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Inspection Summary

Overall summary & rating


Updated 28 March 2017

We rated this hospital as “Good overall.”

This was because

  • There were adequate systems in place to protect people from avoidable harm and learn from incidents.

  • The hospital was visibly clean and well maintained. There were systems in place to prevent the spread of infection.

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

  • Mandatory training levels for staff were good.

  • There were adequate numbers of suitably qualified, skilled and experienced staff to meet patients’ needs.There were effective arrangements in place to ensure staff had, and maintained the skills required to do their jobs.

  • People received nutrition and hydration that met their preferences and needs.

  • Care was delivered in line with national guidance and outcomes for patients were good.

  • The individual needs of patients were met including those in vulnerable circumstances such as those living with a learning disability or dementia.

  • Patients could access care when they needed it and were treated with compassion. Their privacy and dignity was maintained at all times.

  • Staff were aware of the vision and strategy of the hospital.

We found areas of practice that required improvement across the hospital.

  • Duty of candour processes were not always being followed as outlined in the hospital policy.

  • Root cause analysis methodology was not always applied in the investigation of incidents.

  • There was no process in place to risk assess or check areas of non-compliance with National Institute of Health and Care Excellence (NICE) guidance.

  • The hospital risk register was not a live document and risks did not appear to be actively managed.

  • Complaints were not always managed in a timely manner.

In out-patients and diagnostic imaging:

  • Not all patient records included discharge summaries.

  • Records did not always show if there was a safe-guarding concern for the patient.

  • Records did not always show if a patient had additional needs for example, communication issues or a learning disability.

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

Ellen Armistead

Deputy Chief Inspector of Hospitals (North)

Inspection areas



Updated 28 March 2017

Are services safe?

We rated safe as good because:

  • There was a positive incident reporting culture within the hospital, with the majority of incidents being no or low harm. We saw examples of learning from incidents and were able to see analysis of themes and actions taken in response to these.

  • Infection control and prevention measures were in place and there had been no reported hospital acquired infections in the period July 2015 to June 2016. All areas were visibly clean and there were audits in place for hand hygiene compliance.

  • Mandatory training levels were good with 100% compliance. No safeguarding concerns had been raised at the hospital in the period June 2015-July 2016. Safeguarding training was part of mandatory training and there was 100% compliance with this training and it was at the appropriate level.

  • Medicines were stored and dispensed appropriately. There had been an issue with the fridge used for the storage of some medicines in the out-patients department but this had been addressed.

  • There were processes in place to reduce the risks to patients including protocols for the transfer of patients in an emergency. The hospital referral criteria for surgery were for low risk patients. Surgery services were using the World Health Organisation checklist as part of the Five Steps to Safer Surgery. Resuscitation trolleys were available and checked regularly.

  • Staffing including nurse staffing was good. There were vacancies at the hospital but these were covered by bank and agency staff. Theatre staffing was arranged in line with national guidance. There was a resident medical officer who was on a one week in three week rotation.

  • Records were a combination of paper based and electronic records. They were stored securely while in use and when in storage at the hospital.


  • The treatment room, on the announced inspection, was observed as small and difficult to access in the event of an emergency situation; however, the room had been re–located at the time of the unannounced inspection.

  • There was no dedicated area to clean endoscopes for ear, nose and throat (ENT) in the OPD, except for consulting rooms, however; we saw that this was being addressed at the unannounced inspection.

  • There were items identified as out of date on the announced inspection, however; this was addressed immediately and the items were removed.

  • Staff told us discharge summaries were not always available in patient records at follow–up appointments.

  • Records did not always show if there was a safe-guarding concern for the patient.



Updated 28 March 2017

We rated effective as good because:

  • Policies were based on national guidance that included the National Institute for Health and Care Excellence (NICE) and Ionising Radiation (Medical Exposure) Regulations (IR (ME) R).

    Staff had access to national guidance to provide consistent good quality care. Updates to guidance were disseminated to staff including consultants.

  • National and local audits were undertaken to measure the quality of care and patient outcomes. Where findings could be improved, action was taken. There were examples of clinical audits undertaken as part of the Commissioning for Quality and Innovation payments framework (CQUIN’s) .The hospital used the CQUIN programme to drive improvements and improve quality.

  • There was effective multidisciplinary team working that included medical staff, nurses, radiographers, physiotherapists and administrative staff. Staff worked together to enhance care provision, both within the hospital and externally. Services were available across six days in theatres and seven days on the ward. Out of hours support from physiotherapy, diagnostic imaging, pharmacy and medical staffing was also available.

  • Staff completed competencies and were appraised annually in line with the corporate values. All staff had completed their appraisals.

  • Pain was managed and patients had access to a range of food and refreshment throughout their stay.

  • There were processes in place for obtaining consent and there were three monthly consent audits. The Mental Capacity Act was included in mandatory training and staff had training and access to information about mental capacity, and deprivation of liberty safeguards. Patients considering cosmetic surgery underwent a ‘cooling off’ period to ensure they had the chance to think carefully before proceeding.


  • Compliance to NICE guidance was not determined by clinical audit.



Updated 28 March 2017

We rated caring as good because:

  • Patients we spoke with were happy with the care and treatment provided. The NHS friends and family test showed that the vast majority of patients would recommend the service.

  • We saw staff interacting with patients in a respectful friendly way, whilst being considerate of their privacy and dignity. A patient-led assessment of the care environment (PLACE) audit between February 2016 and June 2016 scored 85% for privacy, dignity and well-being.

  • Information was provided to patients and those close to them in a way they could understand. Visitors were welcomed to the ward to see patients.

  • Counselling services were available for patients and there were specialist nurses who supported particular patient groups with one to one care and advice, these included the breast care nurses.



Updated 28 March 2017

We rated responsive as good because:

  • Services were planned to meet the needs of local people and there were three satellite clinics to make out-patient services more accessible. The environment in the hospital was pleasant and refreshments were available.

  • The hospital was consistently meeting the target of treating patients within 18 weeks of their referral to the hospital and waiting times for some diagnostic screening tests were very low. There were systems in place for timely discharge of patients.

  • The individual needs of patients were met. Some of the staff were dementia champions who could support patients living with dementia. Provision was made for patients with a learning disability or with complex needs. Interpreting services were available and information could be translated if necessary. Sign language services were also available.

  • There were one stop clinics for some conditions so that patients received their diagnosis and a decision about their treatment in a timely manner.


  • The hospital had a complaints process and aimed to acknowledge and respond to complaints within 20 days, the hospital were not meeting some of the timescales for acknowledgement and response to complaints.

  • There was no system to identify if a patient had a special need such as a learning disability in their patient record.



Updated 28 March 2017

We rated well-led as good because:

  • Staff were aware of the vision and strategy for the hospital.

  • The appraisal system linked to the departmental objectives and the company values.

  • The Medical Advisory Committee (MAC) minutes of meetings were comprehensive and covered the expected agenda items through the standard agenda template.

  • There was a clinical governance committee at the hospital with a standard agenda template; there was also a clinical effectiveness committee that was attended by members of the medical advisory committee.

  • Staff described a positive open culture at the hospital.


  • The central hospital level risk register did not appear to be a live document and although the hospital managed risk this was not reflected by the risk register.

Checks on specific services

Outpatients and diagnostic imaging


Updated 28 March 2017

The service was available to NHS patients and self – funding patients from the age of 18 years. The service included the main outpatient department (as well as three satellite clinics), diagnostic imaging and physiotherapy. There were processes in place to protect patients from avoidable harm and processes to monitor the effectiveness of the services.

Staff were very caring to patients and supported each other. Managers were responsive to feedback to ensure a positive outcome for patients.



Updated 28 March 2017

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.

There was a culture of reporting and learning from incidents amongst staff. Staff followed good practice guidance relating to the control and prevention of infection, medicines and controlled drugs were available, stored, checked and dispensed in line with good practice and legislation. Staff accessed national guidance to provide consistent good quality care.

Patients were consistently happy with the care and treatment provided and we saw staff interacting with patients in a respectful friendly way, whilst being considerate of their privacy and dignity.