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The Princess Grace Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 30 May 2018

The Princess Grace Hospital is operated by HCA International. The hospital has 126 beds. Facilities include eight operating theatres, outpatient and diagnostic facilities.

The hospital provides surgery, medical care, urgent care, outpatients and diagnostic imaging. We inspected surgery, urgent care centre and outpatients and diagnostic imaging.

The CQC had received information raising concerns about the outpatients and diagnostic imaging service during the 12 months before this inspection, which led to the decision to plan this inspection. The concerns were around staffing issues, imaging request procedures and culture. The hospital has been inspected twice previously, and the most recent inspection took place in August 2016.

We inspected Urgent Care, Surgery and Outpatients and Diagnostic Imaging using our focussed inspection methodology. We carried an unannounced visit to the hospital on 6 and 7 February 2018.

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.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

Services we rate

We rated Urgent Care, Surgery and Outpatients and Diagnostic Imaging as ‘good’ overall.

The ratings of the Urgent Care and Surgery core services improved from requires improvement to good since our last inspection.

The rating for Outpatients and Diagnostic Imaging core service was good, which was the same as the last inspection. Concerns raised with the CQC about this service were found to have been dealt with by the provider or could not be substantiated during inspection, except for a few individual staff members expressing worries about the culture in the hospital.

We found good practice in relation to urgent care, surgery and outpatients and diagnostic imaging:

  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.

  • The service controlled infection risk well. Staff kept equipment and the premises clean. They used control measures to prevent the spread of infection.

  • 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.

  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance. The service monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn and improve.

  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.

  • People could access the service when they needed it and there were no waiting lists. Waiting times for consultations, treatments and diagnostic services were minimal.

  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff.

  • Leaders were committed to improving services and had implemented positive changes since the previous inspection.

  • There was a realistic strategy for achieving the priorities and developing good quality and sustainable care. The hospital had effective structures, systems and processes in place to support the delivery of its strategy including a sound governance system.

  • Patients had opportunities to give feedback on the service they received in a manner that reflected their individual needs.

We found areas of outstanding practice in outpatient care :

  • A patient navigator role was implemented in the breast institute, the role is designed to ensure the patient pathway is fully completed and continued after the patient leaves the department. The navigator calls the patient at home to organise any further care if needed and this has ensured that patients are followed up appropriately and that no patient is missed.

We found areas of practice that require improvement in urgent care:

  • The electronic systems did not always work well together in the urgent care centre to allow staff access to all necessary information at all times.

  • Patients’ privacy was not always ensured.

We found areas of practice that require improvement in surgery:

  • Assessments for risk of venous thromboembolism were not always completed correctly.

  • Possible risks of cross contamination in theatres were not always kept at a minimum.

We found areas of practice that require improvement in outpatient care:

  • Out of the 24 staff we spoke with the majority of staff spoke positively regarding the working culture, however four members of staff told us they felt there was a culture of bullying.

Amanda Stanford

Deputy Chief Inspector of Hospitals (London)

Inspection areas

Safe

Requires improvement

Updated 30 May 2018

Effective

Good

Updated 30 May 2018

Caring

Good

Updated 30 May 2018

Responsive

Good

Updated 30 May 2018

Well-led

Requires improvement

Updated 30 May 2018

Checks on specific services

Urgent care centre

Good

Updated 30 May 2018

The urgent care centre provides urgent care for adult patients without appointment and is open daily.

We rated this service as good because it was safe, effective, caring, responsive and well-led.

Medical care (including older people’s care)

Good

Updated 23 March 2017

The infrastructure for medical services had been progressively developed to enable the delivery of safe and effective for patients. This included the identification of risks at a service and individual patient level, and taking steps to limit the number of patients on the ward when challenges in achieving appropriate staffing levels occurred. There was access to specialist services when patients deteriorated. Sufficient staff, with the appropriate level of knowledge and skills for their job role, were available and they had access to appraisal and support.

Staff were kind and compassionate and patients felt involved in their care and treatment. Psychological support was available for patients to help them cope emotionally with their diagnosis and treatment.

Patients had timely access to care and treatment and investigative and diagnostic services were available seven days a week when required.

There was good access to interpreting and translation services for patients for whom English was not their first language.

There was effective leadership at all levels of medical care services and staff felt supported, valued and engaged. Medical care services had been progressively developed and steps taken to ensure the safety and quality of services when challenges occurred. The consultant team for oncology brought significant expertise and were actively engaged in research and development.

The requirements of vulnerable patient groups were not always fully recognised and met. For example, the requirements of the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards were inconsistently applied and the needs of people living with dementia were not fully explored and addressed.

Audits to assess the outcomes of care and treatment and benchmark them with other services needed further development.

Care records did not always meet professional standards for documentation and some lacked the detail necessary to provide personalised and effective care for patients.

End of Life Care (EoLC) services required further development and documentation of discussions with patients and decision making in relation to palliative care required improvement.

Critical care

Good

Updated 23 March 2017

Staffing in the unit was compliant with Intensive Care Society (ICS) guidance, with appropriate numbers of suitably qualified and registered staff. Nurse to patient and doctor to patient ratios were consistently in line with this guidance.

An experienced team of consultants and nurses delivered care and treatment based on a range of best practice guidance. Suitably qualified nursing staff cared for patients. Medical staff were supported by consultants.

There was good access to seven-day services and the unit had input from a multidisciplinary team

The unit had fewer readmissions within 48 hours of discharges, compared to other similar units.

The critical care unit provided a caring, kind, and compassionate service, which involved patients and their relatives in their care. All the feedback from patients and their relatives we spoke with was positive.

Observations of care showed staff maintained patients’ privacy and dignity and patients and their families were involved in their care.

ICNARC (Intensive Care National Audit and Research Centre) data for April 2015 to March 2016 showed that the unit performed better than similar units in many quality indicators.

The complaints process was effective, with appropriate investigations and there was culture of learning from complaints across the board.

There were good governance structures within the hospital and linked with critical care unit.

We saw good local leadership within the unit and staff reflected this in their conversations with us. Staff said the culture on the unit was supportive and any member of staff could approach the leadership team with any issues or new ideas.

The management team had oversight of the risks within the services and mitigating plans were in place.

Although learning from incidents was shared with all staff via learning grids, not all staff were able to give us an example of any changes in the unit due to an incident. This indicated that learning from incidents could be improved among  staff members.  

The storage area where unit waste was collected before disposal was not kept locked and did not comply with the Department of Health 2011 Safe Management of Waste guidelines.

There were no regular joint MDTs within the unit. The unit had put a plan in place to introduce this initiative.

The dietitian told us that they only visit when CCU staff referred patients. Although this was in line with the hospital policy but there were plans to start daily visits to the unit in line with the HCA (provider) standards.

There was poor compliance with DNACPR policy, but action plan was in place to improve compliance.

The unit did not meet all the standards of Intensive Care Society related to screening patients for delirium. Staff were developing a policy to meet this standard.

The relatives we spoke with were not aware of how to make a complaint but they said that they don’t need any information leaflet regarding this as they were happy with the care received and staff were always there to resolve any concerns.

There was no quiet or prayer room facilities for relatives.

Outpatients and diagnostic imaging

Good

Updated 30 May 2018

Outpatients and diagnostic imaging services includes all areas where patients undergo diagnostic testing, receive diagnostic test results, are given advice or provided care and treatment without being admitted as an inpatient.

We rated this service as good because it was safe, effective, caring, responsive and well-led.

Surgery

Good

Updated 30 May 2018

Surgery was the main activity of the hospital. Where our findings on surgery also apply to other services, we do not repeat the information but cross-refer to the surgery section.

We rated this service as good because it was safe, effective, caring, responsive and well-led.