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The Princess Grace Hospital Requires improvement

Reports


Inspection carried out on 6 and 7 February 2018

During an inspection to make sure that the improvements required had been made

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 carried out on 31 August, 1, 2, 14 September 2016

During a routine inspection

The Princess Grace Hospital is a 126 bedded private hospital and part of HCA Healthcare UK, who also provide care at five other hospitals in London.

The hospital undertakes a range of surgical procedures and provides medical and critical care for adults. The hospital also provides services for private patients through the outpatients department and the Urgent Care Centre. The Princess Grace Hospital therefore provides five of the eight core services that are inspected by the Care Quality Commission as part of its new approach to hospital inspection.

We inspected the hospital as part of our planned inspection programme, visiting on 31 August, 1 and 2 September 2016, followed by an unannounced visit on 14 September 2016.

Overall, we have rated the Princess Grace Hospital as ‘requires improvement’.

Our key findings were as follows:

Are services safe at this hospital?

By safe, we mean people are protected from abuse and avoidable harm.

Overall, we rated safe as 'required improvement'.

  • Infection Prevention and Control (IPC) did not always reflect current evidence-based guidance, hospital policy and best practice. We observed that best practice guidelines were not always implemented in practice and observed that hospital policies were not always followed.

  • We observed staff washed their hands between seeing patients but staff did not always adhere to the “bare below the elbows” requirement for the prevention and control of infection.

  • We had concerns about the lack of a formal system to prioritise patients by acuity or severity of their condition during the triage process in the Urgent Care Centre. Staff did not follow the hospital’s policy to use National Early Warning Score (NEWS) system to monitor and detect deterioration in patients.

  • Throughout the surgery departments, basic life support training (BLS) was poorly attended when compared to other mandatory training topics. In theatres, only 50% of staff had attended this training.

  • The UCC did not have sufficient numbers of nursing or medical staff trained to to level 3 in safeguarding children in line with the intercollegiate guidance for clinical staff working with children, young people (including people aged 16-18 years old) and/or their parents/ carers and who could potentially contribute to assessing, planning, intervening and evaluating the needs of a child or young person.

  • Incidents were discussed at monthly divisional governance meetings and information and lessons learnt were shared with staff and staff were encouraged to report incidents. 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 due to an incident. This indicated that learning from incident was not widely spread. Incident reporting in some areas such as theatres was low.

  • Records were not consistently kept up to date and we saw documentation that did not meet GMC standards. We saw and nurses told us that consultants did not always document in the patients notes when they reviewed patients. Nursing care plans did not always continue all the necessary information required to provide personalised care to patients.

  • The storage room on ITU 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.

  • Medicines were stored appropriately and were managed safely although medicine administration did not always follow best practice guidelines on the surgical wards. We saw drug omissions were not always recorded and we saw staff administrating medication without checking the patients name and date of birth.

  • Flooring in most outpatient clinic rooms did not meet national standards, but we were shown an action plan to resolve the situation by March 2017.

  • All equipment was safety tested and maintenance contracts were in place to make sure specialist equipment was serviced regularly.

  • Staff were clear about their responsibilities to report adult safeguarding concerns.

  • Staffing levels and skill mix was planned, implemented and reviewed to keep people safe at all times. Staff shortages were responded to quickly. 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.

  • The wards had clear systems to manage a deteriorating patient and patient risks were appropriately identified and acted upon.

  • Plans and arrangements were in place to respond to emergency situations.

Are services effective at this hospital?

By effective, we mean that people’s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence.

Overall, we rated effective as 'good'.

  • Patients received coordinated care from a range of different teams. An experienced team of consultants and nurses delivered care and treatment in line with current evidence-based guidance, standards, best practice and legislation.

  • Staff were supported by managers, mentors and practice development nurses to deliver effective care and treatment, through meaningful and timely supervision and appraisal. Medical staff received regular training as well as support from consultants.

  • The hospital had a process for checking competency and granting and reviewing practicing privileges for consultants. The medical advisory committee (MAC) reviewed patient outcomes and the renewal of practicing privileges of individual consultants. It also reviewed policies and guidance and advised on effective care and treatments.

  • There was participation in relevant local and national audits where appropriate. Accurate and up-to-date information about outcomes was shared internally amongst staff. Although in the medical departments, audits to assess clinical outcomes and benchmark them with other services were not well developed.

  • Patients had good access to seven-day services and the unit had input from a multidisciplinary team.

  • Staff at all levels had a good understanding of the need for consent.

  • The urgent care centre (UCC) offered access to on-site diagnostics and imaging services.

  • Intensive Care National Audit Research Centre (ICNARC) data for the period, April 2015 to March 2016 showed no cases of unit-acquired infections in the blood. This was better than similar units. The unit did not meet all the standards of Intensive Care Society related to screening patients for delirium. There was no regular joint multidisciplinary team (MDT) meeting. The unit had put plans in place to improve both issues.

  • We had concerns about the combined use of electronic and paper based records which resulted in difficulties in obtaining a full contemporaneous picture of the patients’ health care information. Documentation such as fluid charts were not consistently completed.

  • Pain was assessed using different scoring systems. Patient feedback and audits demonstrated post-operative pain was not always effectively managed. Pain relief scores were not always documented in patient notes in the UCC. On the medical ward, systems to monitor and manage patients’ pain were not always effective.

  • The dietitian told us that they only visit when critical care 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 Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) policy in critical care, but an action plan was in place to improve compliance.

  • The requirements of the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards were not well understood and applied. No doctors in the UCC received mental capacity act training.

  • An End of Life care plan had only recently been introduced and was not fully embedded in practice.

Are services caring at this hospital?

By caring, we mean that staff involve and treat patients with compassion, dignity and respect.

Overall, we rated caring as 'good'.

  • During the inspection, we saw that staff were caring, sensitive to the needs of patients, and compassionate. Staff maintained patients’ dignity and respect at all times.

  • Patients commented positively about the care provided by all staff and said they were treated courteously and respectfully.

  • Patients told us they had sufficient information about their treatment and were involved in making decisions about their care.

  • Staff supported patients emotionally with their care and treatment as needed. In addition, a psychologist attended the oncology ward regularly and offered support.

  • We found an absence of documentation of discussions with patients about their prognosis and discussions about their options in relation to their care and treatment when they had a poor prognosis.

  • There was no formal feedback recorded for patients attending the Urgent Care Centre.

Are services responsive at this hospital/service?

By responsive we mean that services are organised so they meet people’s needs.

Overall, we rated responsive as 'good'.

  • Services were planned and delivered in way that met the needs of the local population. Patients were able to access care and treatment in a timely way and action was taken to minimise the time patients had to wait for investigations. We observed that there was good access to appointments and there were minimal waiting times for outpatient clinics and diagnostic imaging. Patients we spoke with confirmed this. Diagnostic appointment slots were available on the same day.

  • Facilities and premises were appropriate for the services being delivered. Waiting areas were furnished to a high standard, provided free refreshments and were well stocked in the latest newspapers and magazines.

  • Patients had access to services that met their individual needs including interpreting services for patients that did not speak English.

  • There was an effective complaints process, with evidence of appropriate investigations and there was culture of learning from complaints across all areas. Formal complaints were rare and issues arising from formal and informal complaints led to changes in working practice. Although patient information leaflets regarding complaints procedure were not readily available on the critical care unit.

  • There were no formalised patient pathways in the Urgent Care Centre which had been officially approved by the medical advisory committee (MAC).

  • The Urgent Care Centre had no processes in place to assist patients with complex needs or learning disabilities.

  • The coordination and delivery of medical services did not take account of the needs of people living with dementia and those with a learning disability.

  • There was a large number of hospital cancelled operations and not all patients were rescheduled within 28 days.

  • There was no multi faith room to meet the spiritual needs of patients and their relatives.

Are services well led at this hospital?

By well-led, we mean that the leadership, management and governance of the organisation, assure the delivery of high-quality person-centred care, supports learning and innovation, and promotes an open and fair culture.

Overall, we rated well led as 'requires improvement'.

  • We were shown patient feedback survey forms for the UCC, however there was no evidence that results were collected, analysed or acted upon.

  • The hospital was in the process of implementing a care in the last days of life strategy, aligned to NICE guidance in collaboration with a local NHS trust. Although training had been commenced, limited progress had been made at the time of the inspection.

  • A hospital-wide risk register incorporated risks, which could affect staff, patients and visitors. The management team had oversight of the risks within the services. There were no local risk registers and some staff were unaware of the risks in their local areas. Risks and issues identified during inspection had not been identified or dealt with in a timely way. The risks described did not correspond to those reported to and understood by leaders.

  • Staff who had identified issues such as consultant documentation did not speak up about these concerns.

  • Staff in all areas knew and understood the vision, values and strategic goals for the hospital and corporate provider. There were quarterly staff forums where senior management and all staff could engage regarding the goals and strategy of the hospital.

  • The CEO and other executive team members had an open door policy encouraging staff to engage with them. All staff we spoke with confirmed that the executive team was approachable.

  • Leadership was visible and supportive at all levels and staff told us they felt valued by the senior leadership team. They were able to contribute their views and felt encouraged and supported to innovate and implement new ideas.

  • The arrangements for governance and performance management operated effectively. Hospital wide information was cascaded effectively though the organisation and staff were aware of some quality improvement initiatives.

  • The data from a staff feedback audit showed 97% of staff was ‘committed to doing their best for HCA’.

  • 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.

We saw areas of outstanding practice, including:

  • The London Breast Institute offered a complete and state of the art service for patients, including consultation and diagnostics during one appointment in one clinical area. 

However, there were areas of where the hospital needs to make improvements.

The hospital must:

  • The Urgent Care Centre must have a formal system to prioritise patients by acuity or severity of their condition during the triage process.

  • Staff in the Urgent Care Centre must follow the hospital’s policy to use National Early Warning Score (NEWS) system to monitor and detect deterioration in patients.

  • The theatre department must implement an infection control policy which reflects best practice guidelines to ensure infection prevention control procedures are fully embedded in practice to protect patients from the risk of infections.

  • The hospital must ensure clinical staff have level 3 in safeguarding children in line with the intercollegiate guidance for c

    linical staff working with children, young people (including people aged 16-18 years old) and/or their parents/ carers and who could potentially contribute to assessing, planning, intervening and evaluating the needs of a child or young person.

  • The hospital must ensure patient records are fit for purpose in that there is a full contemporaneous record of patient care and treatment. In addition, ensure the person making an entry is identified, they are legible, include an accurate record of all decisions and make reference to discussions with people who use the service and their wishes.

The hospital should:

  • The hospital should ensure all staff are “bare below the elbows” when in wards and clinical areas.

  • The ward areas should ensure all medicines are administered in line with the corporate policy.

  • The service should ensure all staff are up to date with mandatory and statutory training. Including safeguarding training for staff and mental capacity act training for doctors working in the Urgent Care Centre.

  • The hospital should update policies in the Urgent Care Centre to include author and date.

  • The Urgent Care Centre should have a formalised way to review and manage the opinions of patients.

  • The hospital should take a consistent approach to the identification and management of patients with pain to ensure the timeliness and effectiveness of interventions. The Urgent Care Centre should improve documentation of pain scores in patient notes.

  • The theatre department should ensure all equipment is easy to access and clearly labelled to ensure agency, bank or new staff would know where to find essential equipment.

  • The surgical services should ensure all staff have access to professional development and career progression.

  • The critical care unit should introduce stringent processes in place to ensure full compliance with all applicable standards of the Intensive Care Society.

  • The critical care unit should as a priority review the storage room where unit waste was collected before disposal and to be kept locked at all times with provision for staff to access it when required, in line with the Department of Health 2011 Safe Management of Waste guidelines.

  • The critical care unit should ensure there is wider learning from incidents across all staff level.

  • The critical care unit should ensure more systematic process are in place for MDT jointly with pharmacy, dietitian, physiotherapy and any other relevant professionals.

  • The hospital should review the provision for daily visits to critical care unit by a dietitian to assess all relevant patients.

  • The critical care unit should improve compliance with DNACPR policy.

  • The critical care unit should ensure patient information leaflets about complaints process are available in the unit. Steps to be taken to raise awareness among patients and relatives.

  • The hospital should ensure there is full compliance with the Deprivation of Liberty Safeguards (DoLS) and ensure records provide documentary evidence of mental capacity assessments and best interest decision making when patients are not able to make specific decisions about their care and treatment.

  • The hospital should improve the coordination and delivery of services for people living with dementia and those with a learning disability.

  • The hospital should review its provision facilities for patients and relative regarding quiet or prayer room within the hospital.

  • The hospital should develop and implement a strategy for End of Life Care to reflect current guidance and should develop a governance framework for End of Life Care to monitor implementation of the strategy and best practice guidance.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 28 January 2014

During a routine inspection

The inspection focused on cancer services provided by The Princess Grace Hospital. During this inspection we visited the Breast Unit and the in-patient oncology ward. We spoke with three patients and four relatives who were available during our inspection. We also spoke with 14 staff of all disciplines, including support staff, nurses, medical staff, pharmacists and managers. People were positive about the care and treatment they had received and the survey results we saw supported this.

People received safe, effective care that was planned in a way that ensured their safety and welfare. Peoples' needs were assessed and reviewed by a multi-disciplinary team. Information was provided in a format that met people's needs to ensure they understood and were able to make decisions.

There were arrangements in place to deal with medical emergencies. Treatment protocols and procedures reflected national guidelines. Medicines were stored securely and were safely administered by appropriately trained staff.

Staff received appropriate professional development and support. There were systems in place to monitor the quality of service provided.

Inspection carried out on 20 November 2012

During a routine inspection

During this inspection we visited operating theatres, the endoscopy unit and the four floors on which the wards were located, all within the main building. We also visited the urgent care centre and the recently refurbished intensive therapy unit (ITU).

People told us that the staff at the hospital “really listened” to them and described their care and treatment as “fantastic”. They said they received sufficient information about their care and treatment and felt “fully involved and supported to understand what was happening to me”.

The hospital had systems for diagnosis, assessing people’s needs and delivering care and treatment. People we spoke with were very satisfied with their care and treatment.

When we undertook our inspection visit the hospital was undergoing a phased refurbishment. Feedback from patients and staff was that the environment was clean, bright and comfortable.

There were sufficient staff on duty, a nurse told us “we can get very busy, but if we need extra help we only have to ask”. Managers regularly assessed the service demands in each department to ensure that patient welfare was not put at risk because of insufficient staff.

We reviewed the hospital’s process for handling complaints and found that people were given good information about how to complain and their concerns were addressed within the service’s protocols.

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