Borders General Hospital Inspection Report (August 2012)

Announced Inspection Report care for older people in acute hospitals
Borders General Hospital | NHS Borders

1719 July 2012
Healthcare Improvement Scotland is committed to equality. We have assessed the inspection function for likely impact on equality protected characteristics as defined by age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, and sexual orientation (Equality Act 2010). You can request a copy of the equality impact assessment report from the Healthcare Improvement Scotland Equality and Diversity Officer on 0141 225 6999 or email contactpublicinvolvement.his@nhs.net
Healthcare Improvement Scotland 2012
First published August 2012
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Healthcare Improvement Scotland Announced Inspection Report (Borders General Hospital, NHS Borders): 1719 July 2012 2
Contents
1 2 3 About this report Summary of inspection Our findings 4 5 7 15 17 18 19 20
Appendix 1 Areas for improvement Appendix 2 Details of inspection Appendix 3 List of national guidance Appendix 4 Inspection process flow chart Appendix 5 Glossary of abbreviations
About this report
In June 2011, the Cabinet Secretary for Health, Wellbeing and Cities Strategy announced that Healthcare Improvement Scotland would carry out a new programme of inspections. These inspections are to provide assurance that the care of older people in acute hospitals is of a high standard. We will measure NHS boards against a range of standards, best practice statements and other national documents relevant to the care of older people in acute hospitals, including the Clinical Standards Board for Scotland (CSBS) Clinical Standards for Older People in Acute Care (October 2002). Our inspections focus on the three national quality ambitions for NHSScotland, which ensure that the care provided to patients is person-centred, safe and effective. The inspections will ensure that older people are being treated with compassion, dignity and respect while they are in an acute hospital. We will also look at one or more of the following areas on each inspection: dementia and cognitive impairment falls prevention and management nutritional care and hydration, and preventing and managing pressure ulcers. This report sets out the findings from our announced inspection to Borders General Hospital, NHS Borders from Tuesday 17 to Thursday 19 July 2012. This report gives a summary of our inspection findings on page 5. Detailed findings from our inspection can be found on page 7. The inspection team was made up of four inspectors and two public partners, with support from a project officer. One inspector led the team and was responsible for guiding them and ensuring the team members agreed about the findings reached. A key part of the role of the public partner is to talk to patients and listen to what is important to them. Membership of the inspection team visiting Borders General Hospital can be found in Appendix 2. The report highlights areas of strength and areas for improvement. All areas for improvement from this inspection can be found in Appendix 1 on page 16. Wherever possible, the areas for improvement are linked to national standards published by Healthcare Improvement Scotland, its predecessors and the Scottish Government. They also take into consideration other national guidance and best practice. We will state that an NHS board must take action when they are not meeting the recognised standard. Where improvements cannot be directly linked to the recognised standard, but where these improvements will lead to better outcomes for patients, we will state that the NHS board should take action. A list of relevant national standards, guidance and best practice can be found in Appendix 3. More information about Healthcare Improvement Scotland, our inspections, methodology and inspection tools can be found at http://www.healthcareimprovementscotland.org/HEI.aspx.
Summary of inspection
Borders General Hospital, Melrose, serves the Scottish Borders region. It contains 318 staffed beds and has a full range of healthcare specialties. We carried out an announced inspection to Borders General Hospital from Tuesday 17 to Thursday 19 July 2012. We inspected the following areas: ward 4 (general medicine) ward 5 (general medicine) ward 6 (general medicine) ward 7 (general surgery) ward 9 (orthopaedic surgery) ward 10 (elderly assessment) ward 12 (general medicine), and ward 14 (stroke and palliative care). Before the inspection, we reviewed NHS Borders self-assessment and obtained information about Borders General Hospital from other sources. This included Scotlands Patient Experience Programme, and other data that relate to the care of older people. Based on our review of this information, we decided to focus the inspection on dementia and cognitive impairment, and nutritional care and hydration. On the inspection, we spoke with staff and used additional tools to gather more information. In six wards, we used a formal observation tool. We carried out 10 periods of observation during the inspection. In each instance, two members of our team observed interactions between patients and staff in a set area of the ward for 20 minutes. We also carried out patient interviews and used patient and carer questionnaires. We spoke with 31 patients during the inspection. We received completed questionnaires from 73 patients and 23 family members, carers or friends. As part of the inspection, we reviewed 32 patient health records to ensure the care planned and delivered was as described in the care plans. For this inspection, we reviewed all patient health records for dementia and cognitive impairment. We also reviewed all of them for nutritional care and hydration. Areas of strength We noted areas where NHS Borders was performing well in relation to the care provided to older people in acute hospitals. Relatives and carers of patients in Borders General Hospital are encouraged to take part in patient care. We also acknowledged that the older people psychiatric liaison team is working with medical staff and community mental health teams to enhance the continuity of care for patients with a cognitive impairment. There is a good working relationship between ward staff; the kitchen and the systems in place to aid communication between the two appeared to work well. Referrals to the dietetic service are also regularly followed up within 24 hours.
Areas for improvement However, we did find that further improvement is required in the following areas. The dignity of patients is not always appropriately maintained. Staff sometimes used inappropriate language when speaking about patients. We also found occasions when patient confidentiality was not maintained, including discussing patient care in ward corridors and displaying sensitive and personal information inappropriately. We also noted that the environment in Borders General Hospital is not dementia friendly. Through reviewing patient health records, we noted that personalised care plans are not in place for patients with cognitive impairment and nutritional needs. We also noted that not all patients are screened within 24 hours of admission using a recognised screening tool. We also noted occasions where the needs of patients were not put first. We were made aware of patients being moved a number of times during their stay in the hospital, sometimes late at night. This demonstrated that the needs of the service were put before the needs of the patient. We also observed patients being interrupted during mealtimes either to discuss their treatment or to be moved to another hospital. This inspection resulted in four areas of strength and 13 areas for improvement. A full list of the areas for improvement can be found in Appendix 1 on page 15. We expect NHS Borders to address all the areas for improvement. Those areas where improvement is required to meet a recognised standard must be prioritised. The NHS board has developed an improvement action plan, which is available to view on the Healthcare Improvement Scotland website http://www.healthcareimprovementscotland.org/HEI.aspx. We would like to thank NHS Borders and in particular all staff at Borders General Hospital for their assistance during the inspection.
Our findings
Treating older people with compassion, dignity and respect

Patient comments Through our patient surveys and patient interviews, patients had the opportunity to give us their opinion of the care they received. Overall, patients were positive about the care and assistance they received. Of the 73 patients who completed our questionnaire, 92% stated that staff explained their treatment to them so they could understand. 95% said the quality of care they received was good. Staff [are] very caring and attentive over and above expected. Good variety of food to cater for all tastes. This is my first stay in hospital and the service has been first class. The doctors and nurses were marvellous! I have been cared for very well by all the staff. Some patients told us of some concerns and worries they had. One complaint: lots of moving from ward to ward. Too much in my opinion. The noise at times has been unbearable. Staff often get called away when attending minor needs, maybe to more urgent requests, and then forget to return to complete my task. This can be quite irritating. Relatives and carers who responded to our questionnaire talked about a generally good standard of care. Of the 23 family members, carers or friends who completed our questionnaire, 78% stated that staff take the time to get to know their relative or friend and 73% stated that staff treated their relative or friend with dignity and respect. However, some relatives and carers told us of some concerns and worries they had. My mum, 83 years, was left sitting from 12pm to 10pm with very little attention to her needs. If it was not for her daughters she would have been in distress and dehydrated. Communication and information is the most difficult aspect for the relatives of an elderly person I do not have confidence that staff know what my mothers needs are. Patient and staff interactions We used a formal observation tool in six of the wards inspected to observe interactions between staff and patients. We observed caring interactions with patients across all staff disciplines including nurses, medical staff, physiotherapists and occupational therapists. Staff were encouraging and supportive, talking to patients in a quiet, gentle and respectful manner. The following examples demonstrate how we would expect to see staff and patients interacting. On one ward we saw a student nurse notice that a patient was agitated and took time to find out why the patient was agitated then took action to rectify the problem. We saw staff taking time to encourage patients to eat at meal times and asking if they were ok.
We saw some examples where staff interactions with patients could be improved. We saw a patient in a side room being given a drink in a two-handled cup by a domestic services assistant. The cup was put on their overbed table beside two used urine bottles. On one ward, we heard staff refer to feeding patients. When we spoke to the senior charge nurse about this, she told us this had been discussed with staff, but they had yet to find a more respectful alternative. Involving family and carers in patient care Family and carers are encouraged to participate in patient care if they want to. This included spending time with the patient outwith recognised visiting times and assisting with their personal hygiene and mealtimes. In one ward, nurses spent time with the wife of a patient who had complex needs. They gathered information from the patients wife on how they could best meet these needs. They also gave the patients wife the opportunity to discuss his care. In one ward, we found that a patient was in hospital at the same time as her husband, who was also her primary carer. Staff were encouraging regular contact between both patients. The discharge plan for both patients was being co-ordinated to ensure that they were discharged in a way that would allow their family to support both of them. When reviewing patient health records, we noted that discussions with patients were recorded. We found good evidence of conversations with family and carers. This included two patient health records with do not attempt cardiopulmonary resuscitation (DNACPR) forms. Medical staff had documented discussions that had been held with family about implementing DNACPR forms. In another case, a locum doctor had spoken with relatives to deliver some difficult information. A comprehensive record of the conversation provided information for the team caring for the patient. We were told that Borders General Hospital fully supports both the Princess Royal Trust for Carers and the Borders Independent Advocacy Service (BIAS). The Princess Royal Trust for Carers identifies and gives information to carers as well as providing training for carers and staff. The Borders Independent Advocacy Service aims to act on behalf of vulnerable patients to try to ensure that their wishes are met. Patient confidentiality We noted that patient confidentiality was not always maintained. We heard staff discussing patients in public areas of the ward. This meant that personal or sensitive information was not always kept confidential. We also saw that, at times, staff used small boards or pictorial charts to indicate where patients had particular needs. For example, if a patient needed assistance with eating or drinking, a cross was placed in a box next to a picture of cutlery. We recognise that making these charts easily visible for staff at the patients bedside helped to remind them of the patients needs. Mostly this was done discreetly, however, on some occasions we saw that the board or chart was placed in a way that made the information too public. In one ward, we saw that staff had put the chart outside the door of a single room. This meant that it was obvious to everyone who passed the room that the patient needed help at mealtimes. This compromised the patients right to dignity and respect.
Patient dignity During the inspection, we observed a number of instances where patient dignity could be improved. Several patients did not have their catheter bags covered. Some patients hospital gowns had slipped down off their shoulder. One patient was moved from their bed along the corridor to the bath on a bathing hoist (used for lowering patients into a bath). A bathing hoist does not have any means to hold a patient safely when moving patients over long distances. When we spoke with staff, they said the hoist should not have been used for transporting the patient in this way. Use of the bathing hoist was not dignified for the patient in a public area. The design of the seat meant that the patient could be exposed. On this occasion, staff had unsuccessfully tried to address this by using a blanket. Older people are not routinely given aprons to protect their clothing while eating, however there is no equipment for staff to use should someone need to protect their clothing. We saw patients being covered by towels or being given plastic aprons which are for staff use. Protecting adults at risk In one patient health record, there was good information recorded about an adult support and protection concern that had been brought to the attention of staff on the ward. They had contacted the local authority adult support and protection team for advice and had acted on that advice. Communication between all agencies involved in the situation had been clearly documented in the patient health record.
Areas of strength
Relatives and carers are encouraged to be involved in patient care.
Areas for improvement 1. 2. NHS Borders should ensure that staff do not use inappropriate language when talking about older people in hospital. NHS Borders must ensure that patient confidentiality is maintained at all times.
Dementia and cognitive impairment

Assessment and care planning NHS Borders self-assessment states that the abbreviated mental test (AMT) is used in Borders General Hospital to screen patients over 65 years of age for cognitive impairment. During the inspection, we found that the majority of AMTs were completed on admission. We found that 22 AMTs were completed in 32 patient health records reviewed for dementia and cognitive impairment. In some cases, where the AMT was not completed, the rationale for this was documented, but this was not always the case. Where AMTs had been completed, it was not always clear how these informed the care patients received. We did not see any personalised care plans to address the needs of patients identified as having a cognitive impairment.
We also found that staff were not aware of a way of assessing pain in patients with cognitive impairment. Psychiatric liaison service A psychiatric liaison service within Borders General Hospital specifically for older people is provided by a nurse who covers the site full-time. The service is provided 9am to 5pm weekdays. Emergency cover can be provided at the weekend by the community crisis team. Medical input is provided as required from the consultant psychiatrist from the adult psychiatric liaison service. During the inspection, staff told us that the psychiatric liaison nurse was very visible in the hospital and was available for advice. We also saw the psychiatric liaison nurse on a number of the wards we inspected and found evidence of their involvement in patient health records. The psychiatric liaison service may be asked to assist in diagnosing patients with dementia. Currently, if their initial assessment shows that a patient may have a cognitive impairment, a referral is made to the patients GP to reassess their cognition 3 months later. However, the service is introducing a clinic at the end of August to reassess patients previously assessed within the hospital. This will enable the service to confirm any diagnosis of cognitive impairment and ensure the patient has access to the appropriate treatment and care. This service also provides a link between community mental health teams and medical staff within the hospital. This helps provide continuity in the care given to people who come into hospital and are already known to services in the community. During the inspection, we were told that community mental health nurses also visit their patients who are in hospital to help assess any potential decline in their cognitive functioning. NHS Borders has recently introduced a similar service for older people who are being looked after in community hospitals. This will mean patients receive further psychiatric liaison input when they are discharged from Borders General Hospital. The service will then work with care homes to help those patients who may be moving from a community hospital into a care home setting. In an attempt to reduce inappropriate admissions to acute hospitals, they will also look to support care home staff to care for people in the care homes if this is more appropriate. The psychiatric liaison nurse also provides training to other staff as part of their role. A training session was recently held for consultant surgeons in the use of adult with incapacity (AWI) legislation. NHS Borders has also developed an e-learning module about dementia which is mandatory for all staff. We were also told during the inspection that all executive and non-executive members of NHS Borders Board have undertaken a half day dementia awareness training session. A number of people, both staff and Board members, talked about the fact that the Board had been involved in this training. Adults with incapacity Guidance on the assessment of capacity was available for staff in all of the wards we visited. Medical staff carry out this assessment in line with current legislation. This protects the rights of patients with cognitive impairment, who are sometimes unable to make informed decisions about aspects of their care or treatment. If the patient is assessed as lacking the capacity to make an informed decision, the doctor will then complete a certificate of incapacity. This allows staff to make decisions about specified aspects of care or treatment on the patients behalf. We found that two sets of patient health records with AWI forms in place stated that the patient had a welfare attorney. There was evidence in these records that discussions about the patients care had been held with the welfare attorney. There was no evidence in the
patient health records that staff had satisfied themselves that a welfare power of attorney was in place or the extent of any of the powers granted by such an arrangement. This is not in line with the NHS Borders consent to treatment policy. The local policy states that the medical practitioner must take steps to ascertain if there are any current formal arrangements eg welfare attorney/guardian [] and if the proxy has been granted power to consent to medical treatment. Mental Health Act One patient was detained under the Mental Health Act. Both the medical ward and the mental health ward were caring for the patient. This was agreed to be the best way to meet the persons needs. We looked at the patient health records held on the medical ward. There was a copy of the persons detention certificate in these notes. This was noted to have lapsed and staff were unsure under what authority they were detaining the patient. On investigation, further detention papers were found to be in the patient health records held on the mental health ward. Environment We found that some aspects of the environment in Borders General Hospital did not meet standards for a dementia-friendly environment. At the entrance to the hospital, it was difficult to find your way from the front door to the ward areas due to a lack of signage. In some areas, there were a large number of signs high up on the wall making them harder to see. In other areas, such as beside the lifts, a lack of signage made it difficult to find your way from the main corridors. Lighting at the entrance to wards was poor, making it harder for older people to see. Corridors were cluttered with equipment stored along the length of the corridors. However, in some wards, efforts had been made to keep equipment to one side of the corridor to provide a clearer route. There were no handrails available to assist patients who like to walk around the ward. Clocks were seen in all bed areas and side rooms of all wards inspected. However, these were small, shiny and high up on the wall making them difficult to see. Research suggests that older people are less likely to see something that is above four feet. On the wards visited there were no other ways to help orientate patients to the day or date. There had been some adaptations to the wards we visited to make the environment more dementia friendly, but these were very limited. For example, laminated posters were placed on toilet and shower doors to make them clearer. On one ward, an environmental audit had been completed in 2010 to assess how dementia friendly the environment was and an action plan had been developed. We were told that these improvements had not yet taken place due to financial constraints. On one ward, building works were taking place outside the ward. Noise levels in the ward were particularly high. One patient also informed us that the building works caused beds to vibrate, limiting the amount of rest patients could get. Staff on the ward were unsure when the disruptive phase of the building works would end. Although the works need to continue, we were concerned about the disruption as this was a palliative care ward.
Moving patients During the inspection, we were told of a number of occasions where patients had been moved at short notice, at night and not for their clinical needs. In discussion with one patient, we were told they had been moved four times during their stay in Borders General Hospital. They told us they did not like this and that they had been moved because someone needed the bed more than them. On several occasions the moves had taken place at night with one happening at 3.40am. We also found evidence of patients being moved to other hospitals up to 11.00pm and sometimes at short notice, including patients with cognitive impairment. This demonstrated that the needs of the service were put before the needs of the patient. Areas of strength
There is an older peoples psychiatric liaison service working with medical staff and community mental health teams to enhance the continuity of care for patients with cognitive impairment.
Areas for improvement 3. NHS Borders must fully implement their own policy on consent to treatment, in line with current legislation and published best practice guidance. To ensure full and effective implementation, NHS Borders should provide training on the policy for all medical and nursing staff. NHS Borders should ensure that any member of staff who is involved in the detention of a patient on behalf of the hospital managers is aware of the authority under which they are detaining the patient. NHS Borders should ensure that patients identified as having a cognitive impairment have a personalised care plan in place. This care plan should identify the specific needs of the patient and how staff will meet these needs. NHS Borders should assess signage in Borders General Hospital to ensure the signage is appropriate to meet the needs of all patients and enables them to find their way around the hospital. NHS Borders must make improvements to the ward environment for patients with dementia and cognitive impairment. NHS Borders should review the arrangements for wards adjacent to the building works to ensure minimum disruption to patients need for rest. NHS Borders must have a system in place that monitors the number of bed or ward moves for patients with dementia.
4.
5.
6.
7. 8. 9.
Nutritional care and hydration

Assessment, care planning and record keeping Assessments using a recognised nutritional screening tool should be completed within 24 hours of admission to hospital. In their self-assessment, NHS Borders stated that staff use the malnutrition universal screening tool (MUST). During the inspection, we found that MUST assessments were not consistently completed within the 24-hour timescale. Of the 32 patient health records we reviewed, 21 had completed MUST assessments. We also found that MUST assessments were sometimes completed using estimated weight and height or without any weight or height information entered. For example, one patient health record had a body mass index (BMI) recorded, but no note of the patients height. The BMI is a calculation of weight in relation to height that requires both measurements. As a result of
using estimated values, MUST assessments may not identify all patients at risk of undernutrition. We found there were no personalised nutritional care plans to provide information about individual patients specific needs or preferences. In some patient health records, we found good information about what a patient liked or disliked. However, as there was no care plan, this information was lost in the narrative of the patient health records. Most of the patient health records we reviewed recorded simply no action required or monitor and observe. We also found limited and inconsistent use of food and fluid charts to record patients intake when this was required. Referral to dietetic services A dietetics service is available Monday to Friday in Borders General Hospital. During the inspection, we found that patients referred to the dietetic service were seen quickly by a dietitian and usually within 24 hours. However, we also noted that there was no weekend service for patients who required specialist dietetic input. Referrals to the dietetic service were responded to quickly. However, due to poor documentation, there was no consistent communication between dietitians and nursing staff. As a result, interventions advised by the dietitian were not always carried out. We saw one patient health record where the dietitian had seen the patient several times. The dietitian requested an accurate weight measurement be taken after each review. This did not happen. We also found on two wards that when dietitians requested a 3-day food record be kept, this was not always done. Through discussions with staff, we concluded that staff on the wards relied heavily on verbal handovers and discussions with dietitians and did not always check what had been written in the patient health record. This could result in a delay in any required intervention. Access to food Borders General Hospital has a 4-week menu. Food is cooked and prepared on the premises. Patients told us they liked the food. During the inspection, we observed a breakfast period, two lunch periods and an evening meal. We saw that food previously chosen by patients was brought to the ward in trolleys. The food we saw was well presented and looked appetising. We saw that there was a good working relationship between wards and the kitchen. Staff contacted the kitchen to let them know if a new patient had been admitted since the meals were ordered, or if a patient had moved to another ward. Food could be requested from the kitchen outwith mealtimes up to 7.30pm. When the kitchen is closed, a limited supply of food was available from an out-of-hours fridge. Staff and patients also told us that supper was available on all wards and afternoon tea was available on some. This reduced the period of time that patients went without food. All wards can order snacks to keep in the ward pantry, allowing patients to have a snack between meals. We found that generally staff we spoke with were knowledgeable and well informed about individual patients dietary needs. On one ward, a patient required a special diet and it was clear how staff shared and communicated that information. All cooks in Borders General Hospital have received training in special diets. The catering manager also told us that finger food could be provided for patients who would benefit from this.
Although staff were knowledgeable about different dietary needs, we found that the printed menus did not contain enough information to allow staff and patients to decide what would be suitable. It was not clear, for example, which foods were gluten-free and therefore suitable for someone with coeliac disease. As a result, patients would order something they thought suitable for their diet, for their order to then be changed by a member of kitchen staff to something appropriate for their diet. We were told that this was confusing and frustrating for patients. Protected mealtimes We were informed that protected mealtimes are in place in Borders General Hospital. This reduces non-essential interruptions during mealtimes to ensure that eating and drinking are the focus for patients without unnecessary distractions. However, we noted several instances where protected mealtimes were not being observed. On one ward we saw medical staff speaking to a patient twice about their treatment. On another ward, two patients were unable to finish their lunch as ambulance staff arrived to transfer them to another hospital. The patients families were concerned that the patients would miss lunch as a result of the transfer. On some wards, mealtimes appeared to be managed well. The food was delivered to patients in a timely manner and all patients who appeared to need assistance were receiving assistance. Areas of strength
Referrals to dietetic services are routinely followed up within 24 hours. There is a good working relationship between ward staff and the kitchen. Systems in place appeared to work well and were used effectively by ward staff.
Areas for improvement 10. NHS Borders must ensure that all patients are screened using a recognised screening tool within 24 hours of admission. 11. NHS Borders must ensure that staff accurately and consistently record findings of assessment to ensure all patients have a personalised care plan, documenting their nutritional needs and how these needs will be met. 12. NHS Borders must ensure that all non-essential activity (clinical and nonclinical) is stopped during patient mealtimes. 13. NHS Borders should implement a system which provides ward staff with information about the foods the kitchen is able to provide to patients who require special diets. This will ensure ward staff can help patients with their menus and patients with special diets are given choice.
Appendix 1 Areas for improvement

Areas for improvement are linked to national standards published by Healthcare Improvement Scotland, its predecessors and the Scottish Government. They also take into consideration other national guidance and best practice. We will state that an NHS board must take action when they are not meeting the recognised standard. Where improvements cannot be directly linked to the recognised standard, but where these improvements will lead to better outcomes for patients, we will state that the NHS board should take action. The list of national standards, guidance and best practice can be found in Appendix 3.
Treating older people with compassion, dignity and respect

NHS Borders: 1 should ensure that staff do not use inappropriate language when talking about older people in hospital (see page 9). must ensure that patient confidentiality is maintained at all times (see page 9). This is to comply with the National Standards for Clinical Governance and Risk Management, criterion 3e.2.
Dementia and cognitive impairment

NHS Borders: 3 must fully implement their own policy on consent to treatment, in line with current legislation and published best practice guidance. In order to ensure full and effective implementation, NHS Borders should provide training on the policy for all medical and nursing staff (see page 12). This is to comply with Adults with Incapacity (Scotland) Act 2000 Part 5 Medical treatment and research. 4 should ensure that any member of staff who is involved in the detention of a patient on behalf of the hospital managers is aware of the authority under which they are detaining the patient (see page 12). should ensure that patients identified as having a cognitive impairment have a personalised care plan in place. This care plan should identify the specific needs of the patient and how staff will meet these needs (see page 12). should assess signage in Borders General Hospital to ensure the signage is appropriate to meet the needs of all patients and enables them to find their way around the hospital (see page 12). must make improvements to the ward environment for patients with dementia and cognitive impairment (see page 12). This is to comply with the Standards of Care for Dementia in Scotland, page 26. 8 should review the arrangements for wards adjacent to the building works to ensure minimum disruption to patients need for rest (see page 12).
Dementia and cognitive impairment (continued)

NHS Borders: 9 must have a system in place that monitors the number of bed or ward moves patients with dementia are subject to (see page 12). This is in line with the Standards of Care for Dementia in Scotland, page 26.
Nutritional care and hydration

NHS Borders: 10 must ensure that all patients are screened using a recognised screening tool within 24 hours of admission (see page 14). This is to comply with Clinical Standards for Food, Fluid and Nutritional Care in Hospitals, Criterion 2.1. 11 ensure that staff accurately and consistently record findings of assessment to ensure all patients have a personalised care plan documenting their nutritional needs and how these needs will be met (see page 14). This is to comply with Clinical Standards for Food, Fluid and Nutritional Care in Hospitals, Criterion 2.7 and Record keeping: Guidance for nurses and midwives, page 4. 12 must ensure that all non-essential activity (clinical and non-clinical) is stopped during patient mealtimes (see page 14). This is to comply with Clinical Standards for Food, Fluid and Nutritional Care in Hospitals, Criterion 3.7. 13 should implement a system which provides ward staff with information about the foods the kitchen is able to provide to patients who require specialised diets. This will ensure ward staff can help patients with their menus and patients with specialised needs are given choice (see page 14).
Appendix 2 Details of inspection

The inspection to Borders General Hospital, NHS Borders was conducted from Tuesday 17 July to Thursday 19 July 2012. The inspection team consisted of the following members: Ian Smith Regional Inspector Gareth Marr Associate Inspector Julie Tulloch Associate Inspector Katie Wood Associate Inspector Graeme Ballentine Public partner Norma Duncan Public partner Supported by: Sara Jones Project Officer Observed by: Caroline Ashton Project Officer
Appendix 3 List of national guidance

The following national standards, guidance and best practice are relevant to the inspection of the care provided to older people in acute care. Best Practice Statement for Prevention and Management of Pressure Ulcers (NHS Quality Improvement Scotland, March 2009) Clinical Standards for Food, Fluid and Nutritional Care in Hospitals (NHS Quality Improvement Scotland, September 2003) Clinical Standards for Older People in Acute Care (Clinical Standards Board for Scotland, October 2002) Dementia: decisions for dignity (Mental Welfare Commission, March 2011) Health Department Letter (HDL) (2007)13: Delivery Framework for Adult Rehabilitation - Prevention of Falls in Older People (Scottish Executive, February 2007) National Standards for Clinical Governance and Risk Management (NHS Quality Improvement Scotland, October 2005) Record keeping: Guidance for nurses and midwives (Nursing and Midwifery Council , July 2009) Scottish Intercollegiate Guideline Network (SIGN) Guideline 86 Management of Patients with Dementia (SIGN, February 2006) SIGN Guideline 111 Management of Hip Fracture in Older People (SIGN, June 2009) Standards of Care for Dementia in Scotland (Scottish Government, June 2011)
Appendix 4 Inspection process flow chart

This process is the same for both announced and unannounced inspections.
Appendix 5 Glossary of abbreviations

Abbreviation
AMT AWI BMI CSBS DNACPR HDL MUST SIGN abbreviated mental test Adult with Incapacity body mass index Clinical Standards Board for Scotland do not attempt cardiopulmonary resuscitation Health Department Letter malnutrition universal screening tool Scottish Intercollegiate Guideline Network
How to contact us
You can contact us by letter, telephone or email to: find out more about our inspections, and raise any concerns you have about care for older people in an acute hospital or NHS board. Edinburgh Office | Elliott House | 8-10 Hillside Crescent | Edinburgh | EH7 5EA Telephone 0131 623 4300 Email hcis.chiefinspector@nhs.net
www.healthcareimprovementscotland.org
The Healthcare Environment Inspectorate, the Scottish Health Council, the Scottish Health Technologies Group and the Scottish Intercollegiate Guidelines Network (SIGN) are key components of our organisation.

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Announced Inspection Report care for older people in acute hospitals

Borders General Hospital | NHS Borders

Healthcare Improvement Scotland 2012

First published August 2012

About this report

Treating older people with compassion, dignity and respect

Relatives and carers are encouraged to be involved in patient care.

Dementia and cognitive impairment

Nutritional care and hydration

Appendix 1 Areas for improvement

Treating older people with compassion, dignity and respect

Dementia and cognitive impairment

Dementia and cognitive impairment (continued)

Nutritional care and hydration

Appendix 2 Details of inspection

Appendix 3 List of national guidance

Appendix 4 Inspection process flow chart

Appendix 5 Glossary of abbreviations

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