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Inspection carried out on 12 April 2021 to 15 April 2021

During an inspection looking at part of the service

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 carried out on 3 - 4 July 2017

During a routine inspection

Oaklands Hospital is operated by Ramsay Health Care UK Operations Limited. The hospital has 17 inpatient beds. Facilities include three operating theatres with laminar flow and a designated endoscopy theatre, one inpatient ward with 17 beds, a day case unit and X-ray, outpatient and diagnostic facilities.

The hospital provides surgery and outpatients and diagnostic imaging. We inspected both of these services.

We inspected this service using our comprehensive inspection methodology. This inspection was unannounced. We carried out the inspection on 03 and 04 July 2017.

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 core service.

Services we rate

We rated this hospital as Good overall. This is because whilst the hospital has made significant progress and improvement since their last inspection, there are still areas which require further work and improvement.

We found the following areas of good practice:

  • Incidents were reported, investigated and learned from in an appropriate way.

  • Infection control and prevention was managed effectively with low rates of hospital acquired infections.

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

  • There had been a significant improvement in the management of medications.

  • Levels of mandatory training had greatly improved since the last inspection.

  • Correct numbers of suitably qualified staff were deployed.

  • Evidence based practice was followed and appropriate audits of compliance with best practice were undertaken.

  • Nutrition and hydration were effectively managed.

  • There was good multi-disciplinary team working observed throughout the service.

  • Staff obtained informed consent from patients prior to undertaking interventions and surgery.

  • Patient outcomes were good.

  • Staff in the surgical service had good knowledge of both the Mental Capacity Act and Deprivation of Liberty Safeguards.

  • The service was responsive to the needs of patients and the local population and patients experienced minimal waits.

  • The service was well led with clear and credible leaders, who were visible and supportive of staff.

  • There had been significant improvements since the last inspection and robust plans were in place to sustain these improvements.

  • Staff and the public were sufficiently engaged.

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

  • The hospital participated in national audits.

  • 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.

We found the following areas of practice that require improvement:

  • In one theatre area we found dust and brown splashes on the walls. We raised this with the hospital management team and they dealt with the issue quickly.

  • Although the management and recording of controlled drugs had improved significantly, there were still areas for improvement in one area of the theatres. Timings relating to controlled drugs and other medication administration in theatre were poorly recorded in half the records we reviewed.

  • Some nursing records used in the pre-operative phase did not contain sufficient details about patients’ care and lacked dates and times.

  • We reviewed ten sets of patient records and in six out of ten records we found at least one section of the records had not been completed.

  • We found in some cases key risk assessments had not been completed fully, including the anaesthetic pre-assessment record form, venous thromboembolism.

  • We observed teams undertake the ‘five steps to safer surgery’ procedures, including the use of the World Health Organization (WHO) checklist. We observed that the ‘time out’ phase was not always completed fully.

  • Although improved, nurse staffing in the theatre areas remained a challenge.

  • Uptake levels for some mandatory training subjects were significantly lower than expected.

  • Although improved, the percentage of staff that had an annual appraisal remained low.

  • 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% however this had improved since the last inspection.

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

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 both services. Details are at the end of the report.

Ellen Armistead

Deputy Chief Inspector of Hospitals (North West)

Inspection carried out on 4 to 5 October 2016

During a routine inspection

Oaklands Hospital is operated by Ramsay Health Care UK Operations Limited. The hospital has 17 inpatient beds. Facilities include four operating theatres, one inpatient ward, a day case unit and X-ray, outpatient and diagnostic facilities. The hospital also has plans to open a two-bedded level two facility to accommodate patients with a higher level of clinical need, but not requiring a full intensive care facility; however, this was not in use at the time of our inspection

The hospital provides surgery and outpatients and diagnostic imaging. We inspected both of these services.

We inspected this service using our comprehensive inspection methodology. We carried out the announced inspection on 4 and 5 October 2016 and an unannounced visit to the hospital on 13 October 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 surgery – for example, management arrangements – also apply to other services, we do not repeat the information but cross-refer to the surgery core service.

We rated this hospital as inadequate overall. We served warning notices against the provider and the registered manager following a breach of Regulation 12 Safe care and treatment (Health and Social Care Act 2008 (Regulated Activities) Regulations 2014). This was because there was a failure to assess the risks to the health and safety of patients and to take action to mitigate such risks. The hospital also failed to ensure staff had the necessary qualifications, competence, skills and experience to provide safe care and treatment. Medicines were not managed properly or safely. You can read more about it at the end of this report.

We also served warning notices against the provider and the registered manager following a breach of Regulation 17 Good governance (Health and Social Care Act 2008 (Regulated Activities) Regulations 2014). This was because systems and processes were not operated effectively to assess, monitor and improve the quality and safety of the services provided. There was inadequate management of the risks relating to the health, safety and welfare patients who may be at risk. You can read more about it at the end of this report.

  • Safety was not a sufficient priority. Standard operating procedures and processes designed to keep people safe were not always followed.
  • Staff did not always assess and mitigate risks to patients’ safety. This included poor compliance with the completion of important risk assessments.
  • Patients were at risk of avoidable harm during surgery, because on some occasions anaesthetists did not provide them with the expected level of care.
  • Most staff in the theatre and in the recovery area did not have the correct level of training to care for patients in the event of a respiratory or cardiac arrest.
  • Medicines and other substances were not always stored safely. Controlled drugs were not managed safely and were managed contrary to legislation and national guidelines.
  • Records were poorly maintained and lacked key information, including details of individualised patient risk assessments.
  • Senior staff had little assurance that the temporary staff employed had the relevant qualifications, experience and competence to undertake their role. Systems and processes to check the competence and qualifications of these staff were not robust.
  • There were substantial and frequent staff shortages, which resulted in an over-reliance on agency and bank staff to supplement the staffing establishment. The hospital did not have adequate systems and processes in place to check the skills and competencies of these staff.
  • Governance and risk management systems were not used effectively to ensure the safety of patients and the quality of care delivered.
  • Staff, including senior managers, did not recognise, assess and mitigate risks appropriately.
  • Action was not always taken when areas of serious concern were identified and as a result poor and unsafe practice was allowed to continue.
  • There was a culture of fear within theatres, which resulted in staff not challenging unsafe behaviours.
  • Mandatory training rates were 63.9%, which was significantly below the hospital target of 100%. This included very low numbers of staff undertaking mandatory training in safeguarding children and adults. An example of this was that no staff in the theatre areas had completed level two safeguarding adults training.
  • Staff were not fully aware of their responsibilities in relation to the Mental Capacity Act (2005) and did not receive training in relation to this.
  • Staff were unaware of the hospital’s dementia strategy and only 34.9% of staff had received training on dementia.
  • There were no specific arrangements in place to make reasonable adjustments or considerations for patients with a learning disability or living with dementia.
  • The hospital patient led assessment of the care environment (PLACE) score for the environment for patients with a disability was lower than the England average of 81%.
  • Complaints were sometimes responded to in a defensive way and improvements in the complaints handling process were not yet embedded.
  • There was no credible local vision or strategy for the service and there was a lack of robust governance and risk management systems.
  • Staff and the public were not engaged sufficiently.

However,

  • Staff were aware of how to use the incident reporting system and feedback from incidents was consistent.
  • Infection rates were low. Clinical areas and waiting areas were visibly clean and there were systems in place to prevent the spread of infections.
  • There was appropriate equipment to safely provide care and treatment for patients in the departments. The equipment was well maintained and tested to ensure its safety and effectiveness.
  • Medical staffing was sufficient and patients received care according to national guidelines from organisations such as the National Institute for Health and Clinical Excellence (NICE) and the Royal Colleges.
  • The hospital participated in national audits. Findings from patient reported outcome measures (PROMs) showed most patients had a positive outcome following their care and treatment.
  • 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.
  • There was sufficient capacity for patients to be seen promptly and be cared for in the most appropriate environment.
  • Between July 2015 and June 2016, the hospital consistently met the national standard of 92% of incomplete pathways for patients beginning treatment with 18 weeks of referral.
  • The hospital met the indicator of 90% of admitted NHS patients beginning treatment within 18 weeks of referral for each month between June 2015 and June 2016.
  • Staff had a good knowledge of the complaints process so could direct patients if they had a complaint about the service.

In surgery:

  • The senior managers responsible for theatres did not effectively manage or lead the area.
  • Local audit findings were not always acted on to ensure necessary improvements.

However,

  • Nutrition, hydration and pain relief was managed effectively.
  • Staff spoke positively about the inpatient ward manager and matron.

In outpatients:

  • Only 50% of staff in the outpatient department had completed level two safeguarding training for children.
  • We found equipment in the paediatric resuscitation trolley, which was outside of the manufacturer’s recommended expiry date. This demonstrated that adequate checks were not being carried out.
  • We found that not all clinical waste was being properly stored in the outpatient department, as a sharps bin in the clean utility room was being used for the disposal of contraceptive coils.

However,

  • The departments kept a record of the competencies of all staff and new staff underwent an induction programme to prepare them for working at the hospital.
  • Staff were positive about the leadership of the departments and told us local managers were supportive of them.

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 warning notices that affected the surgical and outpatients and diagnostic imaging departments. Details can be found at the end of the report.

Ellen Armistead

Deputy Chief Inspector of Hospitals (North Region)

Inspection carried out on 26 November 2014

During a routine inspection

Oaklands Hospital is a private hospital located in Salford, Greater Manchester that provides planned (also known as elective) treatment. The hospital is part of Ramsay Health Care UK Operations Limited.

The hospital was built in 1991 and has 24 beds in total made up of 15 single bedded rooms (all with en-suite facilities) and three 3 bed ambulatory units.

Oaklands Hospital provides treatment for patients of all ages (excluding children below the age of three years for inpatient care) whether medically insured, self-funding or from the NHS. The hospital offers a range of treatments and services including ear, nose and throat (ENT) procedures, maxillofacial surgery, plastic surgery, dermatology, gynaecology, general surgery, orthopaedics, ophthalmic and urological procedures. Diagnostic facilities include CT, barium studies, ultrasound, MRI and DEXA for bone density, in addition to general radiology.

A major development commenced in July 2014 which is due for completion in April 2015. This will add a 3rd laminar flow theatre, minor ops/ endoscopy suite, expansion of the outpatients department, inpatient capacity and physiotherapy; replacement of imaging facilities and a purpose built ambulatory care facility. Part of the building redesign will also include the development of a new 2 bed high dependency unit.

We carried out an announced inspection of Oaklands Hospital on 26 November 2014. Due to the range and nature of services provided at the hospital we did not carry out an unannounced inspection.

Our key findings were as follows:

Leadership

  • There were clearly defined and visible leadership roles throughout the service
  • Staff were highly motivated and positive about their work. They received good support from their managers and the matron.

Cleanliness

  • We found the preoperative assessment area, ward areas, outpatients area and theatre areas were visibly clean, well maintained and mostly in a good state of repair. Where building work was being conducted, appropriate measures had been put in place to keep disruption and debris to a minimum.

Infection control

  • The hospital reported there were no cases of Methicillin-resistant Staphylococcus Aureus (MRSA) bacteraemia infections or Clostridium Difficile (C.diff) infections at the hospital between April 2013 and November 2014.
  • All patients admitted underwent MRSA screening. Patients identified with an infection could be isolated in side rooms to minimise cross infection risks.
  • Staff were aware of current infection prevention and control guidelines and we observed good practices such as hand hygiene and ‘bare below elbows’ guidance.
  • However, infection control checking mechanisms were not always effective and we found five mattresses on the ward that were stained on the inside of the mattress covers.
  • We found that procedure packs returned from the sterilisation facility frequently had pin-holes in the packaging. Theatre staff checked all packs prior to use to minimise risk. This had been identified by the hospital as a potential infection control risk and actions were being taken to address the matter with the sterilisation facility.

Incidents

  • Staff we spoke with were confident about reporting incidents, near misses and poor practice via the electronic reporting database and there was evidence of learning from incidents.
  • However, the reporting database did not always reflect up to date information about the incident and the actions taken as a result. This made it difficult to ascertain what action had been taken.
  • The hospital performed root cause analysis investigations for serious untoward incidents. However we looked at an example report and found it explained the incident and the action taken but did not fully analyse and identify possible causal factors.

Treatment of children and safeguarding

  • Oaklands treated low numbers of children. The majority of children treated at the hospital were aged 15 years and over who attended for ENT procedures. The hospital did not treat children below the age of three years for inpatient care.
  • All the nursing staff received level 1 children and young people safeguarding training and the ward manager was due to complete level 3 safeguarding. This was not in line with best practice guidance which states all clinical staff should receive at least level 2 children and young people safeguarding training. At the time of our inspection the hospital calculated that only 52% of staff had received safeguarding children training in the last 12 months.
  • There were three dedicated rooms for children within the ward area. This was in line with best practice standards.
  • Where a paediatric patient was referred to the service, the staff were able to source paediatric trained agency nurses to ensure care was provided by appropriately trained staff. Treatment was performed by paediatric surgeons and anaesthetists.

Staffing levels

  • The hospital did not have a full establishment of trained permanent staff. Staffing levels were maintained through the use of bank and agency staff to ensure that staffing levels met patients care needs. The hospital had robust systems in place to ensure agency staff had appropriate training and qualifications and were competent to carry out their role. All bank and agency staff received an induction prior to commencing work at the hospital

Nutrition and hydration

  • Patient records included an assessment of patients’ nutritional requirements.
  • Patients told us they were offered a choice of food and drink and spoke positively about the quality of the food offered.
  • The hospital undertook a nutrition and hydration audit in June 2014 and found they were 52% compliant with systems and processes in place to support nutrition and hydration in patients. Following training provided to staff in September 2014, a re-audit was undertaken in October 2014 which demonstrated they had improved; results showed they were 92% compliant.

There were some areas of poor practice where the provider needs to make improvements.

Importantly, the provider must:

  • so far as reasonably practicable ensure that people are protected against the identifiable risks of infection by:-
  • (1) maintaining the appropriate standards of cleanliness and hygiene in relation to reusable surgical instruments used for surgery such that theyare sterilised appropriately and are fit for purpose at the point of use
  • (2) having in place an effective audit system and checking mechanisms for infection prevention and control so that they identify areas of concern in a timely manner.

In addition the provider should:

  • ensure the systems used for reporting and recording incidents clearly identify the actions taken and any subsequent root cause analysis fully analyse and identify possible causal factors.
  • Consider providing staff with at least level 2 children’s safeguarding training in line with best practice requirements.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 27 February 2014

During an inspection looking at part of the service

We inspected Oaklands Hospital to follow up on actions taken in respect of the compliance action issued, following concerns at our last inspection in November 2013.

We found that staff had undergone training in relation to the highlighted issues.

We did not speak to any patients on this inspection but spoke to two members of the senior management team.

We looked at seven patient records which were paper based and tracked the patient experience through the departments of the hospital.

We found care and treatment was now planned and delivered in a way that ensured people's safety and welfare.

Inspection carried out on 5 November 2013

During a routine inspection

On the day of the inspection we spoke with two patients, five staff and the registered medical officer.

We found robust safeguarding arrangements were in place at Oaklands Hospital to ensure the safety of all patients attending the service.

Patients using this service gave valid consent to examination and treatment and were given sufficient information to enable them to make informed choices.

Patients and staff were not at risk from unsafe or unsuitable equipment.

We looked at four patient records which were paper based and tracked the patient experience through the departments of the hospital. We found care and treatment was planned but not always delivered in a way that was intended to ensure people's safety and welfare.

Oaklands Hospital had a robust process in place to monitor and evaluate the quality of the service offered to clients. There were up to date policies and procedures in place to ensure the safety of both staff and patients.

Staff told us; �We have had lots of training and we are well supported by the matron and the managers. I really enjoy my job�. �We work well as a team and support each other. I don�t like to go home if I know my colleagues will be left under pressure so I will stay and help them over the difficult period then go. I know I will always be able to get my time back and patients come first with me�.

Inspection carried out on 25 February 2013

During an inspection looking at part of the service

During this follow up inspection we visited the ward areas where we spoke with three members of staff. We looked at records of cleaning and maintenance for the ward and checked all ancillary areas. All areas were found to be clean and repairs had been carried out on area identified at the last inspection. We saw that storage had been addressed by the staff and equipment was now stored in the correct location.

Staff told us: "We have made some changes since the last inspection". "We take pride in our environment so have made sure it is now correct".

Inspection carried out on 3 October 2012

During a routine inspection

During our inspection of Oaklands Hospital we visited the hospital's main ward where we spoke with four patients and several members of staff.

Patients told us that staff were kind and caring, helped them when they needed and treated them with dignity and respect. Nobody had any concerns about their care and they said if they did they would have no worries about raising them. For example, one patient told us; �I am very satisfied and happy. I have all the help I need. I only have to ring and they come.� Another said; �I am very happy with my care and can�t speak highly enough of them all.� And another; �It�s very good on this ward. I have no complaints whatsoever. Nothing is too much trouble for the staff.�

The patients we spoke with all commented positively on the cleanliness of the hospital. The main ward area and the patient rooms we looked in were clean. However we did observe some concerns about the cleanliness, organisation and state of repair of some of the ward's ancillary rooms which meant that patients were not fully protected from the risk of infection.

We looked at patient care records, medication records, staff training documentation and examples of the hospitals quality monitoring and assurance processes. The records we reviewed assured us that the provider had taken appropriate steps to ensure patients' care and welfare needs were met and they were protected from the risks of unsafe or inappropriate care.

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