Judgement framework - Care Quality Commission

Stage 4: Outcome 8
Case study 5
Case study 6
Case study 7
A patient was transferred for an outpatient appointment. During the
journey, the patient noticed the poor condition of the ambulance and
reported this. The complaint was followed up; stains and visible dirt covered
the interior walls and floor, as well as the storage cupboards. The technician
responsible for the ambulance said it was not included in the routine
cleaning rota because it was used primarily for low priority ambulance jobs
such as patient transfers and urgent admissions from GPs.
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This has a low impact on people using the service because they
experience an unclean environment while being transferred between
services. Because the patients are generally fit and well, the impact has
been adjusted to take account of the situation.
The likelihood of it recurring is almost certain because the ambulance is
not part of the cleaning rota.
This means it is a moderate concern.
During a visit, a service was asked about their antibiotic prescribing. It was
found that the guidance was not within the regional joint formulary.
The guidance should have been updated every six months, but no
monitoring or updates had occurred. Auditing of antibiotic prescribing was
infrequent and the last audit showed a trend of high prescribing of
antibiotics.
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This has a medium impact on people using the service because they
could be prescribed antibiotics inappropriately.
The likelihood of it recurring is possible because there is no process to
review prescribing or update policies relating to prescribing.
This means it is a moderate concern.
A patient commented on the condition of an air mask during a visit. When
followed up with staff, it was identified that agency staff had recently been
used who had not received induction training, and they appeared to have
poor knowledge about infection control processes as they re-used single use
equipment. However, there was a policy for single-use equipment that was
reviewed and updated when necessary. The issue involving agency staff had
been identified, and resulted in checks on induction training for agency
staff. Also awareness around policies relating to infection control were raised
with all staff, especially relating to single-use equipment.
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This has a high impact on people using the service because single use
equipment was re-used.
The likelihood of it recurring is unlikely because induction training has
been re-introduced, as has a programme to raise awareness of relevant
policies for all staff.
This means it is a moderate concern.
Care Quality Commission: Guidance about compliance Judgement framework March 2010
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