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Nuffield Health Tees Hospital Outstanding


Inspection carried out on 7 to 8 February 2017

During an inspection looking at part of the service

Nuffield Health Tees Hospital is operated by Nuffied Health. We carried out an announced comprehensive inspection of the hospital on the 7th and 8th February 2017 as part of our national programme to inspect and rate all independent hospitals. We inspected the core services of surgical and outpatients services, as these incorporated the activity undertaken by the provider at this location.

Between October 2015 and September 2016, the service reported 7,060 day case or inpatient attendances. At the time of the inspection, the endoscopy service was not accredited by the Joint Advisory Group for Gastrointestinal Endoscopy (JAG). The outpatient department hosted specialities such as gastroenterology, general surgery, orthopaedic surgery and plastic surgery. Between October 2015 to September 2016, the hospital outpatient department recorded 15,978 total outpatient attendances. Of these, 8,209 were new appointments and 7,769 were follow-up appointments.

The hospital had 30 overnight beds but did not admit emergency patients. It provided some services for young people between the age of 16 and 18 years who had been risk assessed to ensure they could be nursed in an adult setting. Nuffield Health Tees Hospital had contract agreements with external providers for pathology, histopathology, blood transfusion, some diagnostic radiology and sterile services. The hospital was open 24 hours per day. However, outpatient and diagnostic appointments were available between 7.30am to 8.00pm Monday to Friday, with the additional capacity for Saturday working. Some diagnostic imaging services provided evening appointments on selected weeknights. Facilities included a pre-assessment area, two operating theatres and recovery area. There were outpatient clinic rooms, diagnostic imaging rooms and a physiotherapy gym for patients to use under staff supervision to assist rehabilitation. The majority of the work the hospital carried out was NHS (84%) compared to 16% funded by other means such as self-pay or medical insurance.

There were 29 registered nurses, 23 health care assistants or operating department practitioners and 61 other staff including radiographers and administrative staff. The hospital employed two resident medical officers (RMOs) and 112 consultants worked with practising privileges at this hospital. The senior leadership team comprises of the General Manager, Matron and Finance Manager. Experts from Nuffield Healthcare supported the hospital.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so, we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

During the inspection, we visited the pre assessment area, recovery bays, both theatres, three clinic rooms and waiting areas. We spoke with 54 staff including; registered nurses, health care assistants, reception staff, medical staff, pharmacy staff, operating department practitioners, and senior managers. We spoke with 22 patients. During our inspection, we reviewed 28 sets of patient records. We held focus groups with staff to allow them time to talk to inspectors and share their experiences of working in Nuffield Health Tees Hospital. We also interviewed the members of the management team and the chair of the Medical Advisory Committee (MAC). We reviewed all complaints from 2016/17. We reviewed 10 practising privileges consultant personnel files. Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

There were no breaches of regulations, however there were areas where the provider should:

  • Ensure that all ward based stock items are in date in the store room and resuscitation trolley and subject to stock rotation (using the oldest first).
  • Ensure all corporate policies and guidelines on the hospital intranet are in date.
  • Ensure all corporate policies which are being reviewed have a nominated lead and timescale for completion.
  • Ensure that a long term solution to the theatre sterilising machine is in place as soon as possible.

Services we rate

We rated this hospital as Outstanding overall.

We rated it good for being safe and effective and outstanding for being caring, responsive and well led. This was because:

  • Referral to treatment times were consistently good for both privately funded and NHS patients. Managers monitored waiting times for appointments, treatment and cancellations to ensure that waiting time targets were met. Service complaints were low and staff responded to these in a timely manner.
  • All patients we spoke with told us they were treated courteously and respectfully and their privacy and dignity was maintained. The organisation had a strong patient focussed culture and this was clearly visible in the way that staff spoke with and supported patients.
  • Staff recognised the need to approach patient treatment and care from a holistic perspective. The whole surgical pathway was integrated and coordinated to maximise benefit for the patient. There were examples where staff had gone the extra mile to ensure this. Feedback from patients using the service was consistently very positive.
  • The leadership, governance and culture within the service were excellent. There was a vision and strategy that all staff adhered to closely. Governance arrangements were robust.
  • Staff were proud to work for the organisation and staff morale was high. Managers at all levels were visible, approachable and available at all times to all staff regardless of discipline. Staff satisfaction survey results were good.
  • Patient care and treatment was planned and delivered in line with current evidence based guidance, standards and best practice recommendations. Outcomes for patients were good. Patients confirmed pain relief and nutritional standards met their needs.
  • Staff reported incidents and there were robust incident reporting systems in place. We saw incidents were fully investigated and lessons learnt were shared with all staff across the hospital.
  • Infection prevention and control practices were good, and departments were clean and well equipped. Record keeping, including risk assessments and safety checks were very good and policies for medicines management followed recognised guidelines.
  • Staffing levels were planned and monitored to keep patients safe at all times. Staffing levels across departments were good. There were good processes in place to monitor signs of deteriorating health and respond to medical emergencies. Overall, mandatory training figures were very good and attendance was well managed. Staff had an awareness of safeguarding procedures and where to refer for additional support and guidance.
  • Staff received annual appraisals and were supported with revalidation and worked together proactively to ensure best care and treatment was delivered to patients. Consent to care and treatment processes were good and patients were able to make informed decisions.
  • The service made reasonable adjustments to support vulnerable patient groups and was working towards becoming a more dementia friendly service.

There were no breaches of regulations, however there were areas where the provider should:

  • Ensure that all ward based stock items are in date in the store room and resuscitation trolley and subject to stock rotation (using the oldest first).
  • Ensure all corporate policies and guidelines on the hospital intranet are in date.
  • Ensure all corporate policies which are being reviewed have a nominated lead and timescale for completion.
  • Ensure that a long term solution for the theatre sterilising machinery breakdowns is in place as soon as possible.

We found good practice in relation to outpatient care:

  • There were audits of clinical practice undertaken regularly.
  • Ionising Radiation (Medical Exposure) Regulations 2000 IR(ME)R audits were undertaken in line with regulatory requirements. Results indicated the service performance was in line with national standards.
  • Staff informed patients about their care and treatment, and spent time with patients to discuss concerns and answer questions.
  • Staff gave patients appropriate support and information to cope emotionally with their care, treatment or condition.
  • Staff made adjustments to accommodate patients’ individual needs, for example, patients with dementia, learning disabilities physical disabilities or for those whose first language was not English.
  • Patients were able to be seen quickly for urgent appointments, if required and clinics were only rarely cancelled at short notice.
  • There was an open and supportive culture where incidents and complaints were reported, lessons learned and practice changed.
  • The department supported staff who wanted to learn, be innovative, and try new services and treatments.
  • The hospital engaged with staff and there was an annual Leadership MOT carried out.
  • The service managed staffing effectively and services always had enough staff with the appropriate skills, experience and training to keep patients safe and to meet their care needs.

We found areas of outstanding practice in surgery:

  • Staff worked especially hard to make the patient experience as pleasant as possible. Staff recognised and responded to the holistic needs of their patients from the first referral before admission to checks on their wellbeing after they were discharged from the hospital.
  • The hospital had a fully integrated and coordinated pathway for surgical patients that spanned outpatients, diagnostic imaging, preparation for surgery, pharmacy, surgery, post-surgery therapy and follow up appointments.
  • Patients were prescribed take out medication prior to surgery to ensure that discharge was not delayed due to waiting for medication.

Services we do not rate

We regulate cosmetic surgery services but we do not currently have a legal duty to rate them when they are provided as a single specialty service. We highlight good practice and issues that service providers need to improve and take regulatory action as necessary.

Following this inspection, we told the provider that it should make some improvements, even though a regulation had not been breached, to help the service improve. We did not issue the provider with any requirement notices.

Professor Ted Baker

Chief Inspector of Hospitals

Inspection carried out on 11-12 November 2014 and 19 November 2014

During a routine inspection

The Nuffield Health Tees Hospital is part of the Nuffield Health Group which operates as a non-profit organisation. It primarily serves the communities of Stockton on Tees, Middlesbrough and Darlington and accepts patient referrals outside of the catchment area. The hospital has 30 patient bedrooms configured into one ward which is used for either day cases or in patients. It provides acute surgical care for adults, diagnostic services, outpatient facilities and physiotherapy. Referrals are received from self-funding patients, patients with medical insurance and NHS patients via Choose and Book. Referrals for all available imaging modalities are accepted in accordance with statutory regulations from medical referrers and some locally registered non-medical referrers. Patients may self-refer for Breast Screening Mammography (Asymptomatic only). NHS patients account for 60% of the total patient mix.

There are 205 staff and 135 consultants working at the hospital. The senior leadership team comprises a Hospital Director, Matron and Finance Manager. The hospital is supported by experts within the Nuffield Hospital Division Group and externally from local NHS providers.

We inspected the hospital from 11 to 12 November 2014 and undertook an unannounced inspection on 19 November 2014. We inspected this hospital as part of our first wave independent hospital inspection programme. The inspection was conducted using the Care Quality Commissions new inspection methodology.

Overall the care and treatment patients received at Nuffield Health Tees Hospital were safe, effective, caring, responsive and well-led.

Our key findings were as follows:

  • Medical and nurse staffing levels were adequate on the ward, theatres, outpatients and diagnostic services. Staffing establishments and skill mix were reviewed regularly and levels increased to meet patient needs where required.
  • Arrangements were in place to manage and monitor the prevention and control of infection, with a dedicated team to support staff and ensure policies and procedures were implemented. We found that all areas we visited were clean. There were no hospital acquired infections during 2013/14.
  • There were no unexpected patient deaths during 2013/14.
  • Processes were in place to ensure patients nutrition and hydration was effectively managed prior to and following surgery. Where required access to dietician input was available. Patients gave positive feedback about the choice and quality of food they received
  • There was sufficient equipment to ensure staff could carry out their duties. Processes were in place for monitoring and maintaining equipment.
  • Records were well maintained and documents were completed to a good standard including completion of patient risk assessments.
  • Staff understood their responsibilities to raise concerns and record patient safety incidents and near misses. There was evidence of a culture of learning and service improvement.
  • Medicine management arrangements were in place. Medicines were stored securely and staff were competent to administer medicines.
  • There were systems for the effective management of staff which included an annual appraisal. All doctors were appropriately vetted to ensure they had the skills to undertake surgical procedures.
  • The hospital undertook a programme of local clinical audits depending on risk assessments. These covered a range of areas including infection prevention and control, medicines management and audits of pathology, radiology and clinical services.
  • Senior and departmental leadership at the hospital was good. Leaders were aware of their responsibilities to promote patient and staff safety and wellbeing. Leaders were visible and there was a culture which encouraged candour, openness and honesty.
  • Integrated governance arrangements enabled the effective identification and monitoring of risks and action was taken to improve performance. Progress on achieving improvements were reported and measured through the relevant management boards with oversight and scrutiny from the provider’s quality governance committees with ultimate responsibility resting with the group chief executive and board.

In addition to the above, we saw areas of good practice:

  • Physiotherapists were trialling a new exercise group for patients with back pain and had introduced pre-operative group sessions for patients undergoing joint replacements with an aim to help patients achieve realistic expectations of post-operative therapy and recovery.
  • Additional nurse-led pre-assessment clinics had been introduced to enable patient’s sufficient time to be assessed and reduce delays in surgery.
  • Patients undergoing cataract surgery received staggered appointment times to reduce patients fasting pre-operatively for long periods.
  • Flexibility was offered around outpatient appointments and aligned to other investigations for example; phlebotomy appointments were offered to coincide with a visit to x-ray.
  • The governance structures enabled national learning from other hospitals in the Nuffield Health Group. This had led to changes to improve practice in areas such as ophthalmology.
  • Staff had access to an Employee Assistance Programme which provided a variety of services for employee wellbeing and performance.

However, there were some very limited areas of poor practice where the provider needs to make improvements:

The hospital should :

  • Ensure all staff follow the hospital’s infection prevention and control policies and procedures particularly ‘bare below the elbows’ policy and the wearing of personal protective equipment.
  • Ensure staff receive training and are aware of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards and apply these in practice where appropriate.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 27 December 2013

During a routine inspection

We spoke with staff on duty. It was quiet day, which meant we met with one patient and three visitors. We also reviewed the information the hospital gathered from patients about their experience of the service. We found that the hospital treat around 550 patients per month, with 60% of patients using the service through the NHS choose and book facility. The surgical procedures completed are elective. Pre-admission discussion occurred before the patient was accepted for treatment at the hospital. The patient who was using the service at the time of the inspection told us that they were extremely satisfied with the care and treatment provided at hospital.

We reviewed comments from the telephone calls staff made to patients following every treatment. All of the comments were very positive. Comments included, �The staff here are great�, �The care was fantastic� and �I was extremely satisfied with service�. We found that 98% of patients were satisfied with their care and minimal complaints are made .

We saw there were on-going assessments and operations were performed in a safe and effective manner. We found that the hospital staff provided the patient�s GP with information about the patient�s care and treatment.

We found that staff were recruited appropriately and regular checks were completed to make sure their medical and nursing registrations remained current. We also found that there were sufficient staff on duty in the hospital to meet patient�s needs.

Inspection carried out on 12 February 2013

During a routine inspection

People who used the service said they were happy with their care, treatment and support. They said they were well looked after. People said they understood their care and support and that staff had explained things well to them.

During this visit, we spoke with three people who used the service. People we spoke with told us they were happy with the care they received and they were well looked after. One person said, �Had no problems � can�t fault the care�. Another said the �The physiotherapist comes to see me twice a day�. They said their experience had been good.

People were given appropriate information and support regarding their care or treatment.

People were protected from the risk of infection because appropriate guidance had been followed. People were cared for in a clean, hygienic environment.

People were given support by the provider to make a comment or complaint where they needed assistance.