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Nuffield Health Plymouth Hospital Requires improvement


Inspection carried out on 7 and 8 July 2015 (announced) and 15 July. (Unannounced).

During a routine inspection

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 carried out on 13 January 2014

During a routine inspection

This inspection took place on 13 January 2014 as part of our planned schedule of inspections. We spoke with eight people on the ward and out patients department who were receiving care and nine members of staff. We visited the out patients department, inpatients ward and theatre suite.

People using the service spoke very highly about the care and treatment they had received. One person said �From the tea lady to the consultant � everyone has been very friendly�. They described the staff as kind, caring and professional.They told us � They come when you call and always have a smile� and �It works like clockwork. There are so many nurses yet everyone knows what�s happening. They respond to the buzzer quickly. I have no complaints.�

People told us that they had been kept updated about their care and that at all times they had been asked for their consent before treatment had been provided. They told us they felt included in decisions about their care.

People using the service and staff told us they considered there to be sufficient levels of staff with the right skills. Training was ongoing to ensure staff remained aware of current good practice.

Medical and care records for each person were detailed and accurate and provided a clear audit trail of care provided. Storage systems were in place to ensure people�s confidentiality was maintained.

We found that there were appropriate arrangements in place to manage medicines.

Inspection carried out on 20 February 2013

During a routine inspection

We spoke with four people who had used the service and they all confirmed that they had been treated with respect and dignity. "You're a person, not a number here" one person said. One member of staff told us �It isn�t difficult, it�s about involving people and making sure they know what�s going on.�

We spoke with four people who had used the service and they all told us how their care and treatment had been delivered in line with their individual care plan. "I knew what was going to happen and why, and that's what's happened." one person told us.

We saw and heard about the arrangements which the hospital had made to address concerns that people who used the service had experienced abuse.

One member of staff told us �I know I�m responsible for making sure I�m up-to-date and I have an on-line record of all the training I�ve undertaken.� We were told that the newly-appointed Hospital Director was undergoing a period of induction, during which mentorship was provided by another experienced Hospital Director. One member of staff told us that this arrangement applied for all staff, on appointment.

"We set up a 'patient focus group' in March 2012." we were told. The Matron also showed us copies of an Integrated Governance report which she completed on a monthly basis. The focus group receive the same information that is provided in the report to the company. �It�s a good way of me keeping track of what�s going on within the hospital.� we were told.

Inspection carried out on 22 March 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that treatment for the termination of pregnancy was not commenced unless two certificated opinions from doctors had been obtained.

Reports under our old system of regulation (including those from before CQC was created)