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Inspection Summary


Overall summary & rating

Updated 12 January 2017

  • Senior staff were aware of their responsibilities relating to duty of candour legislation and gave us examples of when it had been implemented. The trust had a duty of candour process in place to ensure people had been appropriately informed of an incident and the actions that had been taken to prevent recurrence. Duty of candour is a regulatory duty that relates to openness and transparency and requires providers of health and social care services to notify patients (or other relevant persons) of ‘certain notifiable safety incidents’ and provide reasonable support to that person.

  • The hospital told us that all the patients attending for surgical procedures had previously been identified, by their referring companies, as low risk for anaesthesia. We did see evidence in all of the records we reviewed of a pre-operative assessment, which included an assessment of risk of VTE and blood clotting factor. However, we were not sure who was assessing the patient pre-operatively, as there was no clear evidence of the profession or competencies of the professional undertaking the pre-operative assessment, included on the assessment sheet. However although there was there was a written patient exclusion policy in operation at FTH the hospital was dependent upon the robustness of the pre-operative assessment undertaken by another provider.

  • There was a lack of clinical oversight in the recovery area, where we observed that patients were not being monitored in line with national guidelines, a blood-filled suction tube being used after it had been used in theatre and patients’ privacy and dignity being compromised. We raised these issues during our inspection and they were addressed immediately by managers and clinical leadership.

  • There was a system in place to analyse each incident as it occurred which included the cascading of the investigation to relevant staff. The process of identifying themes and trends was embryonic and required further development. We saw little evidence themes and trends were discussed regularly at team meetings.

  • There was no monitoring of compliance with the hospital hand hygiene policy. We observed poor compliance with the hand hygiene policy and patient feedback had identified that ward staff were not always washing their hands before touching them.

  • Three pieces of anaesthetic equipment were out of date for servicing according to the label on them.

Inspection areas

Safe

Updated 12 January 2017

We inspected but did not rate surgical services at First Trust Hospital. We found:

  • There was a lack of clinical oversight in the recovery area, where we observed a blood-filled suction tube being used in recovery that had been used in theatre for the same patient.We raised this during inspection and it was addressed immediately by the manager and clinical lead.

  • There was a system in place to analyse each incident as it occurred which included the cascading of the investigation to relevant staff.

  • The process of identifying themes and trends was embryonic and required further development.

  • Although staff did receive training in how to report an incident, they did not receive training on the classification of incidents.

  • The system for identifying surgical site infections was not robust and we were not assured that all infections occurring from surgical procedures were being identified. A system for analysing the cause of infections was in place, However the hospital acknowledged the difficulty obtaining comprehensive infection information from the cosmetic surgery companies.

  • There was limited monitoring of compliance with the hospital hand hygiene policy. We observed poor compliance with the hand hygiene policy and patient feedback had identified that ward staff were not always washing their hands before touching them.

  • Three pieces of anaesthetic equipment were out of date for servicing according to the label on them.

  • There was a service level agreement in place with the local acute hospital to provide emergency blood supplies to FTH. We found this agreement had no been reviewed at the time of our inspection, a matter which was immediately rectified. During the time between our announced and unannounced inspection, the policy and procedure had been clarified and confirmed that emergency bloods would be delivered to FTH through an emergency ambulance. There were plans in place to test this procedure in practice.

However:

  • All staff received training in duty of candour as part of the hospital’s mandatory training programme. All staff we spoke with understood their duty to be open and honest with patients in the event of a mistake occurring.

  • All areas of the hospital, that were inspected, were visibly clean and tidy.

  • Personal protective equipment and handwashing facilities were in place within theatres, recovery and all ward areas. In theatres we observed that staff used appropriate gowning procedures and infection control procedures.

  • There was a system in place to monitor resuscitation equipment. This involved a daily check of the contents of the resuscitation trolley and a member of staff to sign a document verifying that all equipment was present, in date and in working order. We found this system was adhered to on all occasions.

Effective

Updated 12 January 2017

We inspected but did not rate surgical services at First trust hospital. We found:

  • We did not see evidence of a programme to measure the effectiveness of surgical procedures carried out at the hospital.

  • We did not see evidence of the full implementation of a robust clinical audit programme.

  • The hospital did not collect information on the outcomes of the surgical procedures it carried out.

  • Not all key clinical roles were supported by a competency framework.

  • The hospital was beginning to make arrangements to ensure that surgical cosmetic procedures were coded in accordance with national coding guidance but had no arrangements in place at the time of the inspection (SNOMED-CT). SNOMED-CT uses standardised codes to describe cosmetic surgical procedures, which can be used across electronic patient record systems.

However:

  • Surgical procedures were carried out by a team of consultant surgeons and anaesthetists registered with the General Medical Council (GMC).All the consultants were employed by other organisations (usually in the NHS) in substantive posts and had practising privileges (the right to practice in a hospital) with First Trust Hospital. The hospital held practising privileges for eight surgeons and 24 anaesthetists.

  • The hospital reported one unplanned transfer of an inpatient to another hospital, in the reporting period April 2015 to March 2016, which was better than the national average.

  • The readmission rate for the hospital was better than the national average.

Caring

Updated 12 January 2017

We inspected but did not rate surgical services at First trust hospital. We found:

  • We observed that care was delivered with compassion and kindness at all stages of the surgical process.

  • We saw patients being treated with great respect, at all times, including throughout the surgical procedure.

  • We spoke with patients and relatives who were extremely happy with the care they had received throughout the procedure.

  • We looked at 20 comment cards which were all highly favourable and stated how well they had been treated.

However:

  • The recovery area was a very small room which held two patient trolleys. There was a mobile screen just outside of the recovery room and we were told this was brought into the recovery area in the event that there were two patients of mixed gender recovering in the room. On three occasions, we observed two patients being cared for in recovery and the screen was not used.

Responsive

Updated 12 January 2017

We inspected but did not rate surgical services at First Trust Hospital. We found:

  • The service had a very regular patient flow through the system. Surgical lists were reviewed a week in advance by the management team and staffing and housekeeping decisions were subsequently made.

  • The hospital provided surgery for patients who had been referred from three other cosmetic clinics, as well as accepting patients who self-referred directly to the hospital.

  • Data provided by the hospital identified nine complaints were received in the reporting period April 2015 to March 2016.The level of complaints was significantly lower than the average of other independent hospitals. The hospital had a complaints procedure and we saw examples of appropriate complaint management.

Well-led

Updated 12 January 2017

We inspected but did not rate surgical services at First Trust Hospital. We found:

  • Policies were in place and were taken to the Medical Advisory Committee (MAC) for approval. However, during our inspection, we found that, out of 94 policies, 61 were noted to be out of date. Managers we spoke with told us there was a plan in place to review all the policies before the end of the year and this was confirmed by data provided by the hospital.

  • The service had a Medical Advisory Committee chaired by the registered manager, which were held quarterly. Minutes from these meetings showed the service did not always follow its own processes and terms of reference for the committee. For example, the minutes of the last three committee meetings showed that the committee did not have the correct medical representation and the process for agreeing practising privileges had not been adhered to in line with the hospital’s own policy.

  • The hospital had introduced revised governance arrangements, in January 2016, but these changes were not yet embedded in the hospital. The hospital senior managers were aware further work was required to raise awareness and to give them greater assurance that policies and procedures were being followed. An audit programme had been developed and the hospital had held its first clinical governance meeting but no minutes were available at the time of our inspection.

  • Service level agreements and contracts were in place with other providers, such as the provision of blood supplies. However, although it was confirmed on the first day of our inspection that contracts were still valid, we found the documentation was out of date and the hospital was not immediately able to confirm an agreement was still valid in the case of an emergency.

However

  • The trust had produced a vision and emerging strategy for the service and staff were aware of this vision.

  • The service received regular feedback from service users and was proactive in responding to comments made for improvement of service delivery.

  • Staff were happy and confident in the trust leadership and felt it was an open and supportive culture.

Checks on specific services

Surgery

Updated 12 January 2017

  • The hospital told us that all patients attending for surgical procedures had previously been identified, by their referring companies, as a low risk for anaesthesia. We did see evidence of a pre-operative assessment in all the patient records that we reviewed.

  • There was a lack of clinical oversight in the recovery area, where we observed patients not being monitored in line with national guidelines.

  • The arrangement for managing medicines was not robust. There was a system in place to monitor the safe keeping of drugs in fridges. However, we found the monitoring processes had not been clearly adhered to. Managers were responsible for investigating incidents and we saw evidence of this. Managers were responsible for investigating incidents and we saw evidence of this taking place. There was a system in place to analyse each incident as it occurred. The process of identifying themes and trends was embryonic and required further development. to prevent reoccurrence.

  • The system for identifying surgical site infections was not robust and we were not assured that all infections occurring from surgical procedures were being identified.

  • We identified that managers were unclear about the policy and procedure for securing large volumes of blood for patients requiring a transfusion. There was a service level agreement in place with the local acute hospital to provide emergency blood supplies to FTH. The documentation for the agreement  was found to be out of date, a matter which was immediately rectified.

  • There was limited monitoring of compliance with the hospital hand hygiene policy undertaken by the hospital. We observed poor compliance with the hand hygiene policy.

  • The majority of provider’s policies such as the appraisal policy and complaints policy were out of date.

  • Three pieces of anaesthetic equipment were out of date for servicing according to the label on them.

  • The provider had begun to develop its governance structure and developed both a vision and strategy for the service. Governance arrangements were embryonic and the service was not able to robustly assess, monitor and improve the quality and safety of the services they provided.