Claremont Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We rated Safe as Good. The environment was clean, and equipment was well maintained and was safe for use. Staff were trained to use equipment.

Medicines and medical gases were managed and stored correctly.

Staff had received safeguarding training and staff we spoke to knew how to raise concerns and those we spoke to knew who the freedom to speak up guardian was.

Staff described a culture where they could raise concerns, and they learnt lessons from incidents.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive learning culture. Incidents were tracked through the governance meetings and shared through the heads of department meeting and then discussed with staff at team meetings. The organisation had Flash reports to share learning from incidents and safety concerns across the Spire group. The daily hospital huddle provided a forum to cascade information to team members who then shared it at departmental handover.

Whilst on site there was a near miss, no harm had come to the patient, the team responded promptly and held a Swarm meeting. All departments who were involved in the patient pathway joined together to identify how it had happened and to implement learning to prevent it happening in the future.

For our detailed findings on incidents and duty of candour see the learning culture section in the surgery report.

The hospital had a policy in place which outlined the admission criteria. Staff discussed patients with changing health needs at weekly multidisciplinary meetings to determine if they were suitable for treatment. The referral to treatment team prioritised patients who had waited longest, and patients had choices about the date and time of their appointments.

The service worked with the local NHS provider and Integrated Care Board to optimise the service they could provide for patients in the local area.

Staff worked together to ensure that patients had everything in place for their treatment to avoid delays or cancellations to their surgery. The service had 3 consultant anaesthetists, who worked with the preoperative assessment team to provide guidance to the nursing team and review patients to ensure they were fit for surgery. The morning hospital huddle enabled the team to raise any concerns and actions needed to mitigate them.

Staff kept people safe. The service had safeguarding policies in place. Staff we spoke with were able to outline the safeguarding process. Safeguarding leads and flowcharts were displayed in the clinical areas for both staff and the public to see. All outpatient and physiotherapy staff had completed the appropriate levels of safeguarding training.

For our detailed findings on how the hospital managed safeguarding see the safeguarding section in the surgery report.

The service had a clear pre-operative surgical risk assessment which they followed to ensure that they cared for patients whose risks they could manage. The preoperative assessment covered both physical and psychological needs of the patient prior to admission.

A patient passport was in place which enabled staff to provide appropriate care for people with autism and learning disabilities. Staff had undertaken mandatory training about autism and learning disabilities.

The service assessed patients for risks relevant to their condition and treatment. Assessments included a patient’s risk of venous thromboembolism (VTE), pressure ulcers, falls, and the risks associated with a patient’s other health conditions or medicines they took for them. These were discussed at the preoperative clinic. Patients gave positive feedback on the information they received.

The outpatient department was visibly clean and tidy. Equipment was tagged to indicate it was clean. Equipment was serviced and dates displayed on it. Staff told us that all items of equipment were readily available and any faulty equipment was repaired or replaced in a timely manner. We observed documents that showed the service recorded and monitored when equipment had been serviced and repaired. The service provided evidence of staff training in the use of clinical equipment and non-clinical equipment.

We heard how they had fedback to service leads some concerns regarding the doors to the main entrance, in that they were unable to communicate with people at the door out of hours or open or close the doors from the ward. As a result, they had installed a new intercom system, and the new doors were being installed on the days of our on-site assessment. The service had also taken actions to reduce the impact of limited parking onsite. Staff were able to use a nearby car park with a short walk and there were plans to extend the car park on site.

All the equipment we saw (such as patient couches and blood pressure monitoring machines) were clean, well maintained and had service stickers displayed showing they were within the service, calibration and electrical safety test due dates.

Staff told us they had the equipment they needed within the department to deliver care. The department displayed the cleanliness audit report in the public area.

Emergency equipment was checked in line with the policy and documented.

The service had a management plan in place for the prevention and management of unplanned and emergency situations. We saw that there was good supply of oxygen which was appropriately stored and utilised.

There were arrangements in place for the handling, storage, and disposal of clinical waste, including sharps. The service complied fully with the Control of Substances Hazardous to Health (COSHH) practices.

The risk register identified where improvements were required in the physiotherapy department whereby an office had been turned into a clinic room and there was mitigation in place for hand washing facilities. The department was due to have refurbishment over the next year.

The service ensured there were enough qualified, skilled, and experienced staff to meet the needs of patients visiting the department. We checked a sample of staff files and required recruitment checks were complete. The outpatient’s and physiotherapy department were fully staffed and currently they had no vacancies. Staffing levels were visible for patients to see. The daily huddle checked there were enough staff, and they flexed staff to support other areas where required.

Consultants worked at the hospital under the terms of the hospital’s practising privileges policy. The service had processes in place to check consultants met the terms of this policy and had completed relevant training. This was overseen by the Medical Advisory Committee (MAC). Consultants were available on-site during clinic hours. The hospital also had resident doctors (RD) available on site 24 hours a day. The RDs were up to date with Advanced Life Support training and all other staff were up to date with their appropriate level of life support training.

Staff told us how they had opportunities for development, and we heard how staff had been supported to complete further training to deliver better care. The physiotherapy service manager had developed their skills into the arthroplasty role which had enable them to deliver post operative clinics.

Training records showed staff completed mandatory training and clinical competencies. Managers monitored compliance and there was a schedule of training in place.

The service managed the risks of infection, there was a comprehensive infection control audit programme. The outpatient’s manager and housekeeping lead undertook monthly departmental audits and results were on display in the department. Audit champions cascaded the findings and any actions at team meetings.

The environment was visibly clean and tidy and staff were seen to be bare below the elbow. We observed staff washing and sanitising their hands, there were handwashing facilities in the clinic rooms and equipment was clean, items were tagged as clean and dated. There was enough personal protective equipment (PPE) for all staff and clinical waste was disposed of appropriately according to the policy.

All staff in outpatients and physiotherapy had completed infection control training. Staff had access to advice from an infection prevention and control (IPC) lead at all times.

Emergency resuscitation trolleys were checked daily and were in date and sealed. Pharmacy also held a list of items which were due to expire in emergency trolleys, to guarantee they would be available before the current drugs expired.

Temperatures were recorded daily in areas where medicines were stored.

Prescription stationery was securely managed by the outpatient’s manager and records kept for monitoring.