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Nuffield Health Plymouth Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 4 November 2015

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

Inspection areas

Safe

Requires improvement

Updated 4 November 2015

  • Staff mostly understood their obligations under the duty of candour rules to explain and apologise when things went wrong. They understood the need to be open and transparent. The hospital matron took lead responsibility for safeguarding adults from abuse and the paediatric nurse performed the role in relation to children advising the matron when required. Staff reported incidents of harm or risk of harm, which were investigated and any lessons to be learned were shared. There were enough staff in all areas of the hospital apart from paediatrics where one paediatric nurse was supported by nurses trained to care for adults. However, nursing staff did not have opportunities to maintain and update their skills and experience to care for children and young people in a surgical setting due to the limited amount of surgery on children performed at the hospital. Following our inspection, increased access at an alternative hospital was organised to support staff skills in this area. We saw that medicines were available for children and that 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. The Resident Medical Officer worked on the ward and provided care in emergencies until the consultant or emergency services were called. Staff handovers were conducted in each patient’s room using the care plan to review and discuss all care and treatment. Audits of safer surgery checklists demonstrated further work was required to ensure the standard was met at all times.

Effective

Good

Updated 4 November 2015

  • Paediatric care was not audited for patient outcomes to establish if it met national targets and benchmarks. This was because such small numbers of procedures were undertaken. As a result it was not clear how the service measured this aspect and used information to improve the service provided. Three out of the four directors did not have a medical background and the Medical Advisory Committee was not involved in the development and agreement of all national Nuffield policies but consultants from most specialties within the Hospital, was involved in the development of clinical services within the hospital. This meant that local procedures and service plans did routinely include input from experienced and highly qualified consultants who were responsible for the delivery of the clinical service. Systems were in place to ensure that practising privileges for consultants working at the hospital were up to date. Staff demonstrated an understanding of the Mental Capacity Act 2005. There was a dementia lead in the hospital, who was used as a source of reference for staff. While staff had received training on the deprivation of liberty safeguards they said they had never had to submit a request to restrict a patient’s liberty.
  • We did not have enough evidence to rate the effective domain for outpatients and diagnostic imaging.

Caring

Good

Updated 4 November 2015

  • We saw all staff throughout the hospital treating patients with kindness and compassion. Friends and Family Test scores for NHS-funded patients between October 2015 and March 2015 were consistently high, demonstrating patients’ happiness with the care they received. There was support available for adult patients who were vulnerable or had extra care needs. A psychologist was available by appointment in the outpatients department to meet with young people. Visiting hours were flexible and there were facilities for relatives to stay overnight to support their emotional wellbeing. Extra staff were available to support patients with an encroaching dementia.

Responsive

Good

Updated 4 November 2015

  • Admission, treatment and discharge pathways were well organised and flexible so that they were responsive to patients’ changing needs. Access to pharmacy support was always available, including outside normal working hours. The hospital provided elective surgery and treatment. As no emergency and high dependency care was provided, patients with multiple health problems would not be considered for treatment. The hospital services were accessible to both private and NHS patients who met the criteria for treatment. There were systems to respond to complaints, with review at head of department and hospital board level. Clinical complaints were reviewed at the Medical Advisory Committee meetings. A recent example of complaints management was provided when learning was taken through the MAC meeting and information cascaded to consultants.

Well-led

Requires improvement

Updated 4 November 2015

  • Staff were clear about and worked in accordance with the values and principles of the hospital. They felt supported by their line managers and were clear that patients were at the heart of what they did. There was a governance structure that involved key performance indicators being reviewed and discussed.The Medical Advice Committee (MAC) was made up of consultants who worked at the hospital and met to discuss issues related to their practice. Other hospital groups included regular meetings between nursing staff and estates and heads of departments meetings. All of which fed into the hospital Integrated governance committee together with other governance groups including pathology, radiology and blood transfusion. The Integrated Governance Committee reported to the Hospital Board which then reported to the company executive board. Governance minutes submitted to the board were not well documented, for example, there was no evidence of discussion, debate or recommendations or information about how issues were moved to the risk register for action.
  • While some departments demonstrated governance systems were in place locally there was little evidence of robust overarching governance and risk systems that ensured the hospital management team were able to capture, identify and manage issues and risks at organisational level. Issues which affected the delivery of safe and effective care were not identified with adequate action being taken.
  • The radiography department had a strong ethos of self-governance using audit and learning to ensure their practise was safe for patients and in responding to patient’s needs.
  • There was insufficient oversight of the service for children and young people. Review of paediatric outcomes were not measured to ensure review and development of the service. No review had been considered to ensure that the service was suitable. Since the inspection, we have been advised by the hospital management team that a review of the children’s service had led to an agreement to treatment only children over eight instead of children over the age of three years. This decision took immediate effect as a temporary initiative, with plans for a review in the future however the hospital was unable to demonstrate the basis for this decision within the governance and risk arrangements.
  • In the surgical department there were governance processes and evidence of investigation of serious incidents and ongoing audits. However, in some areas there was a lack of detail and understanding to demonstrate how issues had been interrogated, or how action plans would be used to drive improvements.
Checks on specific services

Services for children & young people

Requires improvement

Updated 4 November 2015

Services for Children and Young people require improvement. Caring was rated as good, safe, effective and responsive were rated as requires improvement, and well led as inadequate. The hospital had policies in place to ensure appropriately qualified staff cared for children in outpatients, operating theatres and on the ward. But there was no assurance that appropriately trained staff provided care for children at all times. Monitoring of skills by the hospital management team ensured medical staff were competent to practice.

Nurses were allocated to any children admitted for surgical procedures one of which was a registered children’s nurse (RN child) and others were adult nurses who were assessed for children’s competencies. These competencies were arranged and assessed locally, requiring little demonstration of competence in practical skills with caring for children.

There had been limited procedures undertaken for children aged between three and eight years, as a result a temporary decision has been taken by the hospital management since the inspection to only undertake surgical procedures for children aged eight years and above. The hospital was unable to demonstrate the basis for this decision within the governance and risk arrangements.

The hospital policy did not follow the Royal College of Nursing guidance around safe staffing for children. There was little contingency to cover for sickness or annual leave of the RN (child) creating a risk that surgery would be cancelled if she were unavailable. The RN (child) offered support to any member of staff and department around the care of children and staff found her to be always available.

Children benefitted from the standards of care and infection prevention activities afforded to adults in the hospital. There was little evidence of specific provision for care of children in the hospital and ward environment.

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. The hospital leadership meetings had no lead representation to advocate for the care of children at the time of our visit but a new lead was identified on our return in the week of 14th July 2015.

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.

The hospital was responsive when concerns were raised, by investigating situations and drawing up action plans.

Governance and leadership was designed for adults’ services with insufficient systems and processes in place specifically for children’s services.

Parents and children we spoke with felt informed and cared for by staff at the hospital.

Outpatients and diagnostic imaging

Good

Updated 4 November 2015

We found the outpatients and diagnostic imaging service at this hospital to be well run with safe practices.

Audit programmes were in place to monitor safety of care provided to patients. There were sufficient trained staff numbers for the needs of patients in the department. Patients were seen promptly and felt informed of any procedures and plans for their health care

There was a culture of learning and openness within both radiology and outpatients departments.

Patients were able to contribute their comments about their care and the facilities in the hospital.

Staff were able to contribute to their thoughts and ideas about the hospital environment and the care they deliver by attending regularly held forums. Diagnostic imaging had devised a survey for patients to feed back their thoughts about the service. The hospital had processes to ensure staff maintained their competencies in order to practice safely which included confirmation that consultants met the requirements for practising privileges.

Staff were aware of complaints and incident reporting procedures and were confident in their abilities to deal with any complaint. Apologies were offered to patients who complained and they were responded to in a timely way. They felt part of a team, proud to work at the hospital and able to instigate changes if a need was identified. Staff felt listened to and care for by the hospital and were positive about the appraisal process in supporting them professionally. They were able to access training to maintain and develop their skills

Surgery

Requires improvement

Updated 4 November 2015

The surgical services at Nuffield Health Plymouth were rated as outstanding for caring, good for effective and responsive and requires improvement for safe and well led, some areas of risk management and quality performance processes.

We saw evidence that patients were risk assessed to ensure only those who met strict eligibility criteria received treatment at the hospital. Records highlighted that risks were continually reviewed and actions were updated from pre-admission through to discharge. Staffing levels were sufficient to meet the needs of patients and there was good access to medical support at all times.

Treatment and care was provided in line with national guidance and there were processes in place to update policies and procedures. The service scored highly on national patient outcomes for knee and hip replacement surgery.

There was good flow throughout the department and patients’ needs were assessed and actions were delivered in a timely and effective manner. Patient feedback was overwhelmingly and consistently positive regarding care received. Staff was visibly committed to person-centred care, attentive to needs, reassuring, compassionate and professional. There were effective systems in place which enabled patients to be fully informed and included in all aspects of their treatment and care. Review of the five steps to safety checklists did not demonstrate robust evidence that safety processes were embedded to prevent further occurrence of wrong site surgery.

Outstanding care was provided to patients who consistently provided positive feedback. Staff were seen to be providing person-centred care, which was responsive, attentive, reassuring, compassionate and professional. Staff on the surgical ward cared for patients so they remained fully informed, included and supported in all aspects of their treatment and care at all times

There were governance processes and evidence of investigation of serious incidents and ongoing audits. There was evidence of investigation of serious incidents and audits were undertaken but there was a lack of detail and recording to demonstrate how some issues had been interrogated or how action plans would be used to drive improvements. All staff we spoke with enjoyed working at the hospital and were proud of the care they provided. Senior staff were reported to be visible and supportive. There was evidence staff were striving to make improvements through education and innovation.