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Inspection Summary

Overall summary & rating


Updated 9 February 2017

Inspection areas



Updated 9 February 2017

  • The hospital promoted a culture of reporting and learning from incidents. Incidents were fully investigated with actions for improvement identified and put into place. Staff were familiar with the duty of candour regulation. We saw evidence it had been applied when the service investigated incidents/complaints.

  • There was a resident medical officer on duty 24 hours a day who was competent to deal with clinical emergencies.

  • The management of medicines and infection control was in place with audit tools used to monitor practice.

  • Staff were clear about safeguarding practices and knew what actions to take if they had concerns. However the service was not clear how many staff had completed their safeguarding training since the organisation had moved to a new recording system.

  • Records were stored securely and audited for compliance with protocols.

  • Nursing and medical records had been completed appropriately and in line with each individual patient’s needs.

  • Surgical safety checklists were completed as required and a modified early warning score system was in place to support staff to recognise a deteriorating patient.

  • The provider was not assured that all relevant staff had received their mandatory training since a new system of recording had been introduced within the organisation.

  • Infection rates were monitored.

  • The radiology department did not have hot water and soap to comply with recommendations for hand hygiene.

  • There were service level agreements with the local acute trust if patients needed to be transferred from New hall hospital. However the hospital did not have sufficient assurance about the maintenance and water quality in a hydro pool, which was at the local acute trust, to ensure it was safe for their patients to use.



Updated 9 February 2017

  • Needs were assessed and treatment was provided in line with legislation and using National Institute for Health and Care Excellence (NICE) guidance. Staff were aware of the guidance relevant to their area of work.

  • Policies and procedures incorporating national guidance were in place and available to all staff. Staff knew where to access guidance and policies.

  • The service had achieved Joint Advisory Group (JAG) accreditation or Endoscopy Global ratings Scale (GRS) for its endoscopy service.

  • Staff training and appraisal was ongoing. Although the provider was not assured that all relevant staff had received their mandatory training since a new system of recording had been introduced within the organisation.

  • Consent to care and treatment was discussed and obtained in line with legislation and guidance.

  • Patients had good outcomes as they received effective care and treatment to meet their needs.

  • Regular audits were carried out to monitor performance against corporate and national patient outcomes and to maintain standards.

  • Patients were at the centre of the service and the priority for staff. High quality performance and care were encouraged. All staff were engaged in monitoring and improving outcomes for patients.

  • The Medical Advisory Committee (MAC) met regularly and were proactive. Consultants were only granted practising privileges once their information had been scrutinised and agreed by the MAC.



Updated 9 February 2017

  • Patient feedback about the service was positive. Patients said staff were kind, caring and supportive. We saw staff were kind and caring, their focus being on individualised patient care.

  • The FFT response rate for NHS patients, at New Hall Hospital, ranged from 29 % in January 2016 to 34% in October 2015. This was lower than the England average of around 40%, for the same reporting period. However, the satisfaction scores were higher than the England average for the same reporting period ranging from 97% to 100% satisfaction with the service.

  • Staff ensured people’s privacy and dignity was respected. In the NHS FFT 99% of responders said they were treated with privacy, dignity and respect.

  • Staff communicated well with patients to reduce their anxieties and keep them informed of what was happening and involved in their care.

  • Relatives were encouraged to be involved in care as much as they wanted to be, while patients were encouraged to be as independent as possible. They were able to ask questions and raise anxieties and concerns and receive answers and information they could understand.

  • There were different visiting hours for NHS and self-pay patients. The service said this had come about as NHS patients usually stayed in shared bays where lengthy visiting hours had been reported, by patients, to be affecting their wellbeing. Self- pay patients always had a single room and therefore visiting was allowed for longer as it did not affect other patients. The service said if patients in shared bays wanted flexible visiting hours this could always be accommodated,

  • We observed staff treating patients with kindness and warmth. They were polite, calm and reassuring. The ward and departments were busy and well run, but staff always had time to provide individualised care.



Updated 9 February 2017

  • Services were planned to meet patients’ needs. The flow of patients through the hospital was well organised.

  • There was 24 hour medical cover on site to enable the service to respond to any emergencies

  • Patients felt well informed about their procedure and what to expect during their recovery.

  • Services were tailored to meet the needs of individual patients and were delivered in a flexible way. In June 2016 the service opened a dementia friendly room. The room had been made to look less like a hospital room and had room for family and friends to stay with the patient as necessary.

  • There was level access into the building and a passenger lift to all floors ensuring patients could move around the building.

  • Complaints were responded to in a timely manner and any learning was taken forward to develop future practice.

  • Staff actively invited feedback from patients and their relatives and were very open to learning and improvement.



Updated 9 February 2017

  • The hospital had a vision for developing the service and shared this with their staff.

  • There were clear governance processes in place to monitor the service provided.

  • Risks were identified and ways of reducing the risk investigated. Any changes in practice would be introduced, shared throughout the hospital and monitored for compliance.

  • Leadership at each level was visible. Staff felt listened to and had confidence in their managers.

  • The leadership, governance and culture of the service helped to drive and improve the delivery of high-quality care. The heads of departments were committed to the patients in their care, their staff and the ward/unit.

  • Frontline staff and managers were passionate about providing a high quality service for patients with a continual drive to improve the delivery of care.

  • Staff said they were proud of their ward/departments as a place to work. They showed commitment to the patients, their responsibilities and to one another. All staff were treated with respect and their views and opinions heard and valued.

  • Patients were able to give their feedback on the services they received; this was recorded and acted upon where necessary

  • Audit and governance processes were in place and reported to leadership and governance committees.

  • The service ensured they were using skills and experience of organisations and specialists independent of the hospital
Checks on specific services

Outpatients and diagnostic imaging


Updated 9 February 2017

  • Incidents were reported and acted upon and risk was managed. Feedback and learning was shared with staff.

  • Treatment and care were effective, and delivered in line with best practice and recognised national guidance.

  • Patients were at the centre of the service and the priority for all staff. Feedback from people who had used the service was positive. Patients spoke very highly of the staff and the care and support they were given.

  • Patients received care from dedicated, caring staff who were skilled in working with and communicating with patients and their families.

  • Services were designed and delivered to meet patient’s needs.

  • There were clear lines of accountability and lines of management in place. The management team were described as approachable. The culture of the service drove improvement and the delivery of high quality care.

  • There were clear systems in place for managing governance and measuring quality.



Updated 26 July 2018