North Downs Hospital

We carried out a comprehensive inspection of North Downs Hospital on the 17 and 18 May and 1 June 2016 as part of our national programme to inspect and rate all independent hospitals. We inspected the core services of surgical services and outpatients and diagnostic services as these incorporated the activity undertaken by the provider, Ramsay Health Care UK Operations Limited, at this location.

We did not inspect a private GP service which operates at this location as this is a service from another provider. Physiotherapy services at this location were provided from a third party on a contract basis to the location, and likewise were not inspected.

We rated the both core services, and the hospital as good overall. However, we found that safety in the outpatient department required improvement because we had concerns about the suitability of the environment and had insufficient assurance in relation to the maintenance and use of some equipment.

Are services safe at this hospital?

We found improvements were required to minimise risks and promote safety.

• In the outpatient department, we found that the clinical environment did not meet national guidelines, for example in the design of sinks or floor coverings which could lead to ineffective prevention of infection.
• We also found that in this department there were insufficiently robust systems to maintain and calibrate equipment in use.
• There were insufficiently robust systems for control of prescription pads to prevent potential mis-use. Medical gases were not securely stored.
• We also found that mandatory training rates in some topics were below 50% in all departments so the provider could not be assured of the skills and competence of staff providing care. The hospital did not have systems to be assured of the qualifications of external staff working as first assistants.

However, we also found:

• There were systems for the reporting and investigation of safety incidents that were well understood by staff.
• Staff could demonstrate their understanding of the duty of candour and provide examples of its implementation.
• There were arrangements to transfer patients whose care needs exceeded what the hospital could safely provide, and saw that staff used these processes when patients’ conditions required this.
• We found suitable medical cover at all times from a resident medical officer and on-call consultants and noted arrangements for consultants to provide cover for absent colleagues.
• There were sufficient numbers of nursing and support staff to meet patients’ needs.
• We saw there were efficient and effective methods for the handover of care between clinical staff.
• There was a designated lead for safeguarding vulnerable adults and staff were trained appropriately to recognise and report suspected abuse in vulnerable adults.

Are services effective at this hospital?

• We found there were arrangements to review guidance from national bodies such as the National Institute for Health and Care Excellence (NICE) and that care was delivered in line with best practice.
• There was a system for reviewing policies and these were discussed at the medical advisory committee (MAC) and other governance forums at the hospital.
• Care was continually monitored to ensure quality and adherence to national guidelines to improve patient outcomes and the hospital participated in relevant national audits and benchmarking activities.
• Patient outcomes were good when benchmarked against national standards. There were no concerns regarding rates of unplanned admission, return to theatre or transfer to another hospital.
• We found arrangements that ensured that doctors and nurses were compliant with the revalidation requirements of their professional bodies. All consultants had clear practising privileges agreements which set out the hospitals expectations of them, and ensured they were competent to carry out the treatments they provided.
• Systems for obtaining consent were compliant with legislation and national guidance, including the Mental Capacity Act (2005) and these were adhered to by staff.

Are services caring at this hospital?

• We observed that patients were treated with dignity and respect and their privacy was maintained.
• We saw that staff offered appropriate emotional support.
• Patients who share their views said they were treated well, with compassion, and that their expectations were exceeded.
• We saw that results of the friends and family test and other patients satisfaction surveys demonstrated that patients would recommend the hospital to others.

Are services responsive at this hospital?

• Services were planned to meet the needs of patients.
• We saw that some services operated in the evenings and at weekends to give patients flexible access to these services.
• We saw examples of systems to support patients living with dementia and learning difficulties. The environment allowed for patients with physical disabilities to be safely cared for.
• The hospital was exceeding national referral to treatment time standards.
• Patients were assessed prior to admission to ensure that hospital could safely meet their needs.
• There was a robust complaints procedure, which was well publicised and understood by staff. Complaints were investigated, actions taken to resolve issues and there was learning evident from the content of complaints.

Are services well led at this hospital?

• We found that staff were conversant with the corporate vision and values and strove to demonstrate these in their daily work.
• There was an appropriate system of governance and mangers knew the key risks and challenges to the hospital and were taking steps to mitigate the impact of these.
• However, the management team had limited understanding of the Workforce Race Equality Standard (WRES) despite this being a national requirement, and were yet to consider how this would be implemented locally.
• Practising privileges were received, authorised and granted in conjunction with the Medical Advisory Committee  and kept under review.
• There were clearly defined and visible local leadership roles and managers provided visible leadership and motivation to their teams.
• The provider was responsible for ensuring that those in director level roles fulfilled the fit and proper person test.
• Managers were aware of the need to develop their service and to ensure its sustainability by responding to new markets.
• We saw examples of initiatives that were introduced to improve patient experience and to ensure the safety and quality of care kept pace with new developments and growing expectations.

Our key findings were as follows:

• There were adequate systems to keep people safe and to learn from critical incidents.
• The hospital environment was visibly clean and well maintained and there were measures to prevent the spread of infection.
• There were systems to ensure the safe storage, use and administration of medicines.
• There were adequate numbers of suitably qualified, skilled and experienced staff (including doctors and nurses) to meet patients’ need. There were arrangements to ensure staff had and maintained the skills required to do their jobs.
• There were arrangements to ensure people received adequate food and drink that met their needs and preferences.
• Care was delivered in line with national guidance and the outcomes for patients were good when benchmarked.
• Robust arrangements for obtaining consent ensured legal requirements and national guidance were met.
• The individual needs of patients were met including those in vulnerable circumstances such as those learning disability or dementia.
• Patients could access care when they needed it.
• Patients were treated with compassion and their privacy and dignity were maintained.
• The hospital was managed by a team who had the confidence of patients and their teams. Staff felt motivated by the management team.
• There was appropriate management of quality and governance at a local level and managers were aware of the risks and challenges they needed to address.

There were also areas of where the provider needs to make improvements.

Importantly, the provider must:

• Improve compliance with its mandatory training programme.
• Ensure first assistant have the necessary skills and competence to carry out their roles.
• Store medical gases securely, and have systems to minimise the mis-use of prescription pads.

In addition the provider should:

• Carry out planned works without delay to ensure clinical areas comply with Health Building Note (HBN) 00/10 Part A Flooring (DH 2013).
• Consider the controls in place for the monitoring and provision of prescription slips in the outpatient department to ensure they are sufficiently robust.
• Review the arrangements for Portable Appliance Testing it ensure it is consistent and that all relevant electrical items carry a certificate of testing notice.
• Assess the risks of the use of oxygen cylinders and the absence of piped medical gases.
• Consider the arrangements that ensure the completion of action points following learning from an incident.
• Review the use of latex gloves in theatres.

Professor Sir Mike Richards

Chief Inspector of Hospitals