The Care Quality Commission has criticised a south west trust for failing to keep accurate care plans, leaving patients at risk of developing pressure sores.
Management at North Devon Healthcare Trust took the unusual step of asking the CQC to carry out a review after concerns were raised locally about safeguarding.
Issues raised, which are being reviewed by Devon Council, NHS South West and NHS Devon, include how pressure area care is managed, how well the hospital works with patients with communication difficulties, how the hospital complies with the requirements of the Mental Capacity Act 2005 and whether the hospital was meeting patients’ nutrition and hydration needs.
Three inspectors each spent three days observing care and talking to patients at North Devon District Hospital. They found eight examples of wound care plans where records were unclear about when treatment started or whether improvements were being properly monitored.
As a result of the deficiencies in care plans inspectors concluded that patients were at risk of receiving inappropriate care. They ordered the trust to produce a report within 14 days on how it will comply with the standard.
Inspectors found the trust was meeting standards around nutrition and hydration, application of the Mental Capacity Act and involving people with communication difficulties in their care, although they suggested some minor improvements to the latter two.
CQC south west regional director Ian Biggs 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.”
The CQC will make further unannounced visits to the hospital to check improvements have been made.
In a statement the trust said it had decided to ask the CQC to carry out a review within a week of hearing the concerns in recognition of the “importance of quickly establishing the facts” and “discovering whether there were any improvements we needed to make and lessons we needed to learn for the future”.
The trust has already begun conducting regular reviews of patient records and is in the process of streamlining the format of all healthcare records.
Chief executive Jac Kelly said: “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.”