Nuffield Health Derby Hospital

We inspected the Nuffield Health Derby Hospital on 14 and 15 October 2015 during our announced inspection. We also completed an unannounced inspection of the hospital on 28 October 2015.

The inspection was a comprehensive inspection, which was part of the CQC’s programme of comprehensive, independent healthcare acute hospital inspections. We inspected medicine, surgery and outpatients and diagnostic imaging services.

Overall, we rated the hospital as ‘Good.’ We found surgery and outpatients and diagnostic imaging services were ‘Good.’ We found medicine services ‘Required improvement’;

Are services safe at this hospital

We found services at the hospital were safe:

• Openness and transparency about safety was encouraged and staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses.
• Staff were aware of Duty of Candour regulations and the requirements for them to discuss incidents where patients had been harmed in an open, honest and timely way with patients, providing explanations and apologies where required.
• Staff knew who their safeguarding lead was in the hospital; this was their matron or the deputy matron. Staff were aware of circumstances when they would need to raise safeguarding concerns and had access to contact details for local safeguarding agencies.
• Staffing levels and skill mix were planned and reviewed to keep people safe at all times. Although there was the use of agency and bank, wherever possible the hospital used regular bank and agency staff.
• Resident Medical Officer (RMO) was available to all staff 24 hours a day, seven days a week. Consultants could be contacted for additional, specific support and advice for individual patients.
• Handover was scheduled at the end of each shift to ensure there was handover between RMO and consultants on site, as well as between medical and surgical staff and nursing staff.
• Systems, processes and standard operating procedures in infection control, medicines management, patient records and, the monitoring and maintenance of equipment were mostly reliable and appropriate to keep patients safe.

Are services effective at this hospital

We found services at the hospital were effective:

• Care and treatments were planned and delivered in line with current evidence based guidance, standards and best practice legislation.
• New evidence-based techniques were used to support the delivery of high quality care and staff worked collaboratively to understand and meet the range of people’s needs.
• We found policies and procedures were discussed by the senior management team, were progressed and ratified through the medical advisory committee (MAC) and the integrated clinical governance committee.
• Patient outcomes were audited and benchmarked within the hospital and in comparison to other hospitals in the Nuffield Health provider group.
• Where appropriate, services took part in national audits such as the national joint registry, surgical site infection rates and when appropriate the National Confidential Enquiry into Patient Outcome and Death (NCEPOD).
• The hospital had a formal revalidation process for doctors and nursing staff, including checks for professional registration and indemnity, training, appraisal, Disclosure and Barring Service (DBS). Doctors worked under practising privileges and had to provide information to the Hospital Director in order to maintain their privileges. The MAC provided assurance and support to individual doctors as required and identified by the hospital.
• Not all staff had completed training in the Mental Capacity Act 2005 or Deprivation of Liberty Safeguards. Staff were aware of requesting and speaking with patients about their consent for procedures, care and treatment.

Are services caring at this hospital

We found services at the hospital were caring:

• Feedback from patients was continually positive about the way staff treated people. Patients told us staff were polite, helpful and kind.
• Staff were highly motivated and cared for patients in ways which promoted their privacy and dignity.
• The hospital used a Friends and Family Test to ask patients and their families to rate the service, care and treatment they had received. This formed part of a broader Patient Satisfaction Survey which patients were asked to complete. This was audited by the hospital and compared with other hospitals in the Nuffield Health provider group.
• For outpatient and diagnostic imaging services, between May 2015 and August 2015, 95% of patients would recommend care at the hospital to others.
• For surgery services, during the period March 2015 to August 2015 between 79 and 92% of patients who responded would recommend Nuffield Health Derby Hospital to family or friends. The average percentage for other Nuffield Health hospitals was 89%.
• We were told of an example where staff had provided additional emotional support to a patient in a person centred way to ensure treatment could be given in a manner which protected the patient’s dignity and privacy.

Are services responsive at this hospital

We found services at the hospital were responsive:

• The hospital planned services to meet the needs of its patients in the local area and for individual patients.
• For surgery services, the hospital had a policy which outlined the inclusion and exclusion criteria for patients. Patients with an American Society of Anaesthesiologists (ASA) physical status score of four were excluded. The patients admitted to the hospital had an ASA score of one to three. These patients were generally healthy or suffered from mild systemic disease.
• Waiting times, delays and cancellations were managed appropriately to minimise delays and waiting times for patients.
• Departments had ‘dementia champions’, staff who were the lead for patients living with dementia and who could provide additional information and support to colleagues.
• The Resident Medical Officer was available at all times to provide assistance and support.
• The hospital had good liaison with the neighbouring NHS trust, which provided some out of hours support.
• Complaints and concerns were taken seriously and responded to in a timely way. Feedback and learning from complaints had been shared and changes made as a result of complaints. For example, outpatients leaflets had been redesigned and reworded following a complaint.

Are services well led at this hospital

We found services at the hospital were well-led:

• The hospital had a clear vision and strategy, in line with the Nuffield Health provider values of Enterprising, Passionate, Independent, Caring (EPIC).
• The senior management team and other levels of governance within the organisation functioned effectively and interacted with each other appropriately.
• The Hospital Director and chair of the MAC worked together to ensure doctors working under practising privileges were appropriately monitored and their practising privileges to continue working at the hospital were routinely reviewed.
• The service was transparent and leaders at every level prioritised high quality compassionate care. There was a positive staff culture where innovation was supported.
• The endoscopy services were working towards achieving Joint Advisory Group on Gastro-intestinal Endoscopy (JAG) accreditation.
• Surgery services had introduced a new anaesthetic procedure, called targeted spinal anaesthesia.

Our key findings were as follows:

• The overall leadership of the hospital was good; staff felt able to discuss improvements for their patients and services, to raise concerns and felt part of the hospital team.
• We found the hospital was visibly clean. The hospital senior management team confirmed a programme of refurbishment was on-going to update areas of the hospital which had been identified as needing redecoration.
• We found staffing levels were safe and met the needs of patients. Where bank or agency staff were used, the hospital tried to ensure these staff were used on a longer term basis to provide continuity of patient care.
• We found staff cared for patients and provided them regularly with meals and drinks.

We saw several areas of outstanding practice including:

• The hospital had introduced a new anaesthetic procedure. Patients undergoing certain surgical procedures were given a short-acting spinal anaesthetic using different local anaesthetic based on the time required for the surgery this was called targeted spinal anaesthesia. The effect of this anaesthesia only lasted for the duration of the procedure which meant patients were able to start moving around immediately, were able to eat and drink immediately and could be discharged sooner. This was beneficial for patients, such as those with diabetes, who needed as short a time as possible without being able to eat and drink.
• The hospital had recently introduced "The Nuffield Health Promise" for self-funded patients. This enabled patients to have further care and follow ups at no extra cost if their expectations had not been reasonably met.
• Prior to a patient going into the anaesthetic room, patients were taken to a ‘quiet room’. Patients were introduced to the surgical team. A handover of the patient from the ward nurse to the theatre staff including the patient took place in this room; the patient was involved in the whole process and put at ease.
• During the Five Steps to Safer Surgery safety checklist in the operating theatre, patients who were anesthetised were ‘introduced’ to the team by their full name, for example, ‘team let me introduce to you’, and this was respectful of the patient.
• The hospital’s cancer services offered a range of therapies to cancer patients without any extra charge. Patients could have up to six treatments, such as massages or eyebrow tattooing.
• We were given a positive example of staff going out of their way to protect the dignity and privacy needs of a patient with learning disabilities. The hospital had recognised the patient needed to be brought into the hospital in a special way involving extra staff. We were told how it was dealt with in a person centred way by all staff to ensure treatment could be given in a manner, which protected their dignity and privacy.

However, there were also areas of poor practice where the provider needs to make improvements.

Importantly, the provider MUST:

• Ensure that performance monitoring, quality dashboards and patient outcome measures are in place in endoscopy and cancer services.
• Ensure that service specific policies are fully developed and understood for cancer services.
• Ensure that patient outcomes are reported and used to inform the endoscopy and cancer services.

Additionally, the provider SHOULD:

• Ensure all staff are aware of and understand their responsibilities in relation to the hospital major incident and business continuity plans.
• Review the use of the step down unit in order to comply with the clinical commissioning arrangements and Department of Health same sex accommodation guidance.
• Ensure all staff are aware of and know the requirements in relation to The Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards legislation.
• Ensure staff complete all mandatory training, including in The Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards legislation.
• Ensure all risk assessments in patients records are up to date and accurately reflect the patient’s current condition.
• Review the arrangements for the borrowing of the defibrillator from the ward by other departments.
• Ensure local and national guidance, policies and procedures used in the delivery of care and treatment are current, especially on the step down unit.
• Increase the local understanding and routine completion of monitoring incidents in the outpatients department.
• Consider ensuring patient information leaflets are easily and readily available in languages other than English.
• Ensure the hospital’s local risk register is updated and reflects risks identified by services and departments at the hospital.
• Ensure appropriate storage, management of information governance and patient confidential information is maintained when consultants remove notes from the hospital.

Professor Sir Mike Richards

Chief Inspector of Hospitals