (see page 15).

This is to comply with Clinical Standards for Food, Fluid and Nutritional Care, Criterion 2.1, 2.3 and Best Practice Statement for the Prevention and Management of Pressure Ulcers, Section 2.

2 must ensure clinical staff consistently comply with the national policy on do not attempt cardiopulmonary resuscitation (DNACPR) see page 15.

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

3 must ensure that medicines reconciliation is fully completed within 24 hours of admission (see page 15).

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

4 must ensure all documentation, both nursing and medical, is legible, dated, timed and signed. It should provide details of any assessments and reviews undertaken, and provide clear evidence of the arrangements that have been made for future and ongoing care. It should also include details of information about care and treatment (see page 15).

This is to comply with The Code, Nursing and Midwifery Council (Jan 2015) section 10.4 and the Generic Standards of Record keeping Royal College of Physicians (2009).

Healthcare Improvement Scotland Unannounced Inspection Report (Aberdeen Royal Infirmary and Woodend Hospital, NHS Grampian): 11–14 August 2015

28 Person-centred care planning Outcome 2

NHS Grampian 5 must ensure that patients have person-centred care plans in place for all identified care needs. These should evidence patient or carer involvement and be regularly evaluated and updated to reflect changes in the patient’s condition or needs (see page 17).

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.

6 must ensure that the implementation of care rounding is supported by adequate individualised care planning and evaluation of the patient’s care (see page 17).

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.

Safe and effective care Outcome 5

NHS Grampian 7 must ensure that current legislation, which protects the rights of patients who lack capacity, is fully and appropriately implemented. When legislation is used, this must be fully documented in the patient health record, including any discussions with the patient or family. For example, establishing if a power of attorney is held, and the information shared with staff (see page 19).

This is to comply with Adults with Incapacity (Scotland) Act 2000 Part 5 - Medical Treatment and Research.

Outcome 6

NHS Grampian: 8 must ensure where a patient’s requires nutritional support, this is provided immediately and specialist assessment takes place within 72 hours (see page 23).

This is to comply with Standards for Food, Fluid and Nutritional Care Criteria 2.7 and 2.8

9 must ensure mealtimes are managed in a manner that ensures that patients are prepared for meals and get assistance in a timely manner (see page 23).

This is to comply with Standards for Food, Fluid and Nutritional Care Criteria 4.1 (g). 10 must ensure that food record and 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 23).

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

Healthcare Improvement Scotland Unannounced Inspection Report (Aberdeen Royal Infirmary and Woodend Hospital, NHS Grampian): 11–14 August 2015

29 Outcome 7

NHS Grampian: 11 should ensure that where a falls risk has been identified, the patient should be offered a multi-factorial assessment and intervention. They should ensure that any intervention addresses the patients identified individual risk factors for falling in hospital and takes into account whether risk factors can be treated, improved or managed during the patient’s expected stay (see page 24).

12 should ensure bedrail assessments are carried out consistently. This will make sure that no patients are at risk of falling out of bed or that bedrails are not used unnecessarily on patients (see page 24).

Outcome 8

NHS Grampian: 13 must ensure that where a patient is identified as being at risk, a SSKIN bundle should be implemented. The bundle should contain the frequency of planned intervention. The information gained from each element of the bundle should be used to inform other assessments to ensure appropriate care planning and delivery (see page 26).

This is to comply with Best Practice Statement for the Prevention and Management of Pressure Ulcers, section 1.

14 must ensure that all patients who have a pressure ulcer or other skin wound must have appropriate wound assessment charts completed, which includes grading or ulcers and or sites of wounds. Wound management documents must be completed and evaluated regularly. Advice must be sought from tissue viability specialist nurses as necessary and relevant information communicated if the patient transfers wards or is discharged from hospital (see page 26).

This is to comply with Best Practice Statement for the Prevention and Management of Pressure Ulcers, Section 4.

15 must ensure that the tissue viability team is able to provide a comprehensive service to meet the needs of the patients and staff, providing staff education and advice, as required (see page 26).

This is to comply with Best Practice Statement for the Prevention and Management of Pressure Ulcers, Section 4.

Healthcare Improvement Scotland Unannounced Inspection Report (Aberdeen Royal Infirmary and Woodend Hospital, NHS Grampian): 11–14 August 2015

30 Appendix 2 – Details of inspection

The inspection to Aberdeen Royal Infirmary and Woodend Hospital, NHS Grampian was conducted from Tuesday 11 August to Friday 14 August 2015.

The inspection team consisted of the following members:

Ian Smith Senior Inspector

Claire Blackwood Inspector

Kenny Crosbie Inspector

Julie Miller Inspector

Irene Robertson Inspector

Fraser Tweedie Public Partner

Supported by:

Nicola Grant Project Officer

Healthcare Improvement Scotland Unannounced Inspection Report (Aberdeen Royal Infirmary and Woodend Hospital, NHS Grampian): 11–14 August 2015

31 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.

• Your health, your rights: The Charter of Patient Rights and Responsibilities (Scottish Government, 2012) • The Code: Professional standards of practice and behaviour for nurses and midwives (Nursing & Midwifery Council, 2015) • Equality Act 2010 • Clinical standards for Older People in Acute Care (Clinical Standards Board for Scotland, October 2002). • Human Rights Act 1998 • Older People and Human Rights: A reference guide for professionals working with older people (Age UK & British Institute for Human Rights, 2011) • A Participation Standard for the NHS in Scotland (Scottish Health Council, 2010) • Do Not Attempt Cardiopulmonary Resuscitation (DNACPR): Integrated Adult Policy – Decision Making and Communication (Scottish Government, May 2010) • National Standards for Clinical Governance and Risk Management (NHS Quality Improvement Scotland, October 2005) • Rights, Risks and Limits to Freedom: Principles and good practice guidance for practitioners considering restraint in residential care settings (Mental Welfare Commission for Scotland, 2006) • Generic medical record keeping standards (Royal College of Physicians, 2009) • Best Practice Statement for Prevention and Management of Pressure Ulcers (NHS Quality Improvement Scotland, March 2009) • Food, Fluid and Nutritional Care Standards (Healthcare Improvement Scotland, 2014) • Making Meals Matter resource pack (Healthcare Improvement Scotland, 2011) • Oral Health and Nutrition Guidance for Professionals (NHS Health Scotland, 2012) • Health Department Letter (HDL) (2007)13: Delivery Framework for Adult Rehabilitation - Prevention of Falls in Older People (Scottish Executive, February 2007) • Scottish Intercollegiate Guidelines Network (SIGN) Guideline 111 – Management of Hip Fracture in Older People (SIGN, June 2009) • Adults with Incapacity (Scotland) Act 2000 Part 5 – Medical treatment and research • Scottish Intercollegiate Guidelines Network (SIGN) Guideline 86 – Management of Patients with Dementia (SIGN, February 2006) • Dementia: decisions for dignity (Mental Welfare Commission, March 2011) • Standards of Care for Dementia in Scotland (Scottish Government, June 2011) • Dementia: 10 Care Actions in Hospital (Scottish Government, 2014) • Charter of Rights for People with Dementia and their Carers in Scotland (Cross Party Group on Alzheimer’s, 2009) • Promoting Excellence: A framework for all health and social services staff working with people with dementia, their families and carers (Scottish Government, 2011)

Healthcare Improvement Scotland Unannounced Inspection Report (Aberdeen Royal Infirmary and Woodend Hospital, NHS Grampian): 11–14 August 2015

32 • Scottish Intercollegiate Guidelines Network (SIGN) Guideline 108 – Management of Patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention (SIGN, December 2008) • Scottish Intercollegiate Guidelines Network (SIGN) Guideline 118 – Management of Patients with Stroke: rehabilitation, prevention and management of complications, and discharge planning (SIGN, June 2010) • Scottish Intercollegiate Guidelines Network (SIGN) Guideline 119 – Management of patients with stroke: identification and management of dysphagia (SIGN, June 2010) • Allied Health Professions (AHP) standards

Healthcare Improvement Scotland Unannounced Inspection Report (Aberdeen Royal Infirmary and Woodend Hospital, NHS Grampian): 11–14 August 2015

33 Appendix 4 – Inspection process flow chart

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

Healthcare Improvement Scotland Unannounced Inspection Report (Aberdeen Royal Infirmary and Woodend Hospital, NHS Grampian): 11–14 August 2015

34 Appendix 5 – Terms we use in this report

Terms and abbreviations

AHP allied health professional

AWI adults with incapacity

BMI body mass index

CSBS Clinical Standards Board for Scotland

HDL Health Department Letter

SIGN Scottish Intercollegiate Guidelines Network

SSKIN skin, surface, keep moving, incontinence and nutrition

Healthcare Improvement Scotland Unannounced Inspection Report (Aberdeen Royal Infirmary and Woodend Hospital, NHS Grampian): 11–14 August 2015

35

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.