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Inspection Summary

Overall summary & rating


Updated 27 May 2021

We carried out a focussed inspection of the surgery core service. We did not rate the service at this inspection, and all previous ratings remain.

We inspected this service because we had received information of concern. These concerns included;

  • Numerous whistle-blowers between July 2020 and April 2021 to CQC around staffing and culture. This was discussed during a Transitional Monitoring Approach (TMA) call in February 2021, the management team believed they were well staffed and there had been no concerns voiced to them.
  • All the senior leadership team were new to post within the previous 24 months. They were, however, able to describe and discuss the action plans that were in place.
  • A specific incident regarding the ability and competence to perform nerve block procedure when required.
  • An incident when the lack of available drugs for a procedure impacted on a person who used the service.
  • A review of enquiries made to CQC between December 2019 and December 2020 highlighted concerns including three cases relating to the escalation of the unwell patient which resulted in negative outcomes for the service user.
  • We also noted that the hospital had reported two never events where wrong site surgery was performed, between February 2019 and December 2020. Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them.

During our inspection we found;

  • The service provided mandatory training in key skills to all staff and made sure everyone completed it. However, there was one area which required improvement and the provider had actioned appropriately. This was an improvement on the last inspection.
  • The service controlled the risks associated with infection well. The service had a policy to support the prevention of surgical site infections. Staff used equipment and control measures to protect patients, themselves and others from infection. They kept equipment and the premises visibly clean. However, we noted that some areas did not have sufficient hand sanitiser available and this was not always utilised.
  • The design, maintenance and use of facilities, premises and equipment kept people safe. Staff were trained to use them. Staff managed clinical waste well.
  • Staff completed and updated risk assessments for each patient and removed or minimised risks, this was an improvement on the last inspection. Staff used a recognised tool to identify deteriorating patients however this was a paper-based system that was not always adhered to, but plans were in place to improve.
  • The service had enough nursing and support staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix, and gave bank and agency staff a full induction.
  • The service had enough medical staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix and gave locum staff a full induction.
  • Staff kept detailed records of patients’ care and treatment. However, the information needed to plan and deliver effective care, treatment and support was not always available at the right time. Records were stored securely.
  • The service used systems and processes to safely prescribe, administer, record and store controlled medicines.
  • The service managed patient safety incidents well. Staff recognised and reported incidents and near misses. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support. Managers ensured that actions from patient safety alerts were implemented and monitored.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
  • Leaders had the skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in the service for patients and staff. They supported staff to develop their skills and take on more senior roles.
  • Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service promoted equality and diversity in daily work and provided opportunities for career development. The service had an open culture where patients, their families and staff could raise concerns without fear.
  • Leaders operated effective governance processes, throughout the service and with partner organisations. Staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service.
  • Leaders and teams used systems to manage performance effectively. They identified and escalated relevant risks and issues and identified actions to reduce their impact.
Inspection areas


Requires improvement

Updated 27 May 2021



Updated 27 May 2021



Updated 27 May 2021



Updated 27 May 2021



Updated 27 May 2021

Checks on specific services



Updated 27 May 2021

We carried out a focussed inspection of this service. We did not rate the service at this inspection and all previous ratings remain.

The summary of what we found can be found in the overall summary above.

Outpatients and diagnostic imaging


Updated 18 December 2017

We rated this service as good because:

  • Infection rates were low. Clinical areas and waiting areas were visibly clean.

  • There was appropriate equipment to safely provide care and treatment for patients in the departments.

  • Staffing was sufficient and patients received care according to national guidelines.

  • The hospital participated in national audits.

  • There was good multidisciplinary working between consultants, nursing staff and allied health professionals.

  • Staff treated patients with kindness, dignity and respect and provided care to patients while maintaining their privacy, dignity and confidentiality.

  • The hospitals Friends and Family test showed that patients were happy with the care they received.

  • Staff had a good knowledge of the complaints process so could direct patients if they had a complaint about the service.

  • The service was well led with robust governance and risk processes in place.


  • The arrangements for stock reconciliation for medications was not always clear in the outpatient department.

  • Not all staff were aware of what constituted a reportable incident.

  • The percentage of staff that had received an annual appraisal was lower than the expected target of 90%.

  • Staff within the service had a varied level of knowledge in relation to the Mental Capacity Act.