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Health watchdogs have ordered North Devon District Hospital in Barnstaple to improve its systems for managing wounds.
Care Quality Commission inspectors visited the hospital over three days in July and found care plans and other patient records were not always completed.
They didn't find individual cases of poor care,but they did find a failure to fully assess and plan all aspects of patient care on eight occasions which could have meant that some people might not have got the care they needed.
The inspection looked at four areas of possible concerns relating to patient care which are currently being investigated through safeguarding procedures involving NHS Devon, Devon County Council, Devon and Cornwall police and the CQC.
These were: How pressure area care is managed; how well the hospital works with patients with complex needs or with communications difficulties; consent and assessing mental capacity for patients and meeting nutritional and hydration needs.
They found that the trust was compliant in the other three areas.
Ian Biggs, Regional Director of CQC in the South West said that the trust must now provide its plans to show how it will achieve full compliance.
He said: "In a busy hospital, good patient records are essential. Doctors and nurses depend on them to ensure that their patients are getting the right care throughout the day and night, when shifts change and different staff come on duty or take over responsibility for a particular person’s care.
"Patients we met on the wards had no complaints about their care, although we have identified some key areas of concern, mainly around pressure damage and wound care, where lack of assessment and care planning could place people at risk.
"When we raised the issue of records at North Devon Hospital earlier in the year, the trust gave us a detailed action plan which included some key changes to the documentation being used to ensure good care and treatment. They told us they would be fully compliant by the end of September.
“We are satisfied that the trust is already taking action. If we had any further concerns for people’s safety, we would take action straight away. In the meantime we will continue to monitor the hospital – and we will check to see that all the improvements have been made in further unannounced inspections.”
Jac Kelly, the hospital Chief Executive said: “We take the findings of this report very seriously and are absolutely committed to providing the highest standards of care to our patients. I would like to reassure the public that we are already working hard to ensure this.
“We take reassurance from the fact that the CQC could find no evidence that patient care or patient outcomes have been adversely affected where record-keeping fell below the standard we would expect. However, we recognise we must take a number of actions to demonstrate that the otherwise high standards of care that patients receive at NDDH are backed up by the right documentation.
“We’re glad to note the CQC’s acknowledgement that such actions are already under way within the hospital.”
To see the full report: http://www.cqc.org.uk//newsandevents/newsstories