AN inspection into care of the elderly at the Western General Hospital has uncovered problems with nutrition and the treatment of patients with dementia. Healthcare Improvement Scotland found that while elderly patients at the hospital were generally happy with the treatment given, there was confusion among hospital staff about testing for delirium and cognitive impairment.
The inspection team uncovered some problems with nutrition at the hospital, with nursing staff being unaware that one patient had lost 5kg in three weeks, and two-thirds of patients sampled had not had a nutritional risk assessment within 24 hours, as they should have done.
Two senior managers at the hospital also revealed that some patients had spent ten hours in a trolley area in an assessment unit, while other staff raised concerns about a reduction in bed numbers. It was also found that patients with dementia were being moved to other wards due to pressure over bed numbers, leading to them becoming disorientated and having to stay in hospital longer.
Dr Jean Turner, executive director of the Scotland Patients Association, today said lessons had to be learned from the report.
“We’re delighted that someone is checking up,” she said. “We have got to listen and learn from this report and try to improve. Management should not just pay lip service, but make sure training processes are put in place to enhance what’s found.
“It’s making positive, constructive comments that should be paid attention to.
“These processes are important. Staff have to have the time and facilities to assess patients so they can be treated properly. It’s overdue that the elderly have more care and attention paid to them.
“If we get them treated we can get them back into their own homes. If there’s a delay in diagnosis and treatment they can be in hospital for longer or end up in a care home instead.”
Overall, the agency highlighted four areas of strength at the hospital, 12 areas for improvement and two areas of continuing improvement, where the health board had identified issues before the inspection.
NHS Lothian said that an action plan following the recommendations of the inspection, which took place over three days in April, had already been put in place.
Inspectors found that staff often behaved well towards patients, with the report saying: “We observed positive and caring interactions across all staff disciplines, including nurses, medical staff, physiotherapists and occupational therapists.”
The quality of meals and choice of food was also praised by patients, and one family member said her mother received “superb care” at the Western.
But the lack of clarity over screening for dementia and moving patients with mental health problems unnecessarily was an area of concern for the inspection team, and issues with record keeping were highlighted.
Elderly NHS Lothian patients are supposed to be screened for dementia on admission to hospital, but the report said the approach to testing was “inconsistent”.
The report said: “We spoke with a number of staff across the hospital during our inspection. Most said it was the responsibility of medical staff to complete a cognitive impairment assessment.
“However, on one ward, we were also told that nursing staff were encouraged to complete the cognitive impairment screening if medical staff had not done this. NHS Lothian should be clear who is responsible for screening and what should happen with the results of a cognitive screening assessment.”
It was also found that a financial management form was incorrectly put in a patient’s health record, and in another case, a patient was described as being both wheelchair bound and fully mobile in their records.
There was no evidence of individualised care plans in place highlighting patients’ eating and drinking likes and dislikes, dietary requirements and food allergies.
On one occasion an inspector was unimpressed to see a member of staff going behind a curtain around a patient’s bed to interrupt a colleague because they were looking for keys.
A lack of entertainment for patients was another criticism, with one patient saying: “It’s a long day. It’s the biggest bore ever in your life being in hospital.”
Tom Waterson, Lothian branch chairman for Unison, said that staffing pressures could lead to processes being neglected and that some nurses could not give as much care as they would like to older patients.
“I’ve always been quite clear that NHS care is second to none in most instances,” he said. “But there are clearly issues with staff levels.
“Individuals haven’t lost the ability to care, but time constraints show they are not as able to give as much care as they would like, even if it’s holding someone’s hand or brushing an older person’s hair, or sitting there with a cup of tea and a biscuit.
“NHS Lothian have attempted to address the issues. But non filling of vacancies creates extra problems within ward areas.”
Lothians MSP Sarah Boyack added: “While it’s clear that there is strong, positive feedback from patients about the quality of staff care, the report highlights that there is room for improvement to ensure better care and management to support patients with dementia or mental health needs.”
Music to movement sessions at the hospital, designed to help with co-ordination and to prevent falls, had been scrapped due to a reorganisation of physiotherapy staff.
However, some hospital staff had carried out their own fundraising activities to buy televisions for patients in side rooms.
Melanie Hornett, nurse director at NHS Lothian, said: “The Healthcare Environment Inspectorate highlighted a number of areas of strength during their care for older people inspection at the Western General Hospital.
“Specific points relating to dementia care and treating older people with compassion, respect and dignity were singled out for praise.
“Other areas of good practice, such as providing access to expert advice and interaction with families, were also highlighted. There were some areas the inspectors said could be improved on and these have been addressed as part of an ongoing improvement plan that has been developed following the visit.”
Focus moves to patient wellbeing
IN June last year, Health Secretary Nicola Sturgeon announced that Healthcare Improvement Scotland was to carry out a new programme of inspections on care of older people in acute hospitals.
The new style of inspection involves observing doctors while they treat patients, and fears have been raised that they could be intrusive and could result in conclusions being drawn from a small number of observations. Previously, inspections focused more on cleanliness and infection prevention than patient care.
A pilot inspection was carried out at Liberton Hospital earlier this year, with the hospital generally being given a clean bill of health, and the health board said it was happy with the way the inspection was conducted.
The inspection at the Western General Hospital is the fourth formal inspection to be carried out, and the first in the NHS Lothian area.
The inspection team was made up of four inspectors and two public partners, who were supported by a project officer.
Nine wards at the Western were inspected, as well as an acute receiving assessment unit. Before the inspectors arrived, they reviewed a self-assessment from NHS Lothian and obtained other information about the hospital.
Using that information, they decided to focus their inspection on dementia and cognitive impairment. They also inspected nutritional care and hydration due to concerns that were noted.