A nursing director has admitted “standards had slipped” after both Calderdale Royal Hospital and Huddersfield Royal Infirmary were rapped by a health watchdog for poor bedside and clinical record keeping.
Hospital chiefs were asked to improve documentation regarding Do Not Resuscitate orders after a surprise visit at Calderdale Royal by the Care Quality Commission (CQC) last August.
But during a second unannounced visit by the CQC at Calderdale on March 20, standards were still described as “unacceptable”.
Six sets of patient’s bedside notes and a further six sets of clinical records were deemed sub-standard.
The CQC also highlighted minor concerns following a visit to Huddersfield Royal in January.
Director of nursing Helen Thomson, said they had devised an action plan.
“We shouldn’t underestimate the scale of trying to resolve this issue,” she said.
“We think there are areas where standards have slipped so we will be doing some re-training. Every bit of senior nursing staff has been mobilised to help with the audit process.
“Because we’re doing it across every ward and department it’s a huge piece of work.
“Nurses’ documentation is poor – they probably spend longer looking for things.
“We would like them to spend less time looking for things and more time recording.
“We’re revising nurses’ documentation to make it slicker and this should help us when we move to electronic record keeping.”
The Calderdale and Huddersfield NHS Trust has now been given until May 31 to prove it has corrected the shortcomings.
Chief executive Owen Williams, said: “It’s important to reaffirm the link between record keeping and patient care.
“It’s really important documentation is as up-to-date and accurate as possible to make sure patient care is optimised.
“This is not just about an administrative task, it’s about starting a journey of culture change.
“I’m hoping it will be a boost to patient care. It’s not just about reaching our target on May 31, this is something we’ve got to maintain.”
