Mount Stuart Hospital

Mount Stuart Hospital is an independent hospital and part of the Ramsay Hospital Group. At the time of our inspection, it provided care and treatment to NHS patients and privately funded patients; including self-funded and medically insured.

The hospital provided surgery, and outpatient and diagnostic services. There were no services provided to persons under the age of 18. Day case and inpatient surgery specialties included general surgery, major and minor orthopaedic surgery, ophthalmology, ear nose and throat surgery, gynaecology, urology, dermatology, endoscopy and cosmetic surgery. There were 26 inpatient beds and 12 ambulatory care spaces. There were three main operating theatres, one day case theatre, and a recovery area. There was a physiotherapy service for patients on the ward.

The outpatient department provided a stand-alone service for patients and a service before and after surgery. Outpatient specialities included orthopaedics, general surgery, gynaecology and obstetrics, cosmetic surgery, ear nose and throat, urology, oral and maxilla, ophthalmology, gastroenterology, dermatology, and facial surgery. Diagnostic imaging included plain x-ray, ultrasound, and fluoroscopy. magnetic resonance imagining (MRI) and computed tomography (CT) were provided from a mobile unit by Ramsay UK Diagnostics and were not inspected as part of this visit. Non-surgical cosmetic treatments delivered by the cosmetic suite were not inspected as part of this visit. There was a private physiotherapy service for outpatients.

All treatments were consultant led. All consultants were employed under practicing privileges. The senior leadership team included the general manager, matron, operations manager and decontamination lead, regional finance manager, regional business development manager, personal assistant and human resources lead, and business administration manager. Clinical heads of department reported directly to the matron. Since our last inspection a full time matron had been employed.

We carried out a comprehensive announced inspection of Mount Stuart Hospital on 6 and 7 September 2016, and an unannounced inspection on 15 September 2016. We inspected and reported on two core services: surgery, and, outpatients and diagnostic imaging.

We rated Mount Stuart Hospital as requires improvement. We rated both surgical services and outpatient and diagnostic imaging services as good for caring and responsive. We rated both services as requires improvement for safe and for surgical services inadequate for well led. We rated surgery as requires improvement for effective, but we did not rate the effectiveness of the outpatient and diagnostic imaging service due to insufficient data being available to rate these departments’ effectiveness nationally.

Our key findings were as follows:

Are services safe?

We rated safety as requires improvement:

• The management of incidents did not consistently follow the hospital policy. The management of duty of candour was well understood by staff but its implementation not consistently practised after an incident had occurred.

• There was a lack of up to date service level agreements with acute NHS hospitals for the transfer of patients requiring critical care.

• Not enough staff were directly employed by the hospital to staff the theatres and so agency and bank staff were being used. At our announced inspection 44% of theatre staff were agency and bank staff. Theatre staff were unaware of which skills agency staff had, but action had been taken to address this by the time of our unannounced inspection.

• Infection prevention and control practice was not in line with best practice. Hazardous waste was not managed safely and the flooring in consulting rooms and patient rooms was non-compliant with guidelines for infection control, not always cleaned, and had not been risk assessed.

• Clinical audit arrangements were inconsistent with no consistent departmental actions or timescales. Some aspects of clinical audits scored consistently low with no improvement in scores being demonstrated.

• Some areas of the theatre and ward environment required review including the emergency call system in recovery. The management of damaged equipment made its replacement prolonged.

• There was not clear resuscitation procedures in response to a medical emergency. Resuscitation scenarios had not been practiced in the hospital since July 2014. Fire evacuation drills had not been practiced in over a year and had not taken place since the opening of new theatres and ambulatory care.

However,

• There was a culture of reporting and learning from incidents throughout the hospital.

• The matron was safeguarding lead for the hospital with support during working hours from the Ramsay Hospital Group safeguarding lead. Safeguarding practices were clear, and staff were aware of the actions needed if they had concerns. Staff told us about examples of appropriate safeguarding referrals.

• There was good handover of patients between staff and staff contacted and discussed the patient’s condition with consultants when required.

Are services effective?

We rated effective as requires improvement.

• Information about outcomes of patient care and treatment was not routinely collected and monitored for all patients.

• Assessment of nutrition and hydration were not consistently completed and so risks to patients were not always identified.

• Consent for cosmetic surgery was not in line with company or national best practice.

• Audits were not regularly completed. Actions seen as a result of audits were not followed up to ensure they had been completed.

• Staff appraisals were not always completed which meant staff were not provided with an opportunity to review their skills, performance and development.

However,

• Treatment was in line with best practice guidelines and staff applied this to their practice.

• Practising privileges for consultants were up to date and monitored regularly and any changes responded to.

• Multidisciplinary team working was evident between staff of different roles and from different departments to deliver effective patient care.

Are services caring?

We rated caring as good.

• Staff were professional, kind and attentive with a focus on individualised patient care.

• Patients were kept informed at all times and included in their plan of care, this included discharge arrangements which considered the patients home circumstances. Patient’s privacy and confidentiality was respected at all times.

• Feedback from patients was positive about staff and the service they received at the hospital. Patient questionnaires indicated high levels of patients would recommend the service and a high number of patient comments were positive.

• Staff recognised how they could provide emotional support for patients including identifying anxieties and responding to put the patient at ease.

• Patients were individually supported when intimate examinations were taking place with a chaperone. The availability of a chaperone for any patient was well advertised in patient facing areas.

Are services responsive?

We rated responsiveness as good.

• Services were planned to meet patients’ needs. The hospital was meeting referral to treatment time guidance, patients had the flexibility to arrange a suitable appointment time, and the flow of patients from pre-admission through to discharge was well organised.

• The individual needs of the patients were identified and considered when delivering the patient pathway. Staff had time to explain to patients how their care would be delivered and so patients were well informed about their treatment.

• In theatres, staff were able to respond to the needs of patients out of normal working hours through the use of an on call team. Extra staffing was requested dependant on the workload.

• Complaints were managed effectively and investigations were inclusive of all individuals associated with the complaint. Clinical complaints were overseen by the matron. Learning from complaints and actions were shared with the appropriate individuals.

However,

• There was no clear process for releasing staff from their normal duties if they had been called in or worked longer shifts.

Are services well led?

We rated well-led as inadequate:

• The vision and strategy for the hospital was defined at a corporate level but not clearly defined at a hospital level. Not all services had a strategy for their department and there was not a current clinical strategy.

• There was not an effective governance framework or strategy to support delivery of good quality care.

• Governance processes were not in place and clearly defined to monitor services. Audits were not completed regularity, actions not always followed up, and there was a lack of audits at a departmental level to identify specific issues.

• There was not a complete and accurate systematic programme of clinical and internal audit to monitor quality systems and identify action. Audits were not regularly completed and the results available were not regularly reviewed to ensure they were adequate. Actions seen as a result of audits were not robust or followed up to ensure they had been completed.

• Since our previous inspection in March 2016, the planned changes in governance, risk management and quality by the provider had not been actioned at a suitable pace to ensure patient safety.

• There was no effective system for identifying, capturing and managing issues and risks at a local department level. Staff were unaware of hospital or departmental risks. Staff were unsure of how to escalate a risk to the risk register and risks were not managed or reviewed at a departmental level.

• Clear departmental management was not evident in all departments to ensure safe practice. Staff meetings did not always take place and what was discussed was not always written down for staff to review.

However,

• The corporate values, ‘The Ramsay Way,’ were understood and demonstrated by staff.

• Staff were positive about their departmental managers and the hospital management team. Staff felt management were visible and approachable.

• Since the inspection an appropriate response has been received following the issue of a requirement notice for good governance.

There were areas where the provider needs to make improvements.

Importantly, the provider must:

• There were not clear governance processes in place to monitor the service provided. Audits were not regularly completed. Actions seen as a result of audits were not followed up to ensure they had been completed.

• The provider must have in place a complete and accurate systematic programme of clinical and internal audit which can be used to monitor quality systems to identify what actions should be taken. Comprehensive audits should be completed specific to departments to allow performance and compliance to be monitored at departmental level.

• There were no local risk registers in place and no department ownership of how risks were identified and managed.

• The management of duty of candour was not well understood and its implementation not consistently practised.

• Cosmetic surgery services did not follow the company policy. Psychological reviews had not been considered, recorded or undertaken to ensure that appropriate consideration had been given around body image and patient expectations. There was no record of the cooling off period of time between initial consultation and the date for surgery. Consent for cosmetic services was not in line with company and national guidelines.

• The provider must ensure the arrangements to respond to a medical emergency in the outpatient and diagnostic imaging departments are clear amongst staff, practiced regularly and be assured the resuscitation equipment is readily available. The provider should review the single use resuscitation bag present in physiotherapy department.

• Resuscitation scenarios as a practice exercise had not taken place since July 2014. A resuscitation team had recently been implemented and part of their role was to plan and produce these scenarios. This had not yet taken place and training for this role was not planned until November 2016

• The provider must have an action in place to remove all non-compliant sinks.

• The provider must review their compliance with the Royal College of Surgeons professional standards for cosmetic practice, ensuring consent is obtained in a two-stage process with cooling off period of at least two weeks between stages to allow patients to reflect on their decision.

In addition the provider should:

• Staff should ensure that all medicines are stored securely and at the correct temperature. Staff should know how to reset thermometers and what action to take when readings are recorded outside of the recommended range.

• Medicines, including emergency medicines should be stored securely.

• A fire drill to inform staff of hospital practice should take place. No fire drill had been completed in the previous 12 months, in this time the new theatre and ambulatory carehad been opened.

• Sufficient plans should be in place for cover the following day shift for the out of hours on call theatre team, should they be called in.

• Daily testing of the critical care/resus team bleep should take place to ensure the system is effective.

• Timescales should be recorded of governance of areas reviewed by the Clinical Governance Committee which required an action plan.

• Theatre management was not evident at all levels to ensure safe practice. Leadership should be clear in the scope for their service delivery.

• Assessment of nutrition and hydration should be consistently completed to ensure effective identification of risks to patients.

• Not all staff had received an annual appraisal of their skills and performance. This should be completed for all staff.

• Service level agreements with local trusts for the transfer of patients in an emergency should be updated and the agreement signed.

• Safety review for non NHS patients should be undertaken to ensure there is an overview of patient safety.

• The provider should ensure there is a clearly documented exclusion criteria to be followed for both NHS and private patients.

• The provider should consider how patient outcomes can be monitored and measured in the outpatient and physiotherapy departments.

• The provider should review how cosmetic patients are assessed for the requirement of a psychological review.

• The provider should ensure processes are in place to assure themselves the consultants are abiding by the clinical photography policy and the photos being taken of patients are managed confidentially, kept secure and deleted on a timely basis.

• Some areas of theatre and ward environment should be reviewed to ensure their safety, these included the completion of the theatre development and an emergency call system in recovery. The management and process of damaged equipment made its replacement prolonged and should be improved.

• The provider should ensure the use of carpets in the outpatient department has been risk assessed and included on the risk register.

• The provider should consider implementing departmental risk registers to allow departmental risks to be recorded and managed effectively.

• Patient’s theatre gowns were thin material and small. This should be reviewed to ensure patient dignity and purpose.

• The outpatient department should review the risk of cross infection of staff eating and drinking in a clinical area.

• The safe use of the three-part decontamination system for nasopharyngeal endoscopes should be reviewed and goggles should be made available for personal protective equipment.

• The provider should review the layout of the outpatient department to access the sluice and the risks of dirty items being transported through clean areas.

• The outpatient department should ensure they have appropriate stock rotation in consulting and treatment rooms.

Professor Sir Mike Richards Chief Inspector of Hospitals

Professor Sir Mike Richards

Chief Inspector of Hospitals

This was a focused, unannounced inspection, which looked at surgery services. As such, we focused on specific aspects of four out of the five domains to assess whether surgery services were safe, effective, caring and well led. We did not examine the responsive domain to assess whether the service was organised in a way that met people’s needs.

Overall we found that the service was not always protecting people from risk of harm because:

• The routine management of infection control was on-going with audit tools to monitor the infection prevention practice. However, prior to and during the building work, minimal expert advice was sought and we saw that areas of the theatre department were not monitored to ensure good infection control practice during the project.
• Reliable systems were not in place to protect staff and patients from the risks associated with inappropriate waste storage.
• The security of the hospital and theatre areas in the day could not be assured and fire safety and storage of equipment was not consistently safe.
• Arrangements for managing medicines, which included handling and storage, did not always keep people safe. Staff pre prepared syringes for use and were seen to leave them unattended for periods of time. Medicine audits had not been completed to provide the service with assurance about their medicine systems.
• Not all entries in people’s individual care records were consistently written and managed in a way that keeps people safe.
• The systems used to assess if a patient was deteriorating (National Early Warning Scores) were not fully completed and placed the patient at risk.
• Theatre staff were seen to engage fully in the World Health Organisation checklist (WHO) to ensure safe practice in theatre. However audits of records were not well maintained for the provider to assure themselves that this practice was consistent.
• Staff we spoke with said their competencies had not been assessed by line management.
• We were not assured staff received a regular appraisal. In 2014, 75% of staff received an appraisal. The appraisal system was changed in 2015 and it was difficult to assess how many staff had received an annual appraisal.
• The hospital did not give due regard to providing an environment in which patients’ privacy and dignity could be maintained at all times during their care and treatment in theatre. The positioning of theatre windows in theatres one and two meant that staff could see into theatre from the main theatre corridor. Other staff could see into theatre from the rear access corridor.
• There was an annual audit programme in place in which a variety of outcomes and data were audited to monitor quality and safety. However, some audits identified areas that were not performing well, and there were no actions to show how the hospital were going to make improvements in these areas. A number of these audits were not completed at all, and some were not completed in line with their schedule

However:

• There was a governance structure in place to support the provision of good care. Staff understood who to report to and how information was shared to improve performance.
• The hospital promoted a culture of reporting and learning from incidents.