Archived: Foxbury Ward

This service has not been rated. The unit was previously managed by a local trust and had reopened under the management of the current provider two months prior to our inspection.

• Although the service monitored safety thermometer information, we saw no evidence of any actions taken to improve patient safety. Incidents were not reported in line with the provider’s policy.

• Patient records were not always complete and comprehensive. Care plans were not routinely reviewed. In addition, some of the templates used including wound assessment charts, drug charts and observation charts were those of the local NHS trust.

• Hand hygiene audits were not carried out and there was no system in place to monitor infection rates.

• There were no ongoing audit programmes in place to monitor patient care. Some of the local guidelines developed by the provider referred to certain committees or positions that were not in place on the ward. In addition, the staff still referred to the policies of a local trust. .

• There were no targets set internally to monitor the service and to ensure it was responsive to patients’ needs.

• There was no clear governance structure in place. The unit had no risk register and there were no systems in place to identify, review and mitigate risks. The provider informed us they often held senior staff meetings, but there were no formal notes taken. Therefore, we were not assured of the meetings taking place.

• There were no formal service level agreements with the GP practice that provided medical cover to the unit and the local pharmacy used for supply of medicines.

However:

• The environment and equipment were clean and supported safe care.

• There were safe staffing levels on the unit and most staff had completed their mandatory training. Patients were cared for by appropriately qualified nursing staff who had received an induction to the unit and achieved specific competencies before being able to care for patients independently.

• Staff provided kind and compassionate care and we received positive comments from patients. Patient’s privacy and dignity was maintained.

• Staff had access to translators when needed, giving patients the opportunity to make decisions about their care, and day-to-day tasks.