Nuffield Health Plymouth Hospital

We carried out this inspection as part of the programme of independent healthcare inspections under our new methodology.

Our inspection was carried out in two parts: an announced visit on 7 and 8 July 2015 and an unannounced visit on 15 July 2015. Our key findings were as follows:

We rated the hospital as requires improvement overall, with surgery and children and young people’s services rated as requiring improvement, outpatients and diagnostic services rated as good.

Our Key findings

• Staff told us, without exception, that they enjoyed working at the hospital. They found the management to be supportive and approachable.
• Surgical services were rated as outstanding for caring, good for effective and responsive with well led and safe requiring improvement.The service required improvement in some areas of risk management and quality performance processes. There was good flow throughout the surgery department and patients’ needs were assessed and actions were taken in a timely and effective manner. Patient feedback was overwhelmingly and consistently positive regarding care received. Staff were visibly committed to person-centred care, attentive to needs, reassuring, compassionate and professional. There were effective systems that enabled patients to be fully informed and included in all aspects of their treatment and care.
• We found the outpatients and diagnostic imaging service at this hospital to be well run, with safe practices. There was a culture of learning and openness within both radiology and the outpatients departments. Patients were able to contribute their comments about their care and the facilities in the hospital.
• We found that the service provided for children and young people required improvement. There was no assurance that appropriately trained nursing staff provided care for children at all times. There was little contingency to cover for sickness or annual leave of the paediatric nurse, creating a risk that surgery would be cancelled if she were unavailable. There were no audits or outcome measures available for children. There were no methods for collecting the views of children in order to inform service delivery.
• Medicines were available for children and emergency drugs were being held in the same emergency drugs box that was used for adults. Systems were in place to minimise the risk of incorrect doses of emergency medicine being administered to children.
• There was a lack of leadership at hospital management level for ensuring oversight and monitoring of the childrens’ services, with decisions being made only in response to the inspection team raising concerns.

We saw several areas of outstanding practice, including:

• The Patient-Reported Outcomes Measures (PROMs) data for April 2014 to December 2014, published in May 2015 showed that patients evaluated the effectiveness of hip and knee replacement surgery as very positive. The first (EQ-5D Index) for hip replacement surgery showed that the hospital’s score (0.50) was significantly better than the England average (0.44). Overall, these scores ranked the hospital as the sixth best in the country. The PROMs for knee replacement surgery (Oxford Knee Score) ranked the hospital as 19th best in the country.
• The hospital demonstrated patient-centred handovers during shift changes. Staff handovers were conducted in each patient’s room using the care plan to review and discuss all care and treatment. This system fully involved and included patients and enabled care to be led by patients’ needs. It also provided clarity on what tasks would be completed by which staff and when.
• The physiotherapy service demonstrated dynamic and innovative working. Staff were skilled and independent practitioners who worked responsively and flexibly to meet patient needs. The team demonstrated how they used all opportunities for professional development, which improved their practice for the benefit of patient care.
• The hospital had direct access to electronic information held by community services, including GPs. This meant that staff could access up-to-date information about patients – for example, details of their current medicine.

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

An action that a provider of a service MUST take relates to a breach of a regulation that is the subject of regulatory action by the Care Quality Commission. Actions that we say providers SHOULD take relate to improvements that should be made but where there is no breach of a regulation.

Importantly, the provider must:

• Provide enough appropriately qualified nursing care for children undergoing procedures.
• Ensure that registered nurses caring for children are suitably assessed and can demonstrate appropriate skills required to provide safe care for children.
• Ensure that registered nurses caring for children are provided with opportunities to maintain and update standards of practice in care for children in order for the service to deliver safe care and treatment.
• Provide adequate opportunity to staff who care for children to access professional supervision.
• Ensure risk and management of childrens’ services are an integral part of the governance systems and processes to provide assurance and ensure safe care
• Ensure there are robust governance and risk management arrangements in place to identify and manage issues at all levels of the organisation to enable appropriate action to be taken to maintain a safe service.
• Ensure that 100% compliance with the World Health Organisation (WHO) surgery checklist is maintained and verified in all areas where surgical procedures are undertaken.

In addition, the provider should:

• Ensure that the children’s service is represented at the Medical Advisory Committee in line with organisational policy.
• Ensure that children’s services are monitored through the governance arrangements and that there is representation at senior management and executive level.
• Train staff on the duty of candour regulation and make sure they understand its application in practice when an incident occurs.
• Consider improving the environment for children in the outpatient’s department, ward and recovery areas as they are not child-friendly.
• Consider consulting with children, young people and their families to gain their views for potential improvement of the service.
• Consider a meaningful review of children’s services and consider gathering data to inform improvements in effectiveness of the service to children.
• Obtain feedback from adults and children visiting the outpatients department
• Provide systems and processes to enable all relevant staff to be aware of the surgical department’s risks and priorities and to have effective action plans to improve quality and reduce risks to patients.
• Review the patient discharge information shared with GPs to ensure that the same relevant information is communicated for all patients.
• Provide appropriate training opportunities for staff to update their basic life support skills and monitor completion rates.

Professor Sir Mike Richards

Chief Inspector of Hospitals