Announced Inspection Report care for older people in acute hospitals Gilbert Bain Hospital NHS Shetland 27 28 March 2014
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 2014 First published May 2014 The publication is copyright to Healthcare Improvement Scotland. All or part of this publication may be reproduced, free of charge in any format or medium provided it is not for commercial gain. The text may not be changed and must be acknowledged as Healthcare Improvement Scotland copyright with the document s date and title specified. Photographic images contained within this report cannot be reproduced without the permission of Healthcare Improvement Scotland. www.healthcareimprovementscotland.org 2
Contents 1 About this report 4 2 Summary of inspection 5 3 Our findings 7 Appendix 1 Areas for improvement 15 Appendix 2 Details of inspection 17 Appendix 3 List of national guidance 18 Appendix 4 Inspection process flow chart 19 Appendix 5 Glossary of abbreviations 20 3
1 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 Gilbert Bain Hospital, NHS Shetland from Thursday 27 March to Friday 28 March 2014. 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 two inspectors and one public partner, 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 Gilbert Bain Hospital can be found in Appendix 2. The report highlights three areas of strength, 11 areas for improvement and one area of continuing improvement. All areas for improvement from this inspection can be found in Appendix 1 on page 15. 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/opah.aspx 4
2 Summary of inspection Gilbert Bain Hospital, Lerwick, serves the people of the Shetland Isles. It contains 64 staffed beds and has a range of healthcare specialties. We carried out an announced inspection to Gilbert Bain Hospital from Thursday 27 March to Friday 28 March 2014. We inspected the following areas: ward 1 (general surgical) ward 3 (general medical), and Ronas ward (older adults and rehabilitation). Before the inspection, we reviewed NHS Shetland s self-assessment and gathered information about Gilbert Bain Hospital from other sources. This included Scotland s Patient Experience Programme, and other data that relate to the care of older people. Based on our review of this information, we focused the inspection on the care of people with dementia and cognitive impairment, nutritional care and hydration, and preventing and managing pressure ulcers. Ensuring that older people are treated with compassion, dignity and respect is a focus on all our inspections. On the inspection, we spoke with staff and used additional tools to gather more information. In all wards, we used a formal observation tool. We carried out three periods of observation during the inspection. In each instance, 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 questionnaires. We spoke with 11 patients during the inspection. We received completed questionnaires from 14 patients. As part of the inspection, we reviewed 10 patient health records to check the care planned and delivered was as described in the care plans. For this inspection, we reviewed all 10 patient health records for the care of people with dementia and cognitive impairment. Out of these 10 patient health records, we reviewed nine of them for nutritional care and hydration, and preventing and managing pressure ulcers. Areas of strength We noted areas where NHS Shetland was performing well in relation to the care provided to older people in acute hospitals. Senior charge nurses appeared to lead and manage their wards well. The dementia liaison service demonstrated joint working with other agencies to provide a comprehensive service for patients with cognitive impairment. Wards had access to a range of snacks which enabled them to provide patients with a hot snack out-with set meal times. 5
Areas for improvement We found that further improvement is required in the following areas. Improve working practices with the social work departments to make discharge planning more effective. We found a lack of information in the personalised care plans outlining the individual needs of older people. This care plan should identify the specific needs of the patient and how staff will meet these needs. Patients were not always assessed for the risk of developing pressure ulcers within 6 hours of admission to hospital, or regularly reassessed to take account of any developing risks. What action we expect the NHS board to take after our inspection This inspection resulted in three areas of strength, 11 areas for improvement and one area of continuing improvement. A full list of the areas for improvement can be found in Appendix 1 on page 15. We expect NHS Shetland 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/opah.aspx. We would like to thank NHS Shetland and in particular all staff at the Gilbert Bain Hospital for their assistance during the inspection. 6
3 Our findings Treating older people with compassion, dignity and respect All wards inspected were mixed sex wards. Patients were accommodated in single rooms or single sex bays. Buzzers, water jugs and personal items, such as spectacles, were within reach of the patients where appropriate. All patients were dressed appropriately. Information on display above the patient s bed was kept to a minimum. Patient and staff interactions We used a formal observation tool in all of the wards inspected to observe interactions between staff and patients. Patients were treated with dignity and respect, and the majority of interactions observed were positive. Staff responded to requests from patients for assistance in a timely manner. In the majority of interactions observed, staff used patients preferred name and engaged in friendly, polite conversations. The care plan used in one ward for bed rails uses the term cot sides. This language is not appropriate. Patient comments Patients were positive about the care and assistance they had received from all members of staff. Patients also had the opportunity to give us their opinion of the care they received through our patient surveys and interviews. Of the 14 patients who completed our questionnaire: 100% stated they had been given clear information about their condition and treatment 100% said staff check on them regularly to see if they need anything, and 100% said the quality of care they received was good. We received the following positive comments from patients through the patient questionnaires. Services are very good, staff are polite and helpful. I have been very impressed with not only the care I have received but also the kindness shown by staff but also their willingness to go out of their way to give extra help without being asked. This applies to all staff I have I have encountered irrespective of trade or grade. It has made my stay a pleasure rather than a penance. We spoke with 11 patients during our inspection. All were positive about the care that they received, and we received no negative comments. Staff have been very attentive and supportive. My treatment has been explained every step of the way. Staff are flexible with visiting hours, due to travel distances. During the inspection, we spoke with a public representative who works closely with NHS Shetland to help improve the patient experience. The public representative: 7
assists in the production and content of patient leaflets, and is involved in ward walk-rounds with senior staff. Patient flow and capacity Eight patients were listed as delayed discharge in the hospital. These patients were waiting for either care services at home or long term care. This can cause problems with patient flow by reducing availability of beds for other patients who need to be admitted into the hospital. Boarding is when patients are moved from one ward to another to meet the needs of the service and not the patient s clinical needs. On one ward, staff told us patients can be moved to other wards to create beds for other patients. They can sometimes then be moved back if needed. Several ward moves can increase confusion in patients with cognitive impairment. Discharge planning Discharge planning is a continual process to make sure patients are safely discharged and do not have to stay in hospital longer than required. Effective discharge planning begins on, or shortly after, admission to hospital. NHS Shetland has discharge checklists in the patient health records. However, none of the notes we reviewed had the discharge checklists completed. In Ronas ward, we saw evidence of multi disciplinary team working to fully assess the needs of the patient and actively plan for discharge. Do not attempt cardiopulmonary resuscitation documentation Do not attempt cardiopulmonary resuscitation (DNACPR) documentation relates to the emergency treatment given when a patient s heart stops or they stop breathing. Sometimes medical staff will make a decision that they will not attempt to resuscitate a patient. This is because they are as sure as they can be that resuscitation will not benefit the patient. For example, this could be when a patient has an underlying disease or condition and death is expected. When this decision is made, opportunities should be taken to have honest and open communication to ensure patients and their families are made aware of the patient s condition. However, in some cases, clinical staff may decide not to share this information as they feel it may cause too much distress for the patient and their families. We reviewed four health records for DNACPR documentation. Three of these had been fully completed. The fourth had no review date entered. This meant that it was unclear how long the decision was in place for, or if it would be communicated to others involved in the person s care, on their discharge from hospital. Leadership We found effective leadership at ward level: wards were calm and organised staff stated that they felt supported, and patients told us they always knew who was in charge of the wards. Senior staff carry out walk-rounds on the wards. During walk-rounds, the hospital s senior management come to the wards to speak to patients and staff, to allow issues on the ward to 8
be raised directly to them. Senior charge nurses said that this is beneficial as action plans are produced and followed up. Area of strength Senior charge nurses appeared to lead and manage their wards well. The culture within the ward was to put the patients at the centre of care. Areas for improvement 1. NHS Shetland must ensure effective discharge planning begins on, or shortly after admission, and is a continual process. 2. NHS Shetland must work with the social work department to ensure that patients are not kept in hospital longer than they should be. 3. NHS Shetland should review their bed rail care plan to ensure that the language promotes patient dignity. 4. NHS Shetland should ensure that the management of patient flow in the hospital does not compromise patient safety, care or dignity. Dementia and cognitive impairment Patient environment NHS Shetland has been trying to improve the hospital environment, and we saw some good examples of this: signage in the wards was large with good contrast pictorial signage is used for toilets, shower rooms, bedrooms and sitting room, and entrances to rooms were in contrasting colours to the walls, making it easier for patients to identify rooms. One ward has a sitting room and dining room. The sitting room provides an opportunity for social interaction between patients. Patients spoke highly of this. Screening and assessment NHS Shetland s self-assessment states that all patients over 65 years of age who consent to screening are assessed in the accident and emergency department for cognitive impairment. We found that 50% of patients whose records we reviewed were assessed for cognitive impairment on admission to hospital. However, the result of this did not always lead to further investigation or assessment. In some cases, assessment for cognitive impairment may not be appropriate, for example due to a medical condition. Patient health records in the hospital did not document where this was thought to be the case. This could mean delirium or cognitive impairment is not identified, or the opportunity for early diagnosis and treatment is missed. Staff had no clear guidance to tell them the action to take when the assessment identified a possible impairment. 9
NHS Shetland has a dementia liaison service which includes a dementia clinical nurse specialist. The service has pathways to guide the assessment and diagnosis of dementia. GPs, community nurses and hospital staff can refer patients to the service. A community psychiatric nurse with dementia care expertise, along with a psychiatrist specialising in older people s medicine, complete the assessment. The psychiatrist is based in Woodend Hospital in Aberdeen. Through video conferencing, they provide advice, support and treatment plan details. We were told that this system works well. The community psychiatric nurse co-ordinates investigations. They speak with GPs and work with the dementia clinical nurse specialist and either the hospital or community staff to organise support after dementia has been diagnosed. The service has developed an anticipatory care plan for people with dementia to complete. This includes the Getting to Know Me document which allows the person to record key information which can then be used to inform: care in the hospital ambulance staff paramedics doctors, and nurses in the accident and emergency department. The dementia clinical nurse specialist also provides support to the seven dementia champions based within the hospital. Dementia champions felt supported by this. Delirium Although staff had an awareness of Healthcare Improvement Scotland s Think Delirium project, there was no screening tool used for the identification of delirium. The TIME (think, investigate, management plan, engage) bundle is a tool developed by Healthcare Improvement Scotland. It prompts staff to: think (exclude and treat possible triggers) investigate (and intervene to correct underlying causes) management plan, and engage (and explore with patient and family). NHS Shetland is working with Healthcare Improvement Scotland to implement its TIME bundle and the Scottish Delirium Association s delirium pathway. Adults with Incapacity (Scotland) Act 2000 The adult with incapacity form is used to authorise treatment for patients who are unable to consent themselves. We saw four adults with incapacity certificates. However, there was no evidence in the clinical record to show that an assessment of capacity to consent to treatment had been carried. For example: 10
one patient with dementia had no assessment of cognitive assessment or screening for delirium or an assessment of capacity to consent to treatment, and another patient had an adults with incapacity certificate in place, but had signed a consent form for surgery. While this may have been appropriate, there was no documented evidence of capacity to consent to treatment to inform these decisions. The adult with incapacity certificates were not always fully completed. The proposed interventions stated on the certificates were general and did not always reflect the actual interventions being carried out. For example: one certificate was for personal and clinical care whilst in hospital, but did not state the dates it was valid from and to, and two certificates were for medical management of medical problems. Also, the certificates did not always reflect that patients may have capacity to make some decisions. We saw evidence of care plans being used to inform and evaluate the care given. However, the care plans were generic and not completed to reflect an individual s needs. This meant that they did not provide enough detail to guide appropriate person-centred care. Area of strength NHS Shetland s dementia liaison service demonstrates joint working with other agencies to provide a comprehensive service for patients with cognitive impairment. Areas for improvement 5. NHS Shetland must ensure that all older people who are admitted to hospital are screened and assessed for cognitive impairment. 6. NHS Shetland must ensure that patients identified as having cognitive impairment have a personalised care plan in place. This should identify the specific needs of the patient and how the staff will meet them. 7. NHS Shetland must ensure that current legislation to protect the rights of patients who lack capacity is fully and appropriately implemented. Nutritional care and hydration NHS Shetland s self-assessment states that various risk assessments are carried out when patients are admitted to Gilbert Bain Hospital, including the Malnutrition Universal Screening Tool (MUST). This tool calculates the risk of malnutrition and should be completed within 24 hours of admission. This includes; information on a patient s height and weight the patient s body mass index any unplanned weight loss, and whether the patient is acutely ill or has not eaten for more than 5 days. 11
An appropriate care plan should be produced for each patient once the risk category has been established. Of the nine patient health records reviewed for nutritional care and hydration, only four had the MUST completed within 24 hours of admission. The other five were completed up to 5 days after admission. This can lead to patients who are at risk of malnutrition not being identified and having appropriate interventions and care put in place. A patient s MUST score gives a recommendation for how quickly they should be reassessed. Two patients did not have a review of their MUST within their recommended timeframe. For example, one patient who should be reassessed weekly had not been reassessed for 18 days. We saw evidence in one record that the patient s MUST score prompted referral to the dietitian. There was evidence of assessment by the dietitian and advice entered in the record. Staff told us they had a good relationship with the service. Six of the nine patients had a full nutritional assessment completed. This assessment includes information on: a patient s likes and dislikes any cultural or special dietary requirement, and if any adaptive aids or assistance are normally required. The standard care plans used for nutritional care, after completing MUST and nutritional assessment, contained limited personalised information. For example, a patient required assistance with eating and drinking, but their care plan did not identify how this would be met. Management of mealtimes Protected mealtimes aim to reduce non-essential interruptions during mealtimes, making sure that eating and drinking are the focus for patients without unnecessary distractions. We observed mealtimes, including breakfast and dinner, and noted that protected mealtimes were in place in all the wards. We saw posters on display to explain protected mealtimes and to indicate when meals would be served. Apart from breakfast in one ward, mealtimes were well managed. Meals were given out in a timely manner, and aids and help were given to patients who required it. However, hand hygiene was not always offered to patients before meals were served. Gilbert Bain Hospital had systems to identify patients who required help. However, the level of help required was not noted in the care records. In one ward, we saw breakfast served by the night staff at 7.30am before the day staff started their shift. This meant the number of staff available to help patients prepare for breakfast was limited. The staff member who did help was frequently called away to help other patients, which interrupted them serving the meals. Also in this ward, after meals had been served, we did not always observe staff checking if patients: needed help, or were managing to eat their meal. In another ward, one patient was observed trying to eat their dessert with a knife. This was brought to the attention of the nurse. 12
Menus and provision of snacks Hot snacks are available from the ward if patients miss a meal. The food, fluid and nutrition group has been re-introduced, which means link nurses are more able to influence care. This has already had an effect, and the NHS board plans to introduce an emergency snack box. There are good working relationships with the catering department at the hospital. One ward had a separate dining area in the ward for patients who wished to use it. The wards inspected had adaptive cutlery and crockery available for patients who required it. Each ward had access to snacks, soup and some tinned food. These could be heated in a microwave to give food to patients who had missed meals. Area of strength NHS Shetland hold a range of snacks at ward level which allows staff to offer hot food to patients who are unable to have their meal at the appropriate time. Areas for improvement 8. NHS Shetland must ensure screening for the risk of under nutrition is carried out on admission and on an ongoing basis. 9. NHS Shetland must ensure personalised nutritional care plans are developed, implemented and evaluated for each patient, as appropriate. They should include information about any assistance the patient needs to eat their meals, where appropriate. The care plans must provide sufficient detail to guide staff on how to help those patients. Area of continuing improvement a. NHS Shetland should continue with its plans to introduce an emergency snack box for patients. Preventing and managing pressure ulcers Assessment and care planning NHS Shetland uses an adapted Waterlow risk assessment tool to assess a patient s risk of developing a pressure ulcer. National guidance states that an assessment should be completed within 6 hours of admission. We found four out of nine adapted Waterlow risk assessments had not been completed within this timeframe. Where the adapted Waterlow had been completed, the assessment documentation did not state how frequently the patient should be reassessed. Inconsistent clinical care could potentially lead to patients developing pressure ulcers. The outcome of the Waterlow assessment should inform the frequency of the skin care bundle. A skin care bundle, SSKIN (skin, surface, keep moving, incontinence, nutrition), is in place and is incorporated within the active care checklist. This prompts staff to check patients skin more regularly and reduce variation in care practice. However, there was no evidence of personalised care planning being used to help prevent and manage pressure ulcers. We also found completion of the active care checklist was inconsistent, for example interventions were not always recorded when they should be. 13
Tissue viability service The tissue viability service, led by a senior charge nurse and supported by link nurses from within the hospital, works well. When required, specialist advice is available from Woodend Hospital in Aberdeen. Staff told us this works well. Specialist pressure-relieving equipment Availability of pressure-relieving equipment was good and we saw this in use. Wards had been provided with new, higher specification mattresses. Each area had six airflow mattresses. Two bariatric mattresses, used for patients who are overweight, were available. We observed patients on appropriate mattresses. Areas for improvement 10. NHS Shetland must ensure patients are assessed for the risk of developing pressure ulcers within 6 hours of admission to hospital, and are regularly reassessed to take account of any developing risks. 11. NHS Shetland must ensure all patients have a personalised care plan which identifies all of their individual needs in relation to preventing and managing pressure ulcers, and clearly demonstrates how those needs are to be met. 14
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 Shetland: 1 must ensure effective discharge planning begins on, or shortly after admission, and is a continual process (see page 9). This is to comply with Clinical Standards for Older People in Acute Care, Standard 5c. 2 must work with the social work department to ensure that patients are not kept in hospital longer than they should be (see page 9). This is to comply with Clinical Standards for Older People in Acute Care, Standard 5a. 3 should review their bed rail care plan to ensure that the language promotes patient dignity (see page 9). 4 should ensure that the management of patient flow in the hospital does not compromise patient safety, care or dignity (see page 9). Dementia and cognitive impairment NHS Shetland: 5 must ensure that all older people who are admitted to hospital are screened and assessed for cognitive impairment (see page 11). This is to comply with Clinical Standards for Older People in Acute Care, Standard 2. 6 must ensure that patients identified as having cognitive impairment have a personalised care plan in place. This should identify the specific needs of the patient and how the staff will meet them (see page 11). This is to comply with Standards of Care for Dementia in Scotland, page 15. 7 must ensure that current legislation to protect the rights of patients who lack capacity is fully and appropriately implemented (see page 11). This is to comply with Adults with Incapacity (Scotland) Act 2000 Part 5 - Medical treatment and research. 15
Nutritional care and hydration NHS Shetland: 8 must ensure screening for the risk of under nutrition is carried out on admission and on an ongoing basis (see page 13). This is to comply with Clinical Standards for Food, Fluid and Nutritional Care in Hospitals, Criteria 2.1 and 2.2. 9 must ensure personalised nutritional care plans are developed, implemented and evaluated for each patient, as appropriate. They should include information about any assistance the patient needs to eat their meals, where appropriate. The care plans must provide sufficient detail to guide staff on how to help those patients (see page 13). This is to comply with Clinical Standards for Food, Fluid and Nutritional Care in Hospitals, Criterion 2.7. Preventing and managing pressure ulcers NHS Shetland: 10 must ensure patients are assessed for the risk of developing pressure ulcers within 6 hours of admission to hospital, and are regularly reassessed to take account of any developing risks (see page 14). This is to comply with Best Practice Statement for the Prevention and Management of Pressure Ulcers, Section 2. 11 must ensure all patients have a personalised care plan which identifies all of their individual needs in relation to preventing and managing pressure ulcers, and clearly demonstrates how those needs are to be met (see page 14). This is to comply with Best Practice Statement for the Prevention and Management of Pressure Ulcers, Section 1. Areas for continuing improvement are improvements that the NHS board has already identified and started to address. We acknowledge the work carried out by the NHS board at the time of inspection and encourage progress in these areas. Area for continuing improvement NHS Shetland: a should continue with its plans to introduce an emergency snack box for patients (see page 13). 16
Appendix 2 Details of inspection The inspection to Gilbert Bain Hospital, NHS Shetland was conducted from Thursday 27 March to Friday 28 March 2014. The inspection team consisted of the following members: Ian Smith Senior Inspector Irene Robertson Inspector Marguerite Robertson Public Partner Supported by: Ross McFarlane Project Officer 17
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) 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) 18
Appendix 4 Inspection process flow chart This process is the same for both announced and unannounced inspections. 19
Appendix 5 Glossary of abbreviations Abbreviation CSBS DNACPR HDL MUST SIGN SSKIN TIME Clinical Standards Board for Scotland Do not attempt cardiopulmonary resuscitation documentation Health Department Letter Malnutrition Universal Screening Tool Scottish Intercollegiate Guidelines Network skin, surface, keep moving, incontinence, nutrition think, investigate, management plan, engage 20
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 Gyle Square 1 South Gyle Crescent Edinburgh EH12 9EB 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 part of our organisation.