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The Horder Centre Outstanding

Inspection Summary


Overall summary & rating

Outstanding

Updated 16 May 2017

Horder Healthcare is the provider for The Horder Centre (THC), an independent provider of surgery and outpatient services. 

The centre mainly undertakes elective orthopaedic procedures and a small amount of procedures for the relief of pain, for example epidurals (a pain relieving medicine injected into the back).

The centre undertakes a variety of orthopaedic operations including, hip replacements, knee replacements, foot surgery, ankle surgery, shoulder surgery and hand surgery.

Surgery is only performed on patients aged 18 years and over.

There were 5,456 inpatient and day case episodes of care recorded at the centre between October 2015 and September 2016, of these 94% were NHS funded and 6% were other funded.

Forty five percent of all NHS funded patients and 55% of all other funded patients stayed overnight at the hospital during the same reporting period.

The most common procedure undertaken in this period was major hip procedure, which accounted for 17% of all procedures. Major knee procedure was the second most commonly performed procedure and accounted for 13% of all procedures.

There are 42 single inpatient bedrooms with en-suite facilities, a gym for patient use, a discharge lounge and three pre-assessment rooms.

There are three laminar flow theatres (a system that circulates filtered air to reduce the risk of airborne contamination) with a recovery area and a separate 16 bed day care unit.

There is also a therapy garden, which has been developed for the use of patients.

In addition, there is a theatre sterile supply unit (TSSU) that is also located alongside the theatres. This is used to clean and sterilise all the hospital’s surgical instruments.

The diagnostic imaging services is managed by Medical Imaging Partnership (MIP) a separate company, under a service level agreement (SLA) and therefore not included as part of this inspection.

The outpatient department had 17,167 total attendances in the period October 2015 to September 2016, which is an average of 1,406 a month. The majority of appointments were funded through the NHS accounting for 98% with the other 2% being insured or self-funded.

Referrals are accepted for the outpatient and diagnostic imaging departments for adults above the age of 18 only. The outpatient department had six consulting rooms and one treatment room. The physiotherapy department had five clinical rooms, four curtained cubicles and a gym/studio space over two floors. There were also three pre-assessment consultation rooms and a large room used for ‘Joint School.’

The outpatient physiotherapy service operated between 8am and 8pm Monday to Thursday, 8am to 6pm on Fridays and 8am to 12:30pm on Saturdays.

The outpatient facilities focussed on elective care with defined operational hours. The department opens from 7:30am to 6:30pm Monday to Friday. These hours were extended as and when required. The outpatient service specialises in orthopaedics, accounting for 88.1% patients. Pain and rheumatology patients accounted for the other 11.99%.

We visited all clinical areas during our inspection. We spoke with and observed the care given by more than 34 members of staff including nurses, doctors, allied health professionals, administrative staff and the executive team. We spoke with ten patients and received five patient comment cards with feedback from patients who had received care at the hospital. We reviewed 15 sets of patient records and a variety of data for example, meeting minutes, policies and performance data.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 17th January 2017.

Inspection areas

Safe

Good

Updated 16 May 2017

Incidents were reported, investigated and learning evidenced. Reports were communicated to all staff. 

Patients were cared for in a visibly clean environment that was well maintained. There were arrangements to prevent the spread of infection and compliance with these was monitored. There were no outbreaks of serious infection reported.

There were processes for assessing and responding to patient risk.

The service had enough staff with the skills and experience to care for the number of patients and their level of need.

Staff were aware of their responsibilities with regard to the protection of people in vulnerable circumstances. 

There were adequate supplies of appropriate equipment that was properly maintained to deliver care and treatment and staff were competent in its use. However there was room for improvement with anaesthetic machine daily safety checks.

Staff demonstrated good medicines storage, management and administration.

Effective

Outstanding

Updated 16 May 2017

We found care and treatment reflected current national guidance. There were formal systems in place for collecting comparative data regarding patient outcomes. However, the provider should ensure patient temperatures are measured during their operation in line with national guidance

Staff worked with other health professionals in and out of the hospital to provide services for patients.

Patients were cared for by staff who had undergone specialist training for the role and who had their competency reviewed. 

There were arrangements that enabled patients to access advice and support seven days a week, 24 hours per day. There was comprehensive assessment of patient needs. This included clinical needs, physical health, nutrition and hydration needs. Patients received adequate pain relief. 

Patients provided informed, written consent before commencing their treatment. Where patients lacked capacity to make decisions, most staff were able to explain what steps to take to ensure relevant legal requirements were met. However, the provider should review it’s policy on the use of Advance Decisions (AD) and ensure that staff are accurately recording information in patient records.

There was a proactive audit programme that included national, corporate, hospital and departmental audits. Results were shared throughout the hospital and collated to identify themes.

Caring

Outstanding

Updated 16 May 2017

There was a strong, visible patient-centred culture. Staff were highly motivated and inspired to offer care that was kind and promoted patients' dignity.

Staff provided sensitive, caring and individualised personal care to patients.

Staff supported patients to cope emotionally with their care and treatment as needed. 

Patients commented positively about the care provided from all staff they interacted with.

Patients felt well informed and involved in their procedures and care, including their care after discharge. Patients and their relatives were involved in their care and were given adequate information about their diagnosis and treatment.

Families were encouraged to participate in the personal care of their relatives with support from staff. We observed patients treated with compassion, care and dignity.

Patient feedback was positive and staff demonstrated commitment to continuous improvement.

THC participated in the NHS friends and family test for NHS-funded patients. Data between April – September 2016 showed consistent scores of 99%-100%, which ranked in the top five providers each month. This meant nearly all patients would recommend the centre.

Responsive

Outstanding

Updated 16 May 2017

There were a variety of mechanisms to provide psychological support to patients and their supporters. This range of service meant that each patient could access a service that was relevant to their particular needs. For example those with spiritual needs, patients whose first language was not English, or support for people living with dementia or learning disabilities.

THC was part of the Specialist Orthopaedic Alliance (SOA) leading on orthopaedic service redesign as part of the national Vanguard project for NHS England. THC had undergone a complete refurbishment and redevelopment programme over the last eight years to create a therapeutic environment to aid patient recovery ensuring the flow of services within the building matches the patient pathway.

The services were delivered in a way that met the needs of the local population and allowed patients to access care and treatment when they needed it. Waiting times, delays and cancellations were minimal and well managed.

Patients told us staff were responsive to their needs. Complaints management was a priority in the hospital. The process was transparent and open with learning communicated across the hospital.

Well-led

Good

Updated 16 May 2017

There were clear organisational structures and roles and responsibilities. The senior management team were highly visible and accessible across the hospital.

Staff described an open culture and said managers were approachable at all times. Staff spoke highly about their departmental managers and the support they provided to them and patients. All staff said managers supported them to report concerns and their managers would act on them. They told us their managers regularly updated them on issues that affected the separate departments and the whole hospital. 

There were good governance, risk and quality systems and processes that staff understood. The committee structure supported this with reports disseminated and discussed appropriately.

Staff from all departments had a clear ambition for their services and were aware of the vision of their departments. Staff asked patients to complete satisfaction surveys on the quality of care and service provided. Departments used the results of the survey to improve services.

The hospital had a risk register which was reviewed at the governance committee meetings. 

The management team had an understanding of the Workforce Race Equality Standard (WRES) as there is a national requirement to produce key data relating to race quality in the workplace. They had collected data which they currently held, for example the numbers of staff from black and ethnic minority groups.

Checks on specific services

Outpatients and diagnostic imaging

Good

Updated 16 May 2017

Overall, we rated the outpatients and diagnostics service as outstanding for caring, good for safe, responsive and well led; effective was inspected but not rated.

We found that:

Safety concerns were identified and addressed. Staff were clear with regards to the process to report incidents. Staff were fully aware of the duty of candour regulation.

There were good infection control procedures in place and the areas were generally visibly clean and well organised. However, we found some areas did not fully comply with the Health Building Notes for flooring and chair covers, although risks were minimised as far as possible.

Records were accessible and completed accurately.

Staffing levels were appropriate for the service provision with minimal vacancies. Staff were suitably qualified and skilled to carry out their roles effectively and in line with best practice.

Patients’ needs were assessed and their care and treatment was delivered following local and national guidance for best practice.

Consent was obtained before care and treatment was given. Safeguarding systems were in place and staff knew how to respond to safeguarding concerns.

Staff had received Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS) training. Although the Advance Decisions (AD) policy needed to use current guidance and the recording of AD in patient records was not embedded.

There were systems to ensure that services were able to meet individual patient needs, for example, for patients living with dementia.

Services were tailored to meet the needs of patients offering flexibility, choice and continuity of care.

The department went above and beyond to ensure patients could access the right care at the right time. Person centred pathways supported people with multiple and complex needs.

The learning needs of staff were understood. Staff at all levels were supported to participate in training and development.

Multi-disciplinary teams worked well together to provide effective care.

Referral to treatment times were in line with the national average and appointments could be made easily and quickly if required.

Complaint information or how to raise a concern was readily available for patients. Complaints and concerns were always taken seriously and responded to in a timely manner.

Patients were positive about the way staff treated them in all areas. They were involved in decisions about their care and treatment.

Staff felt able to raise concerns to a leadership team that were visible and approachable. Staff were aware of the values and vision for the hospital. There was good staff satisfaction and staff felt supported and valued. There was a strong culture of team working and support across the areas we visited.

Surgery

Outstanding

Updated 16 May 2017

Overall, we rated surgery services as good for safe and well led and outstanding for effective, caring and responsive.

We found that:

Openness and transparency about safety was encouraged. Staff understood their responsibilities in relation to incident reporting. Staff with the necessary clinical knowledge investigated incidents appropriately.

Decision making about the care and treatment of a patient was clearly documented. Record keeping was comprehensive.

Treatment and care was generally provided in accordance with the National Institute of Health and Care Excellence (NICE) evidence-based national guidelines.

A multidisciplinary approach to care was evident throughout all care pathways.

Patient outcomes and patient satisfaction were better than national averages.

Leadership was good and staff told us about being supported and enjoyed being part of a team. There was evidence of multi-disciplinary working with staff working together to problem solve and develop patient centred evidence based services which improved outcomes for patients.

Feedback from patients was continually positive about the way staff treated people. We saw staff treated patients with dignity, respect and kindness during all interactions. Patients told us they felt safe, supported and cared for by staff.

There were effective systems to assess and respond to patient risk. We observed staff recognised and responded appropriately to any deterioration in the condition of patients.

There were systems, processes and standard operating procedures for example, in infection control that were reliable and kept patients safe.

Patients had comprehensive assessments of their needs and their care and treatment was regularly reviewed and updated.

Patients who used the service were actively involved in the way the service operated

However we also found:

Patient temperatures were not measured in theatres in line with national guidelines.

Gaps were found in the anaesthetic machine log books and it was not documented when the theatre was closed. However, evidence of the checking of anaesthetic machines was documented on the patients anaesthetic record which provided assurances that the safety checks were undertaken.

Mandatory training compliance was below THC target.

The difficult intubation trolley in theatre did not meet the Association of Anaesthetists of Great Britain and Ireland (AAGBI) and Difficult Airway Society guidelines.

There were shelves in theatre with exposed wood, which could pose an infection control risk, as they could not be cleaned effectively.