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Chartwell Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 7 October 2016

Inspection areas

Safe

Requires improvement

Updated 7 October 2016

  • There was a lack of incident reporting and systems and processes to support incident reporting were not robust.
  • Medicines management training was not provided by the service. Fridge temperatures in radiology were not regularly recorded. No regular medicines audits were undertaken.
  • The service did not use a formal early warning score system to monitor and observe patients following procedures for signs of deteriorating clinical condition.
  • Resuscitation equipment was not checked regularly. However, during our unannounced inspection we found that the equipment had been regularly checked since our first visit.
  • During our announced inspection, people’s healthcare records were not stored securely and were kept in a public waiting area. However, during our unannounced inspection we found that these records had been moved and were now secure.
  • Documentation within patients’ healthcare records was clear, accurate and legible.
  • Compliance with mandatory training was exceptionally good.
  • There was a sufficient number of suitably qualified staff on duty at all times.
  • Medicines were stored, prescribed and administered safely.
  • Infection control was practised in line with the hospital policy, which reflected best practice.

Effective

Not sufficient evidence to rate

Updated 7 October 2016

  • Local policies, procedures and care pathways had not been reviewed regularly and were not up-to-date.
  • There was an audit programme which had been developed recently and consisted of 36 audits. However, the majority of audits had not been undertaken and the programme was in its infancy.
  • Pain was assessed and managed appropriately.
  • People’s nutrition and hydration needs were monitored and there were appropriate food and drink facilities available.
  • Multi-disciplinary team working within the hospital and externally was very good.
  • Appraisal rates were excellent and staff had appropriate skills necessary to carry out their roles effectively.
  • Hospital opening hours offered good access and flexible appointment times including evening and weekends.
  • Staff told us that they could access patient healthcare records in a timely way prior to appointments.
  • Training for mental capacity and Deprivation of Liberty Safeguards was provided to staff during mandatory training. Compliance with training was good.

Caring

Good

Updated 7 October 2016

  • People who used the service were treated with kindness, dignity, respect and compassion. Patient feedback was consistently positive.
  • Staff ensured that people received relevant information to ensure that informed decisions were made and that people were involved as partners in their care.
  • The hospital provided relevant support to people who used the service to cope emotionally with their care, treatment or condition.

Responsive

Good

Updated 7 October 2016

  • Services were planned and delivered to meet the needs of people who used the service. This included flexible hospital opening times dependent on service demand which demonstrated outstanding practice.
  • Each area of the hospital had an environment that was appropriate and patient centred.
  • People could access care and treatment in a timely way. Referral to treatment times (RTT) were outstanding with all patients receiving initial consultation or treatment within seven to 10 days.
  • The flow of services within the hospital was seamless and people could access next day appointments if their referral was urgent.
  • Care and treatment was tailored to meet the needs of different people. Interpreters were available as required, and there was extensive patient literature available in a variety of formats including video clips on the hospital website which were impressive.
  • There was an effective complaints system in place with which staff were familiar. People’s concerns and complaints were listened and responded to and used to improve service quality.

Well-led

Requires improvement

Updated 7 October 2016

  • The hospital’s governance framework did not ensure that quality performance and risks were understood and managed effectively. This was in in relation to a weak incident reporting system and a lack of quality measures in place.
  • There was a lack of comprehensive assurance system and service performance measures, which were reported and monitored. For example, hospital managers confirmed that an indicator dashboard to measure service quality was not in use.
  • There was a clear service vision and strategy, which staff knew and adhered to.
  • The hospital held regular hospital-wide meetings, which were well attended and minuted. Information from these meetings was disseminated to all staff.
  • The culture of the service was immensely positive and staff felt valued, respected and well supported by their seniors.
  • Patients and staff were encouraged to engage with the service through meetings and feedback forms.
  • Where we raised concerns, hospital managers took appropriate action promptly and resolved the issue. This included ensuring that patient records were stored securely.
Checks on specific services

Outpatients and diagnostic imaging

Requires improvement

Updated 7 October 2016

We rated the service as requires improvement overall. Safe and well led was rated as requires improvement with caring, responsive and well-led being rated as good. Effective was inspected but not rated.

There was a lack of incident reporting and systems and processes to support incident reporting were not robust. Medicines management training was not provided by the service. Fridge temperatures in radiology were not regularly recorded. No regular medicines audits were undertaken. The service did not use a formal early warning score system to monitor and observe patients following procedures for signs of deteriorating clinical condition. The hospital’s governance framework did not ensure that quality performance and risks were understood and managed effectively. This was in in relation to a weak incident reporting system, a lack of quality measures in place and minimal local audits being carried out. Local policies, procedures and care pathways had not been reviewed regularly and were not up-to-date. Staff had not received training in learning disability or dementia, despite patients with these conditions receiving treatment at the service.

However, we also found that there was a sufficient number of suitably qualified staff on duty at all times, and compliance with mandatory training was excellent. Medicines were stored, prescribed and administered safely. Infection control procedures reflected national best practice. Pain was assessed and managed appropriately. Multidisciplinary team working within the hospital and externally demonstrated outstanding practice. Appraisal rates were excellent and staff had appropriate skills necessary to carry out their role effectively.  People who used the service were treated with kindness, dignity, respect and compassion. Patient feedback was consistently positive and people were involved as partners in their care. Flexible hospital opening times dependent on service demand demonstrated outstanding practice. Referral to treatment times (RTT) were outstanding with all patients receiving initial consultation or treatment within seven to 10 days. Complaints were minimal and handled effectively and used to improve service quality where necessary. There was a clear service vision and strategy, which staff knew. The culture of the service was immensely positive and staff felt valued, engaged with the service and well supported. Where we raised concerns, hospital managers took appropriate action promptly to resolve the issues. This included ensuring that patient records were stored securely.