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Inspection Summary


Overall summary & rating

Good

Updated 1 June 2017

Fulwood Hall Hospital is operated by Ramsay Health Care UK Operations Ltd. The hospital has 29 beds, four of which are double rooms; the others are single en-suite. Facilities include three main operating theatres with laminar flow, an endoscopy/ minor operations unit and outpatient and diagnostic facilities.

The hospital provides surgery, medical care, services for children and young people age 16 and over, and outpatients and diagnostic imaging. We inspected surgery and outpatient and diagnostic imaging.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 1 to 2 November 2016, along with an unannounced visit to the hospital on 14 November 2016.

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 staffing, for example, management arrangements, also apply to other services, we do not repeat the information but cross-refer to the surgical core service.

The hospital provided care for medical conditions, children aged 16 and over and care for patients at the end of their life. The numbers of patients treated in the last 12 months was considered insufficient to provide separate core service reports. Where information applied to these patients it was incorporated into either the surgery or outpatients report as appropriate.

Services we rate

We rated this hospital as good in safe, effective, caring, responsive and in the well-led domain.

  • There was a good incident reporting culture, staff were aware of how to report incidents and were proactive with actions following an incident. Causes were investigated and changes implemented, where appropriate.
  • All departments in the hospital were visibly clean and tidy with hand sanitisers at the entrance to each area. There were infection prevention policies in place that were followed and all staff adhered to the ‘arms bare below the elbow’ policy during the inspection.
  • Staffing levels were planned and reviewed using Ramsay Health Care UK’s national electronic rostering management system. The inpatient ward and theatres were fully staffed using Ramsay employees, either substantive or bank.
  • The hospital had a comprehensive training package in place for all Fulwood Hall hospital staff. New employees undertook a hospital induction package and mandatory training had high levels of attendance. Staff told us they were well supported to continue their education with a scholarship fund.
  • The staff we spoke to during the inspection were passionate about their job and caring. Staff worked especially hard to make the patient experience as pleasant as possible. Staff recognised and responded to the holistic needs of their patients from the first referral before admission to checks on their wellbeing after they were discharged from the hospital
  • The hospital had a robust system for awareness, training and monitoring safeguarding adults at risk of abuse or neglect, and safeguarding children and young persons. Policies were based on national guidelines, and covered a comprehensive range of issues.
  • The hospital had four on-site safeguarding leads, including a registered children’s nurse (who was also the regional safeguarding lead). They delivered training to level three for adult and children’s safeguarding. In addition, monthly safeguarding sessions were delivered with a variety of topics and reflective discussion of cases.
  • A range of care pathways were in place, based on national guidance from the National Institute of Health and Care Excellence (NICE) and the Royal College of Surgeons (RCS). Local and national audits measured outcomes including National Joint Registry and performance related outcome measures (PROMs) for elective surgery.
  • The hospital exceeded its indicators for consultant led referral to treatment waiting times for NHS patients. The referral to treatment and the admitted for treatment waiting times were consistently above the standard.
  • The staff responded to a patients individual needs using a communications slip included in healthcare records prior to admission. Requirements such as air mattresses, moving and handling equipment or diabetic menu required, per prepared in advance.
  • Patient feedback was received from a variety of sources and was positive about the care and treatment received. We received a large number of feedback cards and comments included “Fulwood Hall is amazing, all staff and consultants take time to listen and your care and treatment is to the highest of standards. The hospital is clean and hygienic at all times.” One patient told us they were prepared to travel 100 miles to be treated at Fulwood Hall hospital.
  • All areas were visibly clean and tidy. Sanitisers and hand washing facilities were available in all consultation rooms. The radiology department had cleaning schedules, which included cleaning equipment after each patient. Infection control audits demonstrated excellent compliance.
  • Equipment in the diagnostic imaging department was safe and appropriate for use following Ionising Radiation Medical Exposure Regulations 2000 [IR(ME)R] and IRR99 regulations. Personal protective equipment was regularly checked and safe. All equipment was maintained and regular audits were performed to ensure patient and staff safety.
  • Mandatory training rates for permanent staff within the departments were on target for full completion with dates scheduled for staff to complete outstanding training within the rolling twelve month period
  • Care and treatment was provided to patients who used the outpatient, physiotherapy and diagnostic imaging departments in a kind and compassionate way. This was reflected in the patient satisfaction survey. One nursing staff member told us they started work early to be able to accommodate the needs of one patient who required an earlier appointment slot due to the needs of the patient’s business.
  • Patient clinical pathways were standardised. Pathway documents were used for each procedure, which included a specific outpatient procedure care pathway. These took into account guidance and established practice, and included appropriate pre and post procedure checks and follow-up information.
  • The hospital was proactive in developing practice and improving patient experience, with a number of initiatives in place. During 2016, the hospital had engaged with external participants and the National Institute for Health and Care Excellence (NICE) in reviewing the quality standards for falls and the clinical guidance on urinary incontinence in women.
  • The hospital carried out a quarterly consent audit. Although there were recurring deficiencies identified, such as a lack of clear recording of the patient’s and clinician’s details, the results between July 2015 and June 2016 showed intermittent improvements in compliance with the policy. However, following concerted efforts by staff the audit in September 2016 demonstrated a significant improvement at 97% compliance with the policy.

However:

  • There were no new risks entered on the register since October 2015. Although there was evidence that the management team were aware of their risks and had robust arrangements in place to manage and reduce the risks, these risks were not recorded on any risk register. A number of risks including dementia awareness, falls, and outpatient capacity should have been included. Risk assessments for basic health and safety requirements were in place in all areas but managers had a lack of understanding how to rate a risk appropriately using the likelihood and severity.
  • There was a reliance on bank staff to fill unmet need for shifts.
  • We observed incomplete records of weekly water outlet flushing checks, to reduce risk from legionella bacteria, some months’ records were missing from the file. Staff told us these checks had been done. Managers informed us that paper records for the missing months had been mislaid and that checks were now in place for the future. However, Legionella sampling had been carried out twice in March and October 2016. We viewed this documentation which confirmed there was no legionella present in the water system.
  • At the time of the inspection, there was an approximate two-week wait for reporting of plain film X-rays in the diagnostic imaging department during to staffing issues.
  • The hospital recognised that increasing demands for its services was not being matched by the physical capacity of its facilities. There were issues with privacy and dignity in the diagnostic imaging waiting area, physiotherapy and pre-operative assessment clinic rooms. Staff had made efforts to adapt the area and their process to provide privacy and confidentiality. Managers had developed business plans to increase the size of the hospital which were to be reviewed by the board imminently.

Ellen Armistead

Deputy Chief Inspector of Hospitals (North)

Inspection areas

Safe

Good

Updated 1 June 2017

We rated safe as good because:

  • There were low numbers of clinical and non-clinical incidents throughout the hospital and no never events. Staff understood their duty to report incidents. Incidents were well investigated; the duty of candour was implemented, where necessary and learning was shared. Staff had access to the electronic system to record incidents and could give us examples of what would be reported.
  • The departments were clean, suitable for the services provided and equipment was regularly maintained and in date. Medicines were managed and stored safely, hygiene audits were completed and the diagnostic imaging department had implemented policies and procedures to meet radiation exposure and protection regulations.
  • Staff were trained in the safeguarding of vulnerable adults and children. A safeguarding culture was engrained in the departments and staff were supported to identify and report safeguarding concerns. Patient records were held securely.
  • Mandatory training rates for permanent staff within the departments were on target for full completion with dates scheduled for staff to complete outstanding training within the rolling twelve month period.
  • Sufficient nursing, healthcare assistant and allied healthcare professional staff were rostered for the services provided in the departments.
  • Staff had relevant skills to respond to patients who became unwell within the departments and knew how to get emergency assistance.

However,

  • The hospital reported high use of bank staff in the outpatient department.
  • Figures showed that mandatory training levels for bank staff in the theatre and ward were low.
  • The records of water flushing checks for the surgical unit were incomplete.

Effective

Good

Updated 1 June 2017

We rated effective as good because:

  • A range of care pathways were in place, based on national guidance from the National Institute of Health and Care Excellence (NICE) and the Royal College of Surgeons (RCS). Staff followed policies and procedures, which were based on this national guidance.
  • Hospital policies followed in the outpatient, physiotherapy and diagnostic imaging departments was evidence-based and in line with relevant national and professional guidance.
  • The hospital had a well embedded audit programme. This was predominantly routine practice checklists such as record keeping, medicines management and infection, prevention and control. . The audit results were consistently positive. On the occasions where audit results dropped slightly, improvements were made the following month. We were told there was no medical involvement in clinical audits.
  • Patients were assessed prior to admission for their preferred approach for pain relief. Patients reported that their pain was well managed during their course of treatment.
  • A nutrition and hydration week was held at the hospital in March 2016 and a nutrition and hydration goals plan had been implemented, which was developed by Ramsay Health Care UK.
  • Staff had the knowledge and skills to deliver care and treatment effectively and were supported by the managers in their continuing professional development. Students on the ward reported positive experiences of their placement, with good support from supervising staff.
  • There was a limited, but effective, multidisciplinary approach between the departments with a good working relationship between the staff and consultants.
  • The hospital had established thorough processes for appointing and supervising the Registered Medical Officer and for approving consultants to carry out clinical practice at Fulwood Hall Hospital.
  • The hospital ensured continuous medical cover using the services of a company that provided a Resident Medical Officer (RMO). Although the hospital did not offer a full seven-day outpatient service, the departments scheduled additional clinics when needed to meet demand.
  • Staff were aware of the processes in place for obtaining informed consent, including the need to consider mental capacity assessment if necessary.
  • Despite reminders to staff, there were recurring deficiencies identified by the consent audit. These included the clear recording of the patient’s and the clinician’s details. However, the audit in September 2016 demonstrated a significant improvement at 97% compliance with the policy.

However,

  • The hospital did not routinely collect, or analyse, clinical patient outcome data specifically relating to outcomes for outpatient care and treatments.

Caring

Good

Updated 1 June 2017

We rated caring as good, because:

  • Staff spoke to patients and their carers with kindness, in ways that respected their dignity. Nurses told us they felt they had time to be able to speak with patients and felt able to give 100% of their time in caring for them.
  • Care and treatment was provided to patients who used the hospital in a kind and compassionate way. This was reflected in the patient satisfaction survey. Between January and June 2016, the NHS Friends and Family test scores were an average of 99%, which was positive.
  • Staff supported patients living with dementia or learning disabilities to visit the department prior to treatment to reduce anxiety. The hospital recognised the important role for carers of patients living with dementia or learning disabilities. Carers were able to stay with their relatives and were given free meals in the restaurant.
  • Patients were involved in their care. There were given adequate information to understand the treatment being provided and to understand the role of the clinician looking after them.
  • Staff provided emotional support to patients who received bad news. Appointments were scheduled for the end of the clinic day to enable the patient to take a longer appointment and in order to ask questions and reflect.

Responsive

Good

Updated 1 June 2017

We rated responsive as good, because:

  • The hospital worked with local stakeholders, including the clinical commissioning groups and primary care providers to understand the needs of the local population and to plan its services accordingly.
  • The hospital exceeded its targets for consultant led referral to treatment waiting times for NHS patients. Between July 2015 and June 2016, above 90% of patients were admitted for treatment within 18 weeks of referral for treatment. No patients waited longer than six weeks for a CT scan and only four waited longer than six weeks for an MRI scan.
  • The hospital recognised that increasing demands for its services was not being matched by the physical capacity of its facilities. It had developed business plans to increase the size of the hospital which were to be reviewed by the board imminently. In the interim, daily slot utilisation and weekly capacity meetings were held.
  • Staff met the individual needs of patients. Translation services were available for people whose first language was not English and staff accommodated the needs of patients to pray or to attend appointments around their work commitments.
  • The hospital developed an assistance dogs policy and worked with the Alzheimer’s Society and Galloways Society for the Blind to ensure its services were accessible for patients living with dementia or with a disability.
  • The number of patients who had their appointments cancelled between July 2015 and June 2016 was equivalent to 1% of the total number of patients seen. Of these, 98% received an alternative appointment within 28 days.
  • A communications slip was placed in patients’ notes prior to admission that highlighted an individual’s additional needs. The ward diary noted requirements such as air mattresses, moving and handling equipment or diabetic menu required, as appropriate.

However,

  • There was an approximate two week wait for reporting of plain film X-rays in the diagnostic imaging department at the time of the inspection due to staff holidays.
  • There was a risk that patient privacy and dignity could be compromised in the diagnostic imaging waiting area and that confidential discussions with patients could be overheard in the physiotherapy department.
  • Increasing demand on the services provided, in conjunction with the physical capacity of the hospital, meant there was little room for appointments or clinics to overrun without affecting the remaining slots.
  • Limited information was collected, or available, relating to the clinics running late, cancellations or patients who did not attend appointments. This meant there was a risk that possible trends, which may affect demand on the departments’ services, may not be identified.
  • The room available for pre-assessment appointments was small and was used by up to four members of staff as well as two patients at a time. We felt that this facility did not offer the best environment to protect patients’ dignity and confidentiality.

Well-led

Good

Updated 1 June 2017

We rated well-led as good, because:

  • There was a strong leadership team in place in the hospital. Senior leaders were visible and the majority of staff felt supported by them, although staff were not as aware of the corporate leaders.
  • The Ramsay Health Care UK strategy was embedded in the hospital; staff were aware of the strategy and the values.
  • There was a governance structure in place, which was supported by appropriate policies and procedures. A comprehensive audit programme was in place.
  • The hospital had a clinical governance lead and regular clinical governance meetings were held. The Medical Advisory Committee met quarterly. This meeting included review of incidents, governance reports and accreditation of medical staff.
  • Staff consistently reported positive experiences of working in the hospital. Staff said their leaders were visible, accessible and provided them with support.
  • Although the recent staff survey had highlighted some areas that needed improvement, managers had created an action plan and began work to improve staff engagement.
  • NHS Friends and Family test scores were consistently very high, although the average response rates were low. However, the hospital’s patient satisfaction survey also indicated high levels of satisfaction with the services offered.
  • The hospital engaged with patients and various different patient groups in developing their services. This included the Alzheimer’s society, the Preston Muslim society and the local Healthwatch organisation.
  • High numbers of staff worked to the best interests of patients and colleagues and understood how their role contributed to patient care. Staff were supported to develop and could apply to the Ramsay Scholarship Fund to attend training courses.

However,

  • The hospital level risk register did not appear to be a live document with no new risks added to the register since October 2015. A number of risks that we would have expected to see on the risk register over the last twelve months were not on the risk register, including dementia awareness, falls and high bank staffing levels in surgery.
  • Although there was a strong emphasis on risk assessments of equipment and procedures within the individual departments, there were no separate risk registers held in the specific departments that identified risks to the operation of the services, control gaps or mitigation actions put in place for the individual services. The hospital risk register did not include risks related to the individual departments.
Checks on specific services

Outpatients and diagnostic imaging

Good

Updated 1 June 2017

Mandatory training rates for permanent staff within the departments were on target for full completion within the rolling twelve-month period.

The diagnostic imaging department was involved in multidisciplinary meetings with outpatient consultants to review imaging and reports.

Care and treatment was provided to patients who used the outpatient, physiotherapy and diagnostic imaging departments in a kind and compassionate way. This was reflected in the patient satisfaction survey.

As a response to a number of complaints in the diagnostic imaging department in 2015, the hospital had implemented an improvement plan. This included recruitment of a new departmental manager. There was a clear improvement in the feedback the department had recently received.

The hospital took part in the Ramsay Health Care UK customer service excellence awards scheme. Two staff in the physiotherapy department had received awards and a staff member in the outpatient department had two nominations. One staff member told us the award scheme meant that staff ‘feel appreciated’.

Surgery

Good

Updated 1 June 2017

Staff were trained in the safeguarding of vulnerable adults and children. A safeguarding culture was engrained in the departments and staff were supported to identify and report safeguarding concerns. Patient records were held securely.

There was a higher than average use of bank staff to cover gaps in shifts for nursing and healthcare assistants.

A range of care pathways, policies and procedures were in place, based on guidance from the National Institute of Health and Care Excellence (NICE) and the Royal College of Surgeons (RCS).

The hospital accommodated pre-admission visits for patients living with a learning disability. This visit aimed to reduce patient anxiety, introducing the nursing team and identifying any specific individual requirements, such as equipment or dietary needs. The hospital engaged with the local community to support service improvement. Groups such as the Alzheimers society, Galloways Society for the Blind and the Preston Muslim society all assisted development of the service.