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Inspection Summary


Overall summary & rating

Good

Updated 9 December 2016

We carried out a comprehensive inspection of Epsom Day Surgery on the 13 and 14 September 2016 as part of our national programme to inspect and rate all independent hospitals. We inspected the core services of surgery and outpatients and diagnostic imaging as these incorporated the activity undertaken by the provider, Epsomedical Limited, at this location.

We rated the core services of surgery and outpatients and diagnostic services as good, and  the hospital overall as good. We rated well-led as required improvement as there were no processes to ensure fit and proper persons were employed at board level which met the relevant regulations.

Are services safe at this unit?

We found improvements were required to minimise risks and promote safety as the management of medicines and equipment was not always robust.

However, we also found there were systems to report and investigate safety incidents and to learn from these. Risks to patients were understood and actions taken to mitigate them. The unit employed sufficient numbers of staff with the necessary skill, qualifications and experience to meet patients’ needs.

Are services effective at this unit?

Care was planned and delivered in accordance with current guidance, best practice and legislation. There was a programme of audit to ensure good practice was maintained and patients experienced good outcomes. Patients’ pain was well controlled.

Are services caring at this hospital?

Patients were treated with kindness and respect. Patients gave positive feedback and said they were treated with compassion and dignity.

Are services responsive at this hospital?

Services were planned to meet the needs of patients and give them a choice as to where they received their care and treatment. Patients referred to the unit were consistently seen and treated promptly within nationally set timescales. There were arrangements to ensure that the individual needs of patients were assessed and met. Complaints were appropriately investigated in a timely way.

Are services responsive at this hospital?

There were insufficient processes to ensure board members fulfilled the “fit and proper person” requirements. However, leaders were visible and were valued by staff and there was a clear vision of what the service aimed to achieve currently and in the future. Information technology was used innovatively to improve the efficient running of the service.

Our key findings were as follows:

  • There were adequate systems to keep people safe and to learn from critical incidents.
  • The hospital environment was visibly clean and well maintained and there were measures to prevent the spread of infection.
  • There were adequate numbers of suitably qualified, skilled and experienced staff (including doctors and nurses) to meet patients’ needs and there were arrangements to ensure staff had the competency to do their jobs.
  • There were arrangements to ensure patients had access to suitable refreshments, including drinks, and were not fasted pre-operatively longer than was necessary.
  • Care was delivered in line with national guidance and the outcomes for patients were good when benchmarked.
  • Arrangements for obtaining consent ensured legal requirements and national guidance were met, including where patients lacked capacity to make their own decisions.
  • Patients could access care in a timely way without undue delay.
  • The privacy and dignity of patients was upheld.
  • The hospital management team were visible and were supported by the staff and there was appropriate management of quality and governance.

We noted the following examples of outstanding practice:

  • The provider had direct access to electronic information held by community services, including GPs. This meant the unit staff could access up-to-date information about patients.
  • Epsomedical Limited had invested in bespoke, integrated IT systems to ensure efficient management of staff, finances, other resources, clinical activity and governance.

There were also areas of where the provider needs to make improvements.

Importantly, the provider must:

  • Introduce processes to ensure compliance with the ‘fit and proper person’ requirement.

In addition the provider should:

  • Introduce a robust system for the reconciliation, storage and monitoring of medicines.
  • Consider how contemporaneous safety record checks of anaesthetic machines are maintained.
  • Improve awareness of the duty of candour obligation amongst the management team.

Professor Sir Mike RichardsChief Inspector of Hospitals

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Good

Updated 9 December 2016

Effective

Good

Updated 9 December 2016

Caring

Good

Updated 9 December 2016

Responsive

Good

Updated 9 December 2016

Well-led

Requires improvement

Updated 9 December 2016

Checks on specific services

Outpatients and diagnostic imaging

Good

Updated 9 December 2016

  • The unit had systems and to keep patients free from avoidable harm. Staff were aware of how to report incidents which were then investigated, infection prevention and control practice met national guidelines and the management of medicines was appropriate.
  • Care was delivered in line with national guidance and the unit had a comprehensive audit programme to monitor services and identify areas for improvement.
  • There were sufficient numbers of appropriately trained and competent staff to provide their services.
  • Patients were treated in a kind, caring and considerate manner and staff respected their privacy and dignity.
  • Appointments could be accessed in a timely manner at a variety of times throughout the day and waiting times met national targets.
  • Managers were visible, approachable and effective. There were systems and processes in relation to governance and quality assurance.

Surgery

Good

Updated 9 December 2016

  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and these were appropriately investigated and learning shared. There were effective systems to assess and respond to patient risks and infection prevention and control practices were in line with national guidelines.
  • There were sufficient numbers of staff with the necessary skill, qualifications and experience to meet patients’ needs.
  • Care was planned in accordance with current evidence-based guidance, standards, best practice and legislation. The unit monitored this to ensure consistency of practice and patients experienced good outcomes.
  • Patients were treated with kindness and courtesy and their privacy and dignity promoted. There were arrangements to respond to individual needs.
  • Leaders were visible and were valued by staff. There was a clear vision which was shared through the service. There was innovative use of new technology to run the service.

However we also found:

  • Systems to store, monitor and ensure the availability of medicines were not robust.
  • Equipment was not consistently checked or maintained to ensure it was ready for use and some items of items of emergency equipment were not readily available.
  • There were insufficient processes to ensure that board members fulfilled the “fit and proper person” requirements and there was limited understanding by some senior leaders of the duty of candor regulations.