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Inspection carried out on 14 and 15 August 2018

During a routine inspection

Fulwood Hall Hospital is operated by Ramsay Health Care UK Operations Limited. The hospital/service has 29 inpatient and twelve day case beds. Facilities include three main operating theatres with laminar flow; an endoscopy/ minor operations unit; X-ray, outpatient and diagnostic facilities.

The hospital provides surgery, outpatients and diagnostic imaging services. We inspected surgery, outpatients and diagnostic imaging services.

We inspected this service using our next phase inspection methodology. We carried out the inspection with an unannounced visit to the hospital on 14 and 15 August 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.

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 service level.

Services we rate

Our rating of this hospital stayed the same. We rated it as good overall. We found practice was good in relation to care in surgery, outpatients and diagnostic imaging services:

  • The provider 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 hospital provided mandatory training for all staff and completion rates were high; this was up to date at the time of inspection.
  • Staff were aware of hospital safeguarding procedures and followed these correctly.

  • Staff were aware of the types of incident which could occur and reported these if they occurred. There was a good culture of incident reporting and learning was shared following this.
  • Staff followed evidence-based care pathways for specific conditions; policies and procedures were developed on national guidance.
  • Seven-day services were available in case of emergencies and for responding to concerns.
  • Staff worked well together in multidisciplinary team approach to meet patients’ needs.
  • The service responded well to different patient needs and had well established systems for supporting patients living with dementia or a learning disability.
  • Leaders were visible and there was an open and positive culture amongst staff. The hospital had developed a clear vision and strategy in engagement with staff.
  • There was a clear governance system in place and this had been reviewed and strengthened since our last inspection.
  • The hospital engaged well with patients, staff, the public and local organisations to plan and manage services appropriately, and collaborated with partner organisations effectively.

However

  • Surgical safety and other theatre checklists were not always being carried out in accordance with recognised best practice guidelines. The service did not always control infection risk well and we saw equipment and environmental defects which could present an infection control risk.
  • Managers did not always ensure staff received annual appraisals. Appraisal rates in outpatients were poor and had been low in surgery.
  • Pain scoring tools were used routinely in the physiotherapy department but not used consistently in the outpatient departments to manage patients’ pain levels.

We found areas of outstanding practice in surgery, outpatient and diagnostic care, including

  • Development of a working group for supporting patients who had autism.
  • A focus on safety culture, with implementation of a ‘Speak up for Safety’ initiative and provision of human factors training for all staff.
  • Opportunities for staff development, and access to learning support funding for this, through Ramsay Healthcare.

We found areas of practice that require improvement in surgery and diagnostic imaging services, for

  • Improving practice in World Health Organisation (WHO) checklists.
  • Maintaining robust systems for cleaning radiology equipment used in theatres.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with two requirement notices that affected surgery and diagnostic imaging services. Details are at the end of the report.

Ellen Armistead

Deputy Chief Inspector of Hospitals (North West)

Inspection carried out on 1 to 2 November 2016

During a routine inspection

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 carried out on 23 September 2013

During a routine inspection

During our visit to Fulwood Hall Hospital we spoke with several patients, who all provided us with positive comments about the support they received. People told us they were able to make decisions about their planned care and treatment and that their needs were being met by a kind and caring staff team. They were very complimentary about the meals available and the quality of service provided.

Comments received included:

"I am very happy with all my treatment. I am very lucky to be here."

"The staff are very kind and the food is excellent."

"They have kept me up to date and always let me know what's happening."

During our inspection we looked at standards relating to consent and care and welfare. We also assessed recruitment practices adopted by the hospital and how the service was being monitored. We did not identify any concerns in any of the outcome areas we reviewed.

Inspection carried out on 12 June 2012

During a routine inspection

During our visit to this location we spoke with seven people using the service, who were all very complimentary about the staff team and the facilities available to them at the hospital.

Comments received from these people included:

"The staff are lovely. They really are marvelous and do such a smashing job."

"I have no compliaints at all, not a single one. I would choose to come to this hospital every time."

"I have been here before and I wouldn't want to go anywhere else. It is magnificent."

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