You are here

St Hugh's Hospital Requires improvement

Reports


Inspection carried out on 05 to 06 March 2019

During a routine inspection

St Hugh’s Hospital is operated by The Healthcare Management Trust and serves the population of North East Lincolnshire. The on-site facilities include one ward consisting of 24 single rooms and two double rooms, two laminar flow theatres and eight consulting rooms. The other clinical departments at the hospital include an endoscopy suite, a physiotherapy department and a radiology department with ultrasound and x-ray. The hospital provides surgery and outpatients with diagnostic imaging services.

We inspected this service using our comprehensive inspection methodology. We carried out the unannounced inspection on 05 and 06 March 2019.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

The main service provided by this hospital was surgery. Where our findings on surgery, for example, management arrangements, also apply to other services, we do not repeat the information but cross-refer to the surgery service level report.

Services we rate

Our rating of this hospital stayed the same. We rated the hospital as requires improvement overall. This was because we rated well led as inadequate, we rated safe as requires improvement and we rated effective, caring and responsive as good.

We rated the surgical services as requires improvement. This was because we rated safe as requires improvement. We rated effective, caring and responsive as good. We rated well led as inadequate.

Although the hospital had made some improvements since our previous inspection, there was still work to do in terms of safety and leadership. This was because staff did not always recognise and report concerns, incidents or near-misses. We identified some discrepancies in medicines governance and were not assured there was a consistent approach to reporting medicines incidents and escalating patient risk. Mandatory training compliance remained low in some subjects, for example, safeguarding training. Not all consultants were completing care records in line with the hospitals record keeping policy.

There was no formalised and consistent system of clinical supervision in place. We had concerns formal complaints were not always managed in accordance with hospital policy. We had concerns that the senior leadership team were not proactively managing the concerns identified in some consultants practice, behaviour and record keeping. We also found some the concerns identified at our previous inspection were not fully addressed and some controls were not fully embedded, for example, issues relating to medicines governance, which breached hospital policy. We were concerned that there was not an equitable awareness of safety and risks across all services. Staff across all services raised concerns about low morale and the culture at the hospital since our previous inspection.

However, we found the surgical care areas, equipment and facilities were well maintained and safe. We found robust infection prevention and control processes were in place, audits took place and compliance rates were high. The hospital had reported two never events following our previous inspection. These were in October and November 2017, we found following these incidents the patients were fully informed and duty of candour (DoC) applied. Root cause analysis investigations were completed, learning identified and action plans put in to place to prevent recurrence.

We saw patients were treated with care, compassion, and respect by all staff during their treatment and patients told us they were fully involved in their care.

The hospital worked with other care providers to improve services and to meet the needs of the local population. Patients could access treatment quickly. Referral to treatment performance was good with 90 to 95% of patients being treated within 18 weeks. On average patients completed their treatment within 10 weeks. There were low numbers of complaints. Staff told us the senior managers were visible and supportive. The hospital had a clear set of principles, goals and values. Despite the challenges of the previous year most staff said the hospital was a good place to work with good teamwork in their departments.

Overall, we rated the outpatient’s department as good because we rated safe, caring, responsive and well led as good. We do not rate effective for outpatients.

This was because the department was clean and tidy. All equipment had been serviced in line with requirements. Records were stored securely. Staff were aware of their safeguarding responsibilities, how to assess patients for risks and respond appropriately if any were identified. When incidents occurred, staff knew their responsibilities to report incidents and near misses. There was adequate nursing and medical staffing available in the department to meet the needs of patients.

Patients received evidence-based care delivered by competent staff from a number of different disciplines who understood their responsibilities in relation to mental capacity and consent and focused on providing good quality care and treatment. Patients could access drinks and food if their clinical condition necessitated it however, pain relief was only accessible via a prescription from the consultants working in the department.

Outpatient clinics were offered during the day, evenings and some weekends depending upon demand. Patients we spoke with were happy with the care and treatment they received. Staff were kind, courteous, patient and understanding. Patients were offered support if they needed it and provided with information about their condition presented in terms that were understandable and avoided medical jargon. Services were delivered in a way that met the needs of local people by staff who understood patients had individual needs. The hospital provided support to patients who had sensory, language, physical disability and mental health support needs.

Patients could access appointments quickly. Complaints were few however all staff took complaints seriously and aimed to provide a good quality service for patients.

The department was managed by staff who were experienced in the management of an outpatient department. There was a strategy in place to develop the services delivered by the department in line with local needs and the requirements of local services the hospital engaged with such as the local NHS trust and Clinical Commissioning Group (CCG).

The department collected information about services and had governance processes in place to monitor the quality of services delivered. Risks faced by the department were assessed, recorded and managed. Staff mostly felt well led although some had concerns about their line managers occasionally being unsupportive.

Overall, we rated the diagnostic imaging department as requires improvement. We rated well led as inadequate and safe as requires improvement. We rated caring and responsive as good. We do not rate effective in diagnostic imaging.

This was because during our time on site, the management team were unable to provide us with assurance that equipment being used had been appropriately safety checked and calibrated. This posed a potential risk to both patients and staff. Staff were not wearing appropriate safety equipment and there was no evidence of safety equipment having mandatory safety checks.

Although the hospital had received a safety assessment from their local radiation protection advisor (RPA) in November 2018 highlighting many breaches of IR(ME)R (ionising radiation medication exposure regulations), we found no evidence whilst we were on site and managers could not provide us with any evidence of how these breaches had been addressed other than with an out of date action plan showing no prioritisation and only one action completed.

Whilst on site, we were unable to find, and the hospital was unable to provide us with up to date information about safety and quality checks carried out in the department to ensure ionising radiation procedures were performed in line with national guidance and local procedures. When we arrived at the department, local rules were out of date however these were updated and replaced during the inspection.

The department did not have an established safety checklist for carrying out interventional radiology as highlighted at the hospital’s previous CQC inspection.

We were concerned about the safety of patients and staff visiting the department because the hospital could not provide us with immediate assurance that the department was safe.

The hospital was unable to provide us with evidence of how they were assured they provided evidence-based treatment. Documentation relating to evidence-based care was out of date and had not been updated to reflect the latest IR(ME)R regulations issued in 2018.

The process for quality checking the work of individuals was unclear and there was no evidence that quality assurance of images took place. We found no evidence of discrepancy meetings taking place.

We identified concerns about the senior management of the diagnostic imaging department. They were unclear about the quality assurance and safety processes involved in managing a service that uses ionising radiation. There were no robust embedded systems of governance in place and the department was reliant on one person to oversee governance and quality assurance. Staff were unclear about the governance processes in place to safeguard both them and patients.

Management and leadership was remote. Staff were unaware of any strategies or future plans for the department.

We wrote to the hospital director immediately after our inspection and told him the Care Quality Commission was considering action under section 31 of the Health and Social Care Act 2008. We told the hospital they must provide us with information which showed that patients and staff working in the diagnostic imaging department were safe from harm. The hospital voluntarily suspended diagnostic imaging services until this information was provided. CQC received this information within the required timescales and therefore the hospital was able to resume diagnostic imaging services.

However, we also found the following good practice in the diagnostic imaging department. Staff were aware of their responsibilities relating to consent and mental capacity of patients requiring x-rays or ultrasound.

Patients received care from staff who were kind and compassionate. They were given information in terms they understood and were given emotional support if it was needed. Patient feedback was positive and we were assured the hospital had carried out due diligence to ensure radiology and radiography staff were suitable qualified.

The service was planned to meet the needs of people attending the hospital and x-ray imaging was available whilst clinics were running as well as when required by inpatients. Patients did not have long waits for appointments and could be seen quickly if needed.

Services were designed to meet the needs of individuals and support was available for people living with sensory impairment, physical and learning disabilities, mental health problems and dementia.

The department had received no complaints however complaints received across the hospital were discussed with staff and lessons learned shared to improve services and prevent future complaints.

Following this inspection, we told the provider it must take some actions to comply with the regulations and it should make other improvements, even though a regulation had not been breached, to help the service improve. We issued the provider with two requirement notices. These were related to regulation 12, safe care and treatment and regulation 17, good governance that affected surgery and the diagnostic imaging departments. Details are at the end of the report.

Name of signatory

Ellen Armistead

Deputy Chief Inspector of Hospitals North Region

Inspection carried out on 13 February 2018

During an inspection to make sure that the improvements required had been made

St Hugh’s Hospital is operated by The Healthcare Management Trust and serves the population of North East Lincolnshire. The on-site facilities include one ward consisting of 24 single rooms and two double rooms, two laminar flow theatres and eight consulting rooms. The other clinical departments at the hospital include an endoscopy suite, a physiotherapy department and a radiology department with ultrasound and x-ray. The hospital provides surgery and outpatients with diagnostic imaging services.

The Care Quality Commission (CQC) undertook an announced focused inspection of St Hugh’s Hospital on 22 and 23 August 2017. Focused inspections do not usually look at all five key questions; they focus on the areas indicated by the information that triggers the focused inspection. Although they are smaller in scale, focused inspections broadly follow the same process as a comprehensive inspection. We carried out the focused follow up inspection in order to ensure the provider had taken action to comply with the regulations in the safe, effective and well-led domains in surgery and the safe and well-led domains in outpatients and diagnostic imaging services.

Following this inspection CQC served a warning notice under section 29 of the Health and Social Care Act 2008. The warning notice related to Regulation 12, (1)(2)(g) The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Safe care and treatment. The warning notice required the provider to take action to ensure systems and processes were established to ensure the proper and safe management of medicines. We gave the provider three months to make the necessary improvements.

We undertook an unannounced inspection on 13 February 2018. The purpose of this was to follow up on the actions the provider had told us they had taken in relation to the Section 29 warning notice issued in September 2017.

CQC will not be providing a rating to St Hugh’s Hospital for this inspection. The reason for not providing a rating is because this was a very focused inspection carried out to assess whether the provider had made significant improvement to services within the required time frame. During the focussed inspection we only reviewed the management of medicines in the safe domain of the surgery core service.

At the inspection in August 2017 we found:

  • Staff did not recognise or investigate medicine errors and incidents.

  • Staff did not complete medicines administration charts in line with the hospital’s policy.

  • Staff did not follow the hospital’s policy for the administration of controlled drugs.

  • Gaps in the recording of medicine fridge temperatures.

  • Only 38% of staff had completed medicines management training.

  • The hospital’s own audits and the external pharmacy contractor’s audits did not provide assurance about the safe management of medicines.

At this inspection we found:

  • The medicines management policy at the time of the inspection did not reflect current practice at the hospital and did not support staff to properly manage medicines.

  • Although there was a governance structure and escalation process for issues involving medicines, we were concerned that senior staff’s focus was on the audit’s overall percentage compliance rather than the proper and safe management of medicines. For example, the audit from January 2018 showed 85% compliance with medicines standards, however on the day of our inspection we found 0% of the medicines administration records we reviewed were compliant with the hospital’s policy and national guidance.

  • Staff did not record the temperature of the medicines fridge in line with national guidance.

  • Only two out of 24 staff that worked on the ward had completed the medicines competency. The hospital’s target for completion of this was 100% by the end of February 2018.

However we also found some improvements during this inspection including:

  • Medicines (including controlled drugs) were stored securely and access was restricted to authorised staff.

  • Medicines to be given once-only were appropriately prescribed and staff maintained appropriate administration records.

  • There was an improvement in the number of staff at the hospital that had completed medicines management training.

Although we found there had been improvements made in the proper and safe management of medicines we found there was still more work to do.

On 28 February 2018 we served a warning notice under section 29 of the Health and Social Care Act 2008. The warning notice related to Regulation 17, (1)(2) The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Good governance. The warning notice requires the provider to take action to ensure systems and processes are established to ensure effective governance arrangements are in place in relation to the proper and safe management of medicines. We have given the provider three months to make the necessary improvements.

Ellen Armistead

Deputy Chief Inspector of Hospitals (North Region)

Inspection carried out on 22 to 23 August 2017

During an inspection to make sure that the improvements required had been made

St Hugh's Hospital is operated by The Healthcare Management Trust and serves the population of North East Lincolnshire. The on-site facilities include one ward consisting of 24 single rooms and two double rooms, two laminar flow theatres and eight consulting rooms. The other clinical departments at the hospital include an endoscopy suite, a physiotherapy department and a radiology department with ultrasound and x-ray. The hospital provides surgery and outpatients with diagnostic imaging services.

CQC carried out a comprehensive inspection of St Hugh’s Hospital in August 2015 where it rated the hospital as requires improvement overall and issued requirement notices in regard to compliance with Regulation 12: safe care and treatment, Regulation 17: good governance and Regulation 20: duty of candour. CQC also carried out a focussed inspection in response to information received about the endoscopy service in November 2016. This was also rated as requires improvement overall and further requirement notices were issued in regard to compliance with Regulation 17: good governance and Regulation 18: staffing. The provider put action plans in place, which had been implemented by the hospital and monitored by CQC.

We carried out an inspection on 22 and 23 August 2017 using our focused inspection methodology. A focused inspection differs to a comprehensive inspection, as it is more targeted looking at specific concerns rather than gathering a holistic view across a service or provider.

In our comprehensive inspections, to get to the heart of patients’ experiences of care and treatment we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well led?

Focused inspections do not usually look at all five key questions; they focus on the areas indicated by the information that triggers the focused inspection. Although they are smaller in scale, focused inspections broadly follow the same process as a comprehensive inspection.

We carried out this focussed follow up inspection in order to ensure the provider had taken action to comply with the regulations. At this visit, we inspected the safe, effective and well-led domains in surgery and the safe and well led domains in out patients and diagnostic imaging services. We found there had been some improvements made; however, there was still more work to do.

Where we have a legal duty to do so, we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

The main services provided by this hospital were surgery, outpatients and diagnostic imaging. Where our findings on surgery, for example, management arrangements, also apply to the other service, we do not repeat the information but cross-refer to the surgery core service.

We rated the hospital as requires improvement overall. with surgery rated as requires improvement and outpatients and diagnostic imaging rated as good.

We rated the hospital as requires improvement because:

  • Although there had been improvements there had been a period of time since the last inspection where change had not been implemented and some of the issues raised at the 2015 and 2016 inspections remained a concern. For example, we found medicines management and record keeping was not in line with required standards, some staff did not have evidence of required competencies, there was limited evidence of nutritional screening in the clinical records, staff continued to use different pain assessment scoring systems to assess pain levels and some care pathways did not reference national or professional guidance.

  • We had significant concerns about the management of medicines. Prior to the inspection the hospital provided copies of reports completed by the external pharmacy company and the hospital’s own medicines audit. These did not provide assurance that robust checks were being performed.

  • Some staff in theatre were performing a surgical first assistant role (SFA) which was outside their competency level and job description. This meant the hospital was not meeting the requirements of the Perioperative Care Collaborative (PCC) position statement on surgical first assistants (2012).

  • There was limited evidence that the hospital’s practice met the World Health Organisation (WHO) surgical safety standards.

  • Senior staff and the leadership team did not appear familiar with the national safety standards for invasive procedures (NatSSIPs) and the local safety standards for invasive procedures (LocSSIPs) and practice in relation to safety standards differed across departments. Providers of NHS funded care must be compliant with these safety standards.

  • The medical and nursing care records we reviewed in surgery and inpatients were not completed in line with professional standards or the hospital’s policy.

  • The hospital had introduced a new process to review policies to ensure that they contained the most relevant guidelines and current legislation. The senior management team could not confirm how many policies were left to review and update and identified that they had chosen the policies to complete first on a risk basis.

  • In theatre some of the protocols and policies stored in a folder were out of date for example the Association of Anaesthetists of Great Britain and Ireland (AAGBI) anaphylaxis guidelines. We were not assured the folder was updated with the latest policies and guidance.

  • Work needed to be embedded for local leaders to take ownership of department audits and for clinical staff to be accountable when audits were consistently not met.

  • Staff in theatre showed an awareness of safety and risk; however, this was not mirrored or evident on the ward.

  • Some staff we spoke with were not aware of the principles of the duty of candour.

  • The mandatory training performance for some departments was worse than the hospital target.

  • Information up to August 2017 showed that 65% of ward staff had completed Deprivation of Liberty Safeguards (DoLS) training.

  • At the time of the inspection there was no formal competency framework for staff on the ward to follow, some specific competencies were due to be introduced.

  • Cleaning products, such as chlorine tablets and cream cleanser were not stored securely.

However;

  • The hospital had taken action on some of the issues that were raised in the 2015 and 2016 inspections. For example, an electronic reporting system had been implemented, patient-led assessments of the care environment (PLACE) were carried out and clinical hand wash sinks had been fitted, the hospital had introduced a quality dashboard, a system was in place to record when staff had completed training, the hospital had a vision and set of values, risk registers and department team meetings were in place.

  • The senior management team at the hospital had been restructured and strengthened to include two new posts. We saw that this team’s leadership had developed and changed practice within the hospital in a short period of time, implementing systems and processes to support governance in the hospital.

  • Staff felt valued, enjoyed coming to work at the hospital and held the senior leadership team in high regard.

  • The hospital had a freedom to speak up guardian in post and the culture of the service encouraged candour, openness and honesty to promote the delivery of quality treatment and to challenge poor practice.

  • Staff within the theatre team had changed and a theatre and deputy manager had been appointed. All staff we spoke with in theatre were positive about the culture and new leadership in the department.

  • The hospital reported no never events and one serious incident between January and December 2016.

  • The hospital had no hospital acquired infections and a low surgical site infection rate.

  • Staffing needs were based on acuity of patients and reviewed daily to ensure safe staffing.

  • The pre-assessment of patients had much improved. The hospital produced a guideline for the pre-assessment of patients prior to surgical intervention. This document was based on national evidence based best practice to ensure that all patients were appropriately risk assessed as being suitable for surgery at the hospital. This had resulted in a lower cancellation rate when patients were admitted for an operation.

  • The hospital had a dedicated care pathway for endoscopy procedures, that contained appropriate references to national guidance and evidence based best practice.

  • All staff in theatres, ward and endoscopy had completed an appraisal.

  • All consultants had to meet the criteria set out in The Healthcare Management Trust (HMT) hospitals practising privileges policy to be granted authorisation by the medical director to undertake the care and treatment of patients in the HMT hospitals. Processes had been put into place for medical staff to follow such as a consultants cancellation policy.

  • The hospital had worked to improve the engagement with patients and other stakeholders.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with three requirement notices. Details are at the end of the report.

On 15 September 2017 we served a warning notice under section 29 of the Health and Social Care Act 2008. The warning notice related to Regulation 12, (1)(2)(g) The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Safe care and treatment. The warning notice requires the provider to take action to ensure systems and processes are established to ensure the proper and safe management of medicines. We have given the provider three months to make the necessary improvements.

Ellen Armistead.

Deputy Chief Inspector of Hospitals (North Region).

Inspection carried out on 14 November 2016

During an inspection to make sure that the improvements required had been made

St Hugh’s Hospital is operated by Healthcare Management Trust and serves the population of North East Lincolnshire. The on-site facilities include an endoscopy suite, two operating theatres with laminar airflow; consulting rooms supported by an imaging department offering X-ray and ultrasound, and inpatient and outpatient physiotherapy services. There are 24 patient bedrooms, all with en suite bathrooms. The hospital provides surgical, outpatients and diagnostic imaging services.

We carried out an unannounced visit to the hospital on 14 November 2016 in response to information received from the public about endoscopy services. We inspected endoscopy services using our focussed inspection methodology. A focused inspection differs to a comprehensive inspection, as it is more targeted looking at specific concerns rather than gathering a holistic view across a service or provider.

In our comprehensive inspections, to get to the heart of patients’ experiences of care and treatment we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well led?

Focused inspections do not usually look at all five key questions; they focus on the areas indicated by the information that triggers the focused inspection. Although they are smaller in scale, focused inspections broadly follow the same process as a comprehensive inspection.

At this visit, we inspected the safe and well-led domains and did not inspect or rate the remaining domains: effective, caring, and responsive.

Where we have a legal duty to do so, we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

Services we rate

We rated the endoscopy service as requires improvement overall.

We found areas of practice in relation to endoscopy that required improvement:

  • Staff in the department did not always demonstrate awareness of when to submit an incident report.
  • The introduction of the surgical safety checklist was planned but not in use at the time of inspection.
  • There was an inconsistent approach to managing the risk of diabetes, pacemaker implantation or anti-coagulation treatment for patients being prepared for endoscopy procedures.
  • The quality of consent, procedure reporting and discharge documentation was inconsistent and in some cases illegible.
  • The overall approach to clinical governance in endoscopy needed strengthening and lacked proactive management oversight.
  • There was no evidence of a training needs analysis or competency framework in use for all endoscopy staff.
  • There was limited evidence that development of skills and knowledge to update and increase clinical expertise was achieved.
  • Endoscopy policies and procedural documents required updating.
  • There was a lack of audit of the quality and clinical effectiveness of the service.
  • There was no tool in place to obtain patient experience feedback from endoscopy patients.
  • Staff team meetings were infrequent.

However:

We found areas of good practice in endoscopy services:

  • Patients received comprehensive written information about the risks and benefits of the procedure and received clear instructions about after-care.
  • We reviewed eleven sets of patient records and endoscope traceability records were complete in each.
  • The endoscopy department was visibly clean and tidy in all areas visited.
  • A risk register was in place for the hospital and each department within the hospital. This was under continuous review as it was still under development and staff had received training in risk management.
  • The endoscopy nurse manager regularly attended the Clinical Governance Committee.
  • Mandatory training compliance levels were good and all staff had received appraisals.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with five requirement notices that affected endoscopy services. Details are at the end of the report.

Ellen Armistead

Deputy Chief Inspector of Hospitals (Hospitals North)

Inspection carried out on 25th-26th August and 10th September 2015

During a routine inspection

St Hugh’s Hospital serves the population of North East Lincolnshire and surrounding areas. The hospital offers a range of outpatient services to NHS and other funded (insured and self-pay) patients including: cardiology, dermatology, general medicine, rheumatology, respiratory medicine, radiology and physiotherapy. Inpatient and outpatient services are also provided for cosmetic surgery, ear, nose and throat, general surgery, gynaecology, ophthalmology, oral and maxillofacial surgery, orthopaedics and urology.

The hospital does not provide emergency care services. St Hugh’s Hospital contracts services for pathology, pharmacy, sterile services and MRI / CT scanning and these services do not form part of this inspection report. The registered manager is the Hospital Director who has been in post since October 2010.

This was the first comprehensive inspection of St Hugh’s Hospital. CQC last inspected the hospital in December 2013 and reported compliance with all the standards inspected at that time.

We rated St Hugh’s Hospital as requires improvement overall. We rated the service as inadequate for safe, requires improvement for effective and well-led and good for caring and responsive.

Are services safe at this hospital

Overall we rated safe as inadequate. There was a lack of robust systems and processes in place to manage patient safety. However there was evidence that a review of governance arrangements had started prior to inspection. We did not find evidence of thorough and robust incident investigations and there was a lack of assurance that learning from incidents was shared throughout the surgical service. There was a lack of evidence that action plans following the investigation of incidents were complete and evidence of root cause analysis was weak. Staff demonstrated an understanding of being open with patients when things went wrong but did not have a full understanding of the requirements of the statutory Duty of Candour. For example, incidents were not graded for level of harm which is critical to implementation of the regulation. Completion of risk assessment of venous thromboembolism was inconsistent. There was concern about medicines management including identification of medication errors and the recording of controlled drugs administration. There were no records of child safeguarding training and no Level 3 child safeguarding trained member of staff to lead an investigation if required. We found that records did not include individualised care plans and pre-operative assessment was not in line with national or best practice guidance; documented risk thresholds were not used to ensure patients were appropriately risk rated. We reviewed 19 World Health Organisation 5 Steps to Safer Surgery checklists. The ‘sign in’, ‘time out’, ‘sign out’ section were fully completed for 13 out of 19 forms (68%); however none of the forms indicated the procedure or date and therefore all forms were considered incomplete. Areas were visibly clean and tidy, equipment was visibly clean and available to staff. The rate of surgical site infections was good and lower than the national average.

Are services effective at this hospital

We rated effective as requires improvement as there was limited evidence that policies, care and treatment were evidence-based and that effective systems were in place to improve services. The lack of audit activity provided little assurance that the hospital monitored the quality of care effectively. Responsibility for local audit was centralised at a senior level and not delegated effectively. There was an ineffective response to audit findings and the management of action plans. The lack of robust audit systems was evident in the review of medication administration records, the 5 Steps to Safer Surgery checklists, fluid charts, consent forms and risk assessments. There was also a lack of formal monitoring and audit of outpatient clinic data to ensure that clinics were running effectively. Systems in place to approve and monitor practising privileges were under review and well supported by the Hospital Director and Medical Advisory Committee; however for 21% of NHS consultants, details of the latest appraisal were out of date at the time of the inspection. Whilst the appraisal may have taken place, consultants were not updating their records on a timely basis. Staff demonstrated good multidisciplinary team working; radiographers had regular clinical supervision and kept records; however the system used to record nursing supervision and appraisal was not as robust.

Are services caring at this hospital

We received 18 written feedback comments from patients at the time of inspection all of which provided positive feedback about the standard of care from all staff groups. The hospital incorporated the Friends and Family Test into their patient satisfaction survey. The survey response rate was 49% - 69% between April and July 2015 with 97% - 100% of patients likely or extremely likely to recommend the hospital. The hospital did not use the Friends and Family test for the outpatients department and had not performed an outpatient patient survey for approximately two years. This meant that the department did not have a formal way of measuring patient feedback. All the staff interacted with patients and their visitors in a polite and respectful manner and were helpful and friendly. Patients we spoke with said they felt involved in their care and treatment plans and family members praised the attitude of staff. They said nothing was too much trouble for them.

Are services responsive at this hospital

We rated responsive as good. The main volume of referrals was from the local NHS clinical commissioning groups. The hospital did not accept high-risk patients; however policy documents did not specify inclusion or exclusion criteria for accepting patients. The hospital reported 11 cases of unplanned transfer to an NHS hospital between April 2014 and March 2015 which CQC assessed to be worse than expected compared to the other independent acute hospitals we hold this type of data for during one quarter. Five transfers were to Level 1 care and four to Level 2 care for further assessment and investigations; of these, four were discharged from care within 24 hours. Two patients transferred to Level 3 care; one transfer related to an unpredicted condition and the other for post-operative complications. The hospital extended its services to meet local demand by adding cosmetic surgery services and by offering weekend MRI and CT scanning. Referral to treatment (RTT) data for April 2014 to July 2015 showed that the hospital met the target of 90% of admitted patients beginning treatment within 18 weeks of referral except for a dip in February, March and May 2015. The most common reason for this was reported to be lack of theatre capacity and a second laminar flow theatre had been added. All services at the hospital were on the ground floor; this allowed equal access for people with a physical disability. The hospital admitted patients living with a learning disability or dementia for day surgery supported by a carer or family member. There was a lack of evidence to show complaints and concerns were being used as an opportunity to make improvements or that learning was taking place.

Are services well led at this hospital

We rated well-led as requires improvement due to the lack of assurance that governance, quality improvement and risk management systems were working effectively. There was evidence of committee activity to monitor infection control, health and safety and clinical governance but limited evidence of the effective operation of the supporting risk management systems including learning from adverse incidents. The medical director for the parent organisation was appointed in April 2015 and was taking steps to develop a centralised governance framework led by the board of directors. The hospital director had a clear vision for the hospital and led the strategy to increase the volume of NHS referrals and add cosmetic surgery to the services offered at St Hugh’s Hospital. Staff were less clear about the long term strategy for their departments and the hospital and there was no documented evidence of an overarching vision and set of values for staff. The hospital director was visible and accessible and the Medical Advisory Committee was actively involved in the process to monitor, agree and review practising privileges with the hospital director. There was no clear strategy for staff engagement but there was an open culture and staff reported good working relationships between departments and with the management team.

Our key findings were as follows:

  • Staff and patients told us the hospital was one of the cleanest they had experienced. All areas of the hospital were visibly clean and well-maintained. We saw evidence of cleaning programmes including deep cleaning and of environmental audits and their action plans, but no evidence of the completion of action plans.

  • The hospital had a low infection rate and had had no cases of Methicillin-Resistant Staphylococcus Aureus (MRSA) bacteraemia, Methicillin-Sensitive Staphylococcus Aureus (MSSA) bacteraemia or Clostridium Difficile infections at the hospital between April 2014 and July 2015. The hospital liaised with the infection prevention and control service at the local trust including links with two microbiologists and two infection prevention and control nurses.

  • Nursing recruitment was a challenge but staffing levels had improved in the past year. Senior staff used their experience to determine the dependency of patients and staffing levels required. The hospital had an in-house bank and rarely used agency staff except in theatres where one agency nurse was on a short-term contract.

  • There was limited documentary evidence that the hospital met the nutritional needs of inpatients. For example there was no evidence of nutritional screening in the clinical records and incomplete documentation on fluid balance charts. However patients spoke positively about the choice and quality of the food and drinks received.

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

Importantly, the provider must:

  • Ensure that all staff receive the appropriate level of child and adult safeguarding training in relation to their role and responsibilities.

  • Ensure that all staff receive the mandatory training identified as appropriate for their roles.

  • Ensure that venous thromboembolism (VTE) risk assessment and interventions are consistently applied.

  • Ensure there are systems and processes in place to minimise the likelihood of risks by completing the 5 Steps to Safer Surgery checklist.

  • Ensure that all staff have an understanding of Regulation 20: Duty of Candour and how this is applied. Additionally the hospital must have systems in place to comply with this regulation.

  • Have effective systems in place which enable the hospital to assess, monitor and mitigate the risks relating to the health and safety and welfare of people who use the service.

  • Ensure that staff document consent in line with national guidance from the General Medical Council and Royal College of Surgeons.

  • Document and implement pre-operative assessment guidelines, including anaesthetic risk thresholds, in line with national guidance.

  • Ensure that all care pathways, risk assessments and care planning documents are based on current evidence and national best practice guidance.

  • Ensure staff follow policies and procedures about managing medicines, including prescribing and documentation of administration.

  • Ensure that appropriate audit and data collection take place within the outpatient department to monitor service quality and ensure that this information is used to drive improvements.

In addition the provider should:

  • Strengthen the recording and monitoring systems for mandatory training attendance and clinical supervision.

  • Ensure that nutritional screening is implemented.

  • Ensure that written medical records are legible and in line with national guidance from the General Medical Council.

  • Review the consent policy to include reference to guidelines for children.

  • Ensure that a Did Not Attend (outpatient appointment) policy is in place.

  • Consider ways to promote leadership and innovation from all staff.

  • Develop and launch a vision and set of values for the hospital staff.

  • Consider further participation in national audits to monitor and benchmark patient outcomes.

Professor Sir Mike Richards

Chief Inspector of Hospitals

 

Inspection carried out on 13 December 2013

During a routine inspection

Patients spoke positively about their experience of the hospital. Comments of patients included: �The whole experience has been absolutely fine,� �They can�t do enough; they look after you,� and �This is my fourth visit; each time I have had the same level of care and treatment; the service is excellent and I have not experienced any deterioration.�

Patients spoke very positively about their mealtime experience. Nearly all patients rated the hospital food as excellent or good in the monthly inpatient quality questionnaire. One patient explained, �The food is lovely; you have a choice of three or four things and they ask each day what you want.�

Patients were happy with the way they were given their medicines. One patient who was ready to be discharged said, �I am clear about what I need to do and I have my medication already, with written instructions.� Another patient said, �They give me as required medicine for pain relief.� Another patient commented, �The medicine helped me to walk and I was able to get a good night�s sleep.�

Patients� comments about staff included, �The staff are all very knowledgeable,� �The nursing staff are helpful and friendly and the surgeon has been particularly helpful,� and �Everybody is smiling; the nurses are lovely, and reception staff are ever so nice, so is my consultant and the physiotherapist is spot on.�

Patients we spoke with explained how they would make a complaint although they said they had no complaints to make.

Inspection carried out on 20 December 2012

During a routine inspection

Patients told us they were engaged in discussion before their treatment and gave their consent. One patient said, �We were involved in discussion when I came for my pre op. They are brilliant and they explain everything to you.� We saw a survey response which stated, �The consultant was very good; he was very informative and put my mind at ease.�

Patients and their relatives spoke positively about their experience of the service. One patient commented, �There was someone with me right up to the point they knew my blood pressure was OK, even in the recovery room. No one walked past without saying, �are you OK?�� We saw a survey response which stated, �I have never experienced such professional, caring and considerate care, wonderful; and means I am making a good recovery.� This was typical of other responses we reviewed.

Patients and their relatives spoke positively about their experience of the cleanliness of the hospital and about staff that worked with them. One patient told us, �The nurses and doctors have been really good; you can�t fault them.� We saw survey responses which stated, �The staff were very nice and considerate,� and �I was particularly pleased with the warm friendly feel of the place and staff.�

Patient views were regularly sought through questionnaires given to each patient on discharge. The results of the patient satisfaction survey for November 2012 showed that 92% of patients found the hospital�s service excellent overall.

Reports under our old system of regulation (including those from before CQC was created)