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Inspection carried out on 28 February to 2 March 2017

During a routine inspection

The Lister Hospital is operated by HCA International Ltd. The hospital employs over 500 consultants and nursing staff and has 61 beds. Facilities include four operating theatres, a six bedded level 3 critical care unit and an endoscopy suite.

The hospital provides surgery, medical care, critical care, and outpatients and diagnostic imaging. All services at this hospital were inspected during our visit.

We inspected this service using our comprehensive inspection methodology. We carried out an announced inspection on 28 February – 2 March 2017.

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.

The main service provided by this hospital was surgery. Where our findings on surgery – for example, management arrangements – also apply to other services, we do not repeat the information but cross-refer to the surgery core service section.

Services we rate

We rated this hospital as ‘outstanding’ overall because:

  • Patients were treated with compassion and their privacy and dignity were maintained. Patient feedback forms were positive, as were comments we received from patients themselves.

  • The needs of individuals were taken into account when planning care and treatment. Patients could access care when they needed it. There was a choice and flexibility around appointments and most procedures were elective.

  • The hospital was managed by a team who had the confidence of both patients and their teams. Staff felt motivated and supported by the management team. The vision and strategy of the service was embedded and staff spoke very highly of their management team.

  • There were adequate systems to keep people safe and learn from incidents. Learning from incidents that occurred in other departments was shared across the service.

  • The environment at the hospital was visibly clean and well maintained. There were appropriate measures in place to ensure the spread of infection was prevented.

  • There were systems in place to ensure safe storage, use and administration of medicines.

  • There were sufficient nursing and medical staff to ensure patient safety was maintained at all times.

  • Care was planned and delivered in line with current evidence-based guidance, standards and best practice. Patient outcomes were collected and monitored to improve care.

  • We observed evidence of collaborative working and positive relationships across all departments within the hospital.

  • There were effective governance structures in place.

We found areas of ‘outstanding’ practice in surgery services and critical care services:

  • Within surgery, we found that staff went above and beyond their duty to accommodate patients’ individual needs in different ways.

  • We found a culture of friendly professionalism, support and respect at all levels throughout the surgical division.

  • In critical care, staff demonstrated a consistent approach to providing highly individualised care that contributed to emotional wellbeing and a positive recovery. This included facilitating family visits at mealtimes, and learning Arabic to communicate effectively with patients and their families. Individual examples included ordering fresh flowers to decorate a patient’s hair ready for discharge, and inviting a relative to eat lunch with staff each week.

  • A consultant intensivist led a critical care post-discharge support programme (PDSP), that was based on a holistic model of care. This meant the service provided support for improved physical health and wellbeing, as well as for psychological health. The PDSP had an international scope. Patients who were discharged to countries outside of the UK had access to this by video link.

However, we also found the following issues that the service needs to improve:

  • The hospital should ensure that the quality of documentation of consultants is monitored and any issues are addressed.

  • Not all staff had access to the same system for documentation.

  • Not all staff had completed their mandatory training, and in many cases the hospital target of 85% was not met.

  • Not all complaints in the medical service were responded to within the 20 day timeframe.

  • We found high vacancy rates for inpatient and theatre staff and high turnover rates of inpatient nurses.

  • In radiology, we found that that prescription pads were not stored securely and there was no system in place to log usage of prescription pads.

  • The safeguarding children's policy was out of date as it had not been reviewed in June 2016.

  • The outpatients department did not have a separate waiting area for children. 

Following this inspection, we told the provider that they should make some improvements, even though a regulation had not been breached, to help the service improve. Details are at the end of the report.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 08,09,10 December 2014

During a routine inspection

The Lister Hospital is a 64 bedded private hospital, based in Chelsea, London. In 2000, The Lister Hospital became part of HCA International joining The Harley Street Clinic, London Bridge Hospital, The Portland Hospital, The Princess Grace Hospital and The Wellington Hospital.

The hospital employs five whole time equitant (WTE) doctors, 66 WTE nurses and two WTE healthcare assistants. There were 521 doctors who have been granted practicing privileges at the hospital at the time of our inspection. The hospital undertakes a range of surgical procedures, provides medical and critical care and also carries out outpatient consultations. These are four of the eight core services that are always inspected by the Care Quality Commission (CQC) as part of its new approach to hospital inspection. The hospital has five operating theatres, 17 consultation rooms and 40 inpatient and 24 day case beds all with en-suite facilities. The hospital provides in patient care to male and female patients aged over 16 years of age. The out patients department sees patients of all ages. At the time of the inspection the hospital was not providing care to any NHS patients. The hospital was selected for inspection as an example of a medium size independent hospital in our wave 1 pilot.

The inspection team included CQC inspectors, doctors, nurses, patient representative and a senior manager from another private hospital. The inspection took place on 09 and 10 December 2014. Our key findings were as follows:

Safe:

  • There was a electronic incident reporting system in place which most staff were aware of, most incidents were reported, incidents were investigated and findings fedback to most staff to ensure learning.
  • The principles of the world health organisation (WHO)‘ five steps to safer surgery’ checklist were embedded into practice and surgical safety checklist were complete.
  • All clinical areas and departments were clean and well maintained.
  • There were effective infection prevention and control policies, procedures and practices in place.
  • The national early warning score (NEWS) was in place to monitor patients conditions and there was 24 hour outreach support available from the critical care to assist staff in the management of patients whose conditions was identified as deteriorating.
  • Risks association with the environment and equipment were managed well through checking processes and prompt repair or replacement when required.
  • Safeguarding training was provided at the appropriate level for all staff, although the safeguarding children policy did not reflect up to date national guidance.

Effective:

  • The hospital had a limited audit programme in respect of clinical practice and outcomes for patients.
  • Patient’s satisfaction surveys were undertaken and action taken to address issues raised by patients or their relatives.
  • There were processes in place to ensure adequate pain control and staff had access to a specialist pain control team.
  • Staff participated in an annual appraisal and were provided with training opportunities to gain additional skills and knowledge.
  • Therapy staff were providing support to orthopaedic patients to expedite recovery from surgery, but there was no monitoring of adherence to best practice in enhanced recovery.
  • Consultants provided individual pre and post-operative care guidance for their patients. However, this guidance did not always refer to best practice guidelines and was not standardised.
  • Staff had an understanding of the Mental Capacity Act 2005 in relation to informed consent and deprivation of liberty safeguards. However, staff were not aware of the hospital's restraint guidelines and did not consider restraint to be a deprivation of liberty or that the patient’s best interests needed to be assessed in this situation.
  • Multidisciplinary team working was evident across the hospital.

Caring:

  • Staff were caring and treated patients and their relatives with dignity and respect at all times.
  • Patients commented positively and were satisfied with the support and care provided to them and their relatives.
  • Patients were involved in all aspects of their care, relatives and carers were welcomed and encouraged to be involved during the person’s stay in hospital.

Responsive:

  • Not all services were responsive to the specific needs of patients with cognitive impairment.
  • Patient admissions were arranged in a timely manner with minimal delays for patients.
  • Pre-operative assessments were undertaken in a variety of ways to meet patient's individual needs but there was no pre-assessment policy.
  • There was a higher than national average number of delayed discharges from the critical care unit and some patients were moved between different wards during their stay.
  • Staff had access to interpreters to facilitate communication with patients whose first language was not English.
  • Patients received information about the service and their procedures prior to and during their admission.
  • Complaints were usually responded to within the timescales identified in the hospital’s policy and changes to practice implemented to prevent recurrence of similar issues.

Well-led:

  • Staff were aware of the priorities for their wards and departments and shared the hospital and corporate vision.
  • Wards and departments did not have a documented local vision and clinical strategy to support innovation and growth of the service.
  • There was identified leaders who were visible and accessible and both department and hospital managers were said to be both supportive and approachable.
  • Staff were patient focused and aimed to provide high quality care.
  • Management encouraged an open culture so that the services could learn from incidents and complaints.
  • The hospital risk register documented risks and assigned a manager to manage the risk.

We saw several areas of outstanding practice including:

  • Staff were caring and compassionate and focused on meeting individual patient needs.
  • The infection surveillance data base was linked to the nursing electronic record and the microbiology/pathology laboratories to ensure there was adequate oversight of infection prevention and control issues.
  • The hospital used an electronic system to record patient’s observations and if the score triggered a NEWS alert the RMO and outreach nurse were alerted electronically.
  • The hospital falls prevention programme incorporated innovative technology to reduce patient falls and minimise harm. This is in keeping with national patient safety initiatives.
  • The patient menu had been planned with the input of a dietician and provided an extensive range of high quality  food that met all patients needs.

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

Importantly, the hospital must:

  • Ensure that all staff in the critical care unit have the appropriate skills, knowledge and competencies and that these are in line with national guidance.
  • Implementation effective systems to monitor, review all patient death and disseminate the learning from these reviews.
  • Implement formal systems and process to maintain a record to demonstrate all nurses accompanying medical staff hold an appropriate registration and have completed a Disclosure and Barring (DBS) check.

In addition the hospital should:

  • Ensure that practices and policies reflect up to date national guidance and best practice.
  • Ensure that the process in place which ensures a consultant can be reached in unplanned situations should be explicit.

  • Review its provision of care to patients with cognitive impairment such as dementia, to ensure staff have an understanding of how to assess and meet the needs of this group of patients.
  • That all services such as the endoscopy unit are accredited with the appropriate body or have a plan in place to demonstrate how the unit is working towards accreditation.
  • Review national audits and identify those that they are eligible to participate in.
  • Take action to ensure all incidents are appropriately investigated and the outcomes shared with staff.
  • Consider extending peer observational audits of the use of the WHO surgical checklist to include larger sample sizes and across all theatre lists.
  • Continue to review the practicing privileges granted to consultants to ensure there is an accurate record of those consultants who regularly work at the hospital and that they meet the hospital’s criteria for being granted these privileges.
  • Ensure that there is evidence that MDT meetings take place across all specialities.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 6 December 2013

During a routine inspection

We looked at the results of the patient feedback collected by the hospital in October 2013 to which 183 had responded. 94.3% of respondents said that their proposed course of treatment was always clearly explained to them by consultants and 97.3% of people said their questions were completely answered by nurses when they asked them. We spoke with over 13 people using the service. They told us that "I cannot praise the nursing staff here highly enough. They are sensitive and helpful without being intrusive". Another said that staff were "lovely" and another described them as "very helpful and kindly".

People underwent appropriate assessments on admission to ensure that their needs could be met and any risks mitigated whilst in hospital. Staff had been trained in what to do in a medical emergency. There was appropriate medical emergency drugs and equipment available. 97.5% of respondents to the patient satisfaction survey rated their overall care as "excellent" or "very good" and 99.4% of respondents said they were likely or extremely likely to recommend the hospital to others.

On the day of the inspection all areas of the hospital that we visited appeared clean and well maintained. In the patient satisfaction survey all respondents rated the cleanliness of the hospital positively with the majority of people rating it as "excellent".

There were enough qualified, skilled and experienced staff to meet people’s needs. Accurate medical records were kept securely.

Inspection carried out on 10 January 2013

During a routine inspection

Before undergoing treatment or procedures people using the service received explanations of what was involved and the risks and benefits. They were asked to sign their consent to treatment and care and the service undertook monthly audits to check this.

Appropriate risk assessments and medical checks were undertaken for people using the service before, during and after treatment and procedures. People using the service described it as "first class" and "absolutely outstanding". All staff had been trained in how to manage medical emergencies and there was medical equipment and drugs available for such situations.

On the day of the inspection the hospital appeared clean and tidy. People using the service described it as "spotless" and "very clean". There were appropriate facilities and procedures for the decontamination of instruments and the cleaning of clinical areas. Regular checks were made to ensure that infection control procedures were being followed.

Prospective staff underwent a suitable recruitment procedure before they started work. Appropriate checks were also made, including with the Criminal Records Bureau and on staff professional registration.

People using the service told us that they would be comfortable raising any concerns that they had. There was a complaints policy and procedure in place at the hospital. Details were provided of recent complaints that had been received and how they had been responded to.

Inspection carried out on 24 January 2012

During a routine inspection

People who use the service told us they were able to make decisions about their treatment and how they were looked after. They said the care and treatment at the hospital was “very person orientated” and that staff were respectful towards them. They said that they were provided with a high standard of care and that their treatment had been fully explained to them, and they praised the professionalism and dedication of staff.

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