You are here

Archived: The Foscote Private Hospital Good

The provider of this service changed - see new profile

All reports

Inspection report

Date of Inspection: 11 June 2013
Date of Publication: 12 July 2013
Inspection Report published 12 July 2013 PDF

The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care (outcome 16)

Meeting this standard

We checked that people who use this service

  • Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.

How this check was done

We looked at the personal care or treatment records of people who use the service, carried out a visit on 11 June 2013, observed how people were being cared for and talked with people who use the service. We talked with carers and / or family members, talked with staff and reviewed information given to us by the provider.

Our judgement

The provider monitored the quality of service that people received.

Reasons for our judgement

People who used the service benefited from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.

We looked at the minutes from the monthly Governance Committee and saw that the actions from previous meetings had been completed within the time allocated. There were few actions carried over to the next meeting which demonstrated that staff took responsibility for the outcomes. The Governance Committee was a formal and recorded meeting that addressed a range of quality indicators including Regulation; Incidents; Infection Control; Patient Satisfaction and Health & safety. We were told that the meeting provided a useful forum for staff to discuss quality and review outcomes.

The provider conducted extensive audits covering areas such as records, patient equipment, fire safety and management checks. Any findings and required actions were recorded and people were identified to take any actions forward. We saw that these actions were being completed within identified timescales. For example; one action was noted that a re-audit was required for the following month. A member of staff was identified to carry out this action and we saw evidence that this had been completed.

The provider held policies on a range of topics such as, theatre practices, governance and security, legal and occupational health. These policies underpinned the working practices at the hospital and gave guidance to all staff.

We saw that complaints were well managed, in line with the provider’s policy on complaints that stated all complaints would be acknowledged within five working days and resolved, where possible within twenty. Any delays would be acknowledged with a written response. We saw that there had been fourteen complaints since July 2012, three of which were still to be resolved. All the complaints we saw were of a minor nature. One specific complaint noted a side effect that a patient had experienced following a procedure. The matron told us that following this complaint a new test had been introduced prior to this procedure being carried out that identified the likelihood of any possible side effects and this helped to keep patients informed and enabled them to make more informed choices.

We saw records of staff meetings that were held monthly/bi-monthly. These meetings were scheduled to follow, where possible, clinical governance meetings. We saw that this allowed information to be passed down to nursing staff. We also saw a ‘tracker spread sheet’ that was available to all nursing staff on the computers shared drive and gave access to policies and information. This facility also gave information on results of service user surveys and audits. We saw some results and noted that the service user surveys rated the hospital highly and in comparison with other hospitals in the group, BMI Foscote was currently rated number one.