Inspection and Regulation

01.10.10

CQC lifts registration condition on Surrey and Borders Partnership NHS Foundation Trust

The Care Quality Commission said that Surrey and Borders Partnership NHS Foundation Trust has made improvements to ensure that the needs of people who use its services are properly assessed and that their care plans are kept up-to-date.

CQC will now lift one of two conditions it had imposed on the trust on 1 April, when it introduced a tough new registration system for the NHS. Surrey and Borders Partnership NHS Foundation Trust was one of 22 trusts judged not to be meeting essential standards of quality and safety and was registered on the condition that it improved.

CQC required the trust to take action by 1 July to ensure that:

all people who use services have up to date care plans in place and all relevant staff employed by the trust have received training in the assessment of risk and recording of the assessment of risk

The trust provided evidence that it had met this condition in advance of the deadline and applied for it to be removed. To check whether the necessary improvements had been made, inspectors visited the trust on 5 May, interviewing patients and staff and reviewing documentation at six units.

Inspectors found that the trust has taken action to ensure that it complies with this condition.

The trust has put in place monthly record-keeping audits to check on care plans and risk assessments.
A designated nurse will primarily be responsible for auditing the quality of the Care Plan Approach and risk assessments.
An audit group has been set up to carry out regular audits of inpatient services including record-keeping in relation to referrals, assessments and care plans.
All relevant staff have received their three-yearly Care Plan Approach and risk training. Staff will also receive 10 clinical supervision sessions and an annual appraisal.

CQC had also imposed a second condition relating to consent to care and treatment, requiring compliance by 1 July. CQC inspectors will assess whether the trust has met this condition in the near future.

Roxy Boyce, regional director for the Care Quality Commission in the South East, said: “Many thousands of vulnerable people rely on the services provided by Surrey and Borders Partnership NHS Foundation Trust – and each of them is entitled to expect individual care and attention appropriate to their needs.

“Every person must have an up-to-date care plan, which is reassessed on a regular basis, particularly if their needs or behaviours change.

“It was clear to our inspection team that a considerable amount of work had gone into improving the assessment and recording of patients’ care and needs. There are now better systems in place to ensure patients will have an up-do-date care plan and staff are better equipped to deal with patients’ needs.

“The trust has made a lot of improvement in a short time. We will be looking for a continuation of that work to ensure that every service user has a care plan and is involved in meetings to discuss their plan. These things are very important to people who use services, and we will be requiring the trust to complete this work and to notify us in writing when this has been done.”

The Care Quality Commission will continue to monitor improvement through the new registration process, returning to the trust if necessary, to check compliance with the essential standards

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