The Nuffield Health Bournemouth Hospital is one of 31 hospitals and treatment centres provided by Nuffield Health.
The hospital provides a range of medical, surgical and diagnostic services. The onsite facilities include an endoscopy suite, three operating theatres (two with laminar airflow, one without), a cardiac catheter laboratory, 41 inpatient beds, two minor operations rooms, one treatment room and 13 consulting rooms. The hospital offers physiotherapy treatment as an inpatient and outpatient service in its own dedicated and fully equipped physiotherapy suite.
Services offered included general surgery, orthopaedics, cosmetic surgery, ophthalmology, general medicine, oncology, endoscopy, and diagnostic imaging. Most patients are self-paying or use private medical insurance. Some services are available to NHS patients through the NHS e-referral service.
Care and treatment of children and young people aged 0-16 years accounts for 5% of the overall activity at this hospital. There is no provision for medical care of children and young people aged 0-16 years. There were no children receiving care and treatment at this hospital at the time of our inspection. Care of children and young people was not inspected as a separate core service and is included within the reports for surgical services and outpatient and diagnostic imaging.
The announced inspection took place between 24 and 25 May 2016, followed by a routine unannounced visit on 9 June 2016.
This was a comprehensive planned inspection of all core services provided at the hospital: medicine, surgery and outpatient and diagnostic imaging.
The Nuffield Health Bournemouth Hospital was selected for a comprehensive inspection as part of our routine inspection programme.
The inspection was conducted using the Care Quality Commission’s new inspection methodology.
The overall rating for this service was requires improvement. We rated medicine and surgery as requiring improvement and outpatient and diagnostic imaging as good.
Our key findings were as follows:
Are services safe at this hospital/service
By safe, we mean that people are protected from abuse and avoidable harm.
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We rated safe as inadequate in surgery, requiring improvement in medicine and good in outpatient and diagnostic imaging services.
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Infection prevention and control in theatres did not meet the requirements of the Health and Social Care Act, 2008, Code of Practice on the prevention and control of infections and related guidance. Operating theatres were in a poor state of repair with worn, torn and rusty equipment.Staff in theatres did not consistently adhere to best practice guidance or Nuffield policy in relation to prevention of infection.This was in breach of Regulation 12 of the Health and Social Care Act, 2008, and we issued a Warning Notice to the hospital to take urgent action.
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Nurses who were responsible for decontamination of nasendoscopes were not trained to undertake the decontamination process for those particular nasendoscopes.They had received training in general decontamination of equipment.
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There was inconsistent tracking and tracing of endoscopes meaning that staff could not be assured that the scopes used were clean and ready for use.
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Mandatory training overall compliance at the hospital was 84% against a hospital target of 85%.Training compliance was particularly low in theatres with overall compliance of 74%.
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The wards were clean and cleaning schedules were well maintained.In theatres and outpatients there were significant gaps in the cleaning schedule recordings and the schedules were not effective in ensuring the environments were clean.We saw areas of visible uncleanliness in theatres and outpatient departments.
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Medicines, including controlled drugs, were not always stored securely and records were not appropriately maintained in all areas.Verbal orders were routinely being used to prescribe medicines in the cardiac catheter suite.
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Risk assessments were completed but there were gaps in the assessments of venous thromboembolism (VTE) and in the World Health Organisation (WHO) safer surgical checklist.
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Staff understood the requirements of Duty of Candour legislation and could give examples of when it should be applied.
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Staff across all departments understood their responsibilities in safeguarding individuals from avoidable harm and/or abuse.The matron was the hospital’s safeguarding lead.
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Staff knew how to report incidents and did so.The system was accessible and easy to use.Incidents were investigated and learning was mostly shared across the hospital and the wider organisation.
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Staffing was sufficient to provide safe care and treatment.Where there were gaps, regular bank and agency staff were used to promote consistency of care.
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The Resident Medical Officer provided medical care as needed to patients.Consultants led care and treatment and were always available for advice and support if required.
Are services effective at this hospital/service
By effective, we mean that people’s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence.
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We inspected but did not rate effectiveness in outpatients and diagnostic imaging as we do not currently collect sufficient evidence to do so.We rated surgery as good for effective care and treatment.We rated medical services as requiring improvement.
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Care and treatment in surgery and outpatients took account of national guidance.
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Patient outcomes are monitored appropriately at a local at a local and national level with the exception of patients undergoing gastrointestinal endoscopy.
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There were no standard operating procedures for gastrointestinal endoscopy.
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Appraisal rates were low at 78% for nursing staff.
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Practicing privileges were granted and monitored appropriately by the Medical Advisory Committee (MAC). Nursing and operating department practitioners’ registration was monitored by the human resources manager.
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The hospital participated in national audits such as the National Joint Registry.
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With the exception of patients post knee replacement surgery, the hospital wide unplanned readmission rate was similar to or better than other independent hospitals.
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Patients consented to procedures and staff were clear what action they take if they thought a patient lacked capacity to give informed consent. However, in theatres written consent was obtained on the day of the procedure which did not allow for a ‘cooling off’ period, and not in line with national guidance.
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Endoscopy leads were working towards achieving Joint Advisory Group (JAG) accreditation.The cardiac catheter suite leads were working towards British Cardiac Intervention (BCIS) Society accreditation.
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Some staff were not sufficiently trained to perform their roles.In endoscopy there was no training plan to ensure that staff were competent in the use of use of endoscopes.
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Patients’ nutrition and hydration needs were mostly met.Patients reported being offered a wide range of food choices but there were gaps in the monitoring of food and fluid intake in some cases
Are services caring at this hospital/service
By caring, we mean that staff involve and treat patients with compassion, kindness, dignity and respect.
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Overall, caring was rated as good.We found evidence of kind and compassionate care in medicine, surgery and outpatients and diagnostic imaging.Staff treated patients with kindness and compassion.
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The hospital staff received consistently positively feedback from patients through the Friends and Family Test (FFT).FFT results showed that during the period January 2016 to March 2016, overall satisfaction with patient experience was 94% and rating for being treated with respect and dignity 97%. This information was displayed at the hospital.
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Patients and their relatives were involved in decisions about their care and treatment.Patients told us they were given sufficient information to make informed choices.
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Open visiting hours at the hospital allowed for patients to be emotionally supported by their friends and family throughout their stay.
Are services responsive at this hospital/service
By responsive, we mean that services are organised so that they meet people’s needs.
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Overall, this hospital was rated as good for responsive care. Service planning took account of individual needs and preferences.Patients were offered appointment times to suit their personal circumstances and all inpatients were cared for in private bedrooms with individual bathrooms.
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Staff could describe what actions they would take to meet the needs of vulnerable patient groups such as individuals with a learning disability and/or living with dementia.They would discuss with senior staff or the nominated link nurses and resources were allocated to meet the needs of individuals before their planned treatment.
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The Patient Led Assessment of the Care Environment (PLACE) for 2015, PLACE rated the hospital at 88% dementia friendly, compared with other independent hospitals at 81%.
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The hospital consistently met the national 18 week referral to treatment target for NHS patients across all departments.
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Complaints were taken seriously and responded to in a timely and responsive manner.Learning arising from complaints was used to improved patient care and experience.
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Patients who did not attend for outpatient appointments were followed up proactively but this was not formally monitored.
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Outpatient appointments and surgery were planned mostly between Monday and Friday.However, there were on call services to support responsive care outside of usual working hours such as pharmacy and radiology if required.
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There was no inclusion or exclusion criteria but patients were screened by the lead consultant prior to the onset of the treatment or procedure.This ensured that their treatment could be planned according to their individual needs.
Are services well led at this hospital/service
By well led, we mean that leadership, management and governance of the organisation assure the delivery of high quality person-centred care, supports learning and innovation, and promotes and open and fair culture.
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Overall, we rated leadership at this hospital as requiring improvement though we found leadership in outpatient and diagnostic imaging was good.
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The theatre manager did not have sufficient support or capacity to fully fulfil the requirements of the role.Staff valued the day to day operational leadership but surgical services and endoscopy lacked strategic vision and oversight.
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There were governance arrangements in place with clear reporting lines from frontline staff to the senior management team.The clinical governance group met monthly and ensured that learning occurred following incidents, audits and complaints.However, risks were not always given sufficient priority for action and service leads did not always act promptly where there were areas of increased patient risk or non-compliance.
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The Resident Medical Officer (RMO) was not included in the overall governance structure.
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The Cardiac Catheter Suite provided a service that local cardiologists felt was lacking in Dorset. Staff were proud of the suite as it was the only service of its type available in the independent sector locally.
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Staff were mostly aware of the corporate vision, strategy and values.
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Staff were committed to providing quality compassionate care.
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Staff had confidence in their managers and reported the senior team were accessible and approachable.The senior team were committed to providing excellent customer care but this distracted from improving clinical standards.
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Senior staff could not always accurately describe the risks within their department.The risk register did not accurately reflect the risks which meant that sufficient priority was not always afforded.
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The Medical Advisory Committee oversaw appropriate granting and scrutiny of practising privileges.
Our key findings were as follows:
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Infection control and prevention did not meet the requirements of the Health and Social Care Act, 2008, Code of Practice on the prevention and control of infections and related guidance.This was in breach of regulation 12 of the Health and Social Care Act, 2008, and we have issued a warning notice to the provider.
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Cleaning schedules were not consistently maintained and did not ensure that overall cleanliness was maintained.
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Staffing levels were sufficient to provide safe and effective care and treatment.Regular bank and agency staff were used where gaps occurred.
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Staff had not completed mandatory training in line with targets identified by the provider.
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Some staff were not sufficiently trained to perform their roles.In endoscopy there was no training plan to ensure that staff were competent in the use of use of endoscopes.
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Patients nutrition and hydration needs were mostly met.Patients reported being offered a wide range of food choices but there were gaps in the monitoring of food and fluid intake in some cases.
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Staff were caring and compassionate and patients were included in decisions about their care and treatment.
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Staff valued support from their immediate line managers and reported the senior team was accessible and approachable.However, leadership was focussed on customer service and experience which distracted from the monitoring and improvement of clinical standards.The theatre manager was not afforded sufficient capacity or support to fully fulfil their role.
There were areas where the provider needs to make improvements.
Importantly, the provider MUST ensure that:
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Theatre environments are safe and follow infection prevention and control procedures in line with the Health and Social Care Act, 2008, Code of Practice on the prevention and control of infections and related guidance.
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Staff complied with bare below the elbows guidance and adhere to best practice and Nuffield’s own policies in relation to infection prevention and control.
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Linen is safely stored and handled in theatres.
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Clinical waste is safely stored away from areas of direct patient care until disposal.
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Equipment is safe for use and that the condition of equipment allows for efficient cleaning.
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An effective system is implemented to ensure that worn, torn, broken or rusty equipment is identified, withdrawn from use and replaced in a timely manner.
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Cleaning schedules and effectiveness of cleaning are monitored to ensure that cleaning occurs at agreed intervals.
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All staff receive mandatory training in line with the hospital set minimum target of 85%.
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All staff complete an annual appraisal
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There is an effective and monitored system for the tracking and tracing of endoscopes.
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Staff working in endoscopy are trained and assessed against an identified competency framework that is specific to their role.
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All patients have a documented risk assessment for venous thromboembolism.
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The five steps to safer surgery checklist (WHO) is always appropriately completed.
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The storage and management of medicines including controlled drugs meet the requirements of current legislation, Nuffield policy and standard operating procedures.
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Verbal orders for medicine prescribing are not used when undertaking planned procedures.
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Departments should maintain their own risk registers and ensure staff are fully aware how to raise matters and place them on the risk register.
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There are robust systems and processes for assessment, identification and mitigation of risks across all services and departments of the hospital.
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Risk register includes all risks that may adversely affect patient safety and is shared with and understood by staff across all departments.
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Patient records of care and treatment, including nutritional monitoring, are legible and complete.
In addition the provider SHOULD ensure that:
- Learning from incidents is consistently shared across all hospital departments.
- Ensure pharmacy staff discuss medicines with patients in a manner that maintains patients’ privacy.
- Medicines are stored at the appropriate temperature and there are clearer recording systems so there is assurance that medicines in endoscopy department have been stored within the correct temperature range.
- Relevant staffs receive appropriate training for decontamination of nasendoscopes.
- Ensure there are systems in place to check daily maintenance of nasendoscopic equipment.
- Implement formal systems to inform patients of waiting times of clinic.
- Ensure results of patient satisfaction surveys are shared with staff and displayed publicly.
- That consultants are capturing data after carrying out endoscopy procedures at the hospital, and plan how this data can be used to improve patient outcomes.
- All resuscitation trolleys are checked at agreed intervals and this is reflected in the recording of such checks.
- Boxes are not stored on the floor in the cardiac catheter suite storeroom to enable effective cleaning of the storeroom.
- The theatre manager is afforded capacity and support to fulfil the requirements of the role.
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Develop a pre-operative fasting policy in line with national guidance.
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Consent forms are signed by patients on the day of their procedure to allow a ‘cooling off’ period in line with national guidance.
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The Resident Medical Officer is part of handover and team meetings.
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A strategy for surgical services is developed.
Professor Sir Mike RichardsChief Inspector of Hospitals
Professor Sir Mike Richards
Chief Inspector of Hospitals