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Inspection Summary

Overall summary & rating


Updated 28 December 2016

Renacres hospital is an independent hospital, based in a rural location near Southport and is part of Ramsay Health Care UK. Renacres hospital is registered to provide the following regulated activities:

  • Diagnostic and screening procedures.

  • Surgical procedures

  • Family planning services

  • Treatment of disease, disorder or injury.

Our key findings were as follows:

  • Safety Thermometer information between June 2015 and June 2016 showed there were no pressure ulcers, falls with harm or catheter urinary tract infections reported by the hospital relating to surgical services.

  • Systems were in place to protect people from healthcare associated infections. There had been no cases of MRSA or clostridium difficile at the hospital. There was a lead nurse for infection control that was given protected time in her job role. There were monthly infection prevention audits and hand washing audits

  • Staffing levels were good at the hospital and sickness levels were low. Use of agency staff was low as there was a bank of existing staff that were happy to work additional hours. There was a corporate workforce policy, though senior managers felt that it needed to be strengthened to retain and recruit nursing staff. The Ramsay group was looking at international recruitment for nurses. However, skill mix was not always appropriately used at the hospital. In theatre some of the health care assistants had been trained as first scrub assistants but elsewhere in the hospital there were fewer opportunities. On the ward, trained nurses were cleaning equipment and in the OPD blood was taken by trained nurses. These tasks could be delegated to lower banded staff following appropriate training and competency assessment.

  • Mandatory training levels were good; the hospital informed us that all eligible staff had completed their training. We were shown a completed training matrix for staff and signing in sheets for the face to face sessions.

  • The (resident medical officer) RMO was available 24 hours a day seven days a week and had full access to the consultant surgeon and anaesthetists details. Nursing staff said that they worked well with the RMO but if they had concerns they would contact the consultants directly.

  • There were robust systems in place to ensure that information was communicated with the patients GP.

  • There was a clear patient exclusion criteria to identify patients who were not suitable for surgery at Renacres hospital.

  • The hospital had a ‘management of patient complaints’ policy in place. The rate of complaints received was lower than other independent hospitals. No complaints progressed to the Ombudsman or to ISCAS (Independent Healthcare Sector Complaints Adjudication Service), or were received by CQC in this period.

  • There was a corporate risk register. The current register recorded 10 risks; six of which related to financial risks. The remainder included a number of risks that were not relevant or of very low risk to Renacres hospital. The risk registers were an agenda item on the health and safety committee, which was not attended by the MAC chair; this meant that there was no clinical ownership of risk. Risks were reviewed annually. There were risk registers for clinical areas, some of these had review dates and actions and others did not. Risks were reviewed at the health and safety meetings and did not feed into the corporate risk register.

  • There was a policy in place for the granting of admitting rights and/or practising privileges to health care professionals. Compliance with the policy was mandatory for all consultants, staff and accredited healthcare professionals and approval needed to be granted at a local and national level. Consultants could only practice at the hospital what they practiced in the NHS and the MAC chair would look at the number of procedures that had been carried out in the NHS and the training logs of the consultants, he would also look at local data available on the consultants e.g. complication rates and infection rates

  • Consultants had to provide evidence of revalidation and indemnity insurance. If they did not, payments were withheld The MAC chair was about to start the appraisal training so that he could undertake consultant appraisals.

  • Some of the consultants did not work in the NHS, including the MAC chair; he discussed the robust processes for revalidation and appraisals. Although the hospital were keen to recruit new consultants, the MAC chair said that he would be comfortable refusing a potential new consultant practising privileges if necessary.

  • The MAC chair audited consultants practice and could benchmark this against other consultants in the Ramsay group and identify individual consultants who were outliers. He was proud of his service and the level of governance at the hospital.

  • The hospital had a responding to concerns about a doctor’s practice policy in place. It set out the actions to be taken when concerns were raised about any GMC registered doctor in the hospital. The policy did not set out any details about informing other local healthcare providers about the concerns but the MAC chair said that he would always write to the medical director of the employing trust outlining his concerns if there were any issues about a doctor and he gave us a specific example where this had happened.

  • Staff could be nominated for customer service excellence awards, these were for staff who had gone the extra mile in their work, we saw three nominations for staff working at Renacres.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas



Updated 28 December 2016

We found services to be safe at Renacres hospital,

  • this was because systems and processes were in place to report incidents and to ensure learning from these incidents. During the inspection we saw letters to patients that outlined the duty of candour. The duty of candour is a regulatory duty that relates to openness and transparency and requires providers of health and social care services to notify patients (or other relevant persons) of certain ‘notifiable safety incidents’ and provide reasonable support to that person.

  • There was a lead nurse for safeguarding and staff had received training in safeguarding for vulnerable adults for children and young people. No safeguarding concerns had been raised. All eligible staff had attended mandatory training.

  • Systems were in place to protect people from the risk of healthcare related infections and there were no reported healthcare related infections at the hospital in the period April 2015 to March 2016 and there were no reported incidents of acquired venous thromboembolism or pulmonary embolism in the same period.

  • The environment was visibly clean and tidy and there were audits every six months. Action plans were in place, if appropriate and were reviewed.

  • Records were kept securely and consultants were not allowed to remove records from the hospital. Records removed from the hospital to the GP surgery outreach clinics were transported in lockable boxes.

  • Medicines were stored appropriately and there were pharmacy audits and controlled drugs audits completed.

  • Staffing levels were planned and implemented to ensure that there were sufficient staff to provide safe care. This included the resident medical officer (RMO) cover. There was very low use of agency staff.

  • However, there had been one never event, these are serious, wholly preventable incidents that should not occur if the available preventative measures had been implemented. This had involved wrong site surgery and a root cause analysis had been carried out and lessons learned by the organisation.



Updated 28 December 2016

We found services to be effective at Renacres hospital ,

  • this was because patients received care and treatment according to national guidelines such as National Institute for Health and Clinical Excellence (NICE) and the Royal Colleges.

  • The chair of the medical advisory committee (MAC) was extremely efficient and described robust practising privileges processes. The MAC met every three months, had well-structured agendas with items including National Institute for Health and Care Excellence(NICE) guidelines, consent, audits, complaints and policies. Meetings were well attended with consultants from the range of specialities provided at the hospital and by the matron and the registered manager. The MAC chair was a member of the clinical governance committee at the hospital linking the MAC to the hospital. Consultant revalidation processes were good with evidence of revalidation kept by the hospital.

  • The hospital participated in the national joint registry and the Joint Advisory Group for endoscopy accreditation scheme (JAG GRS) and they reported on PROMS from patients for hip and knee replacement and groin hernia. PROMS are patient report outcome measures which describe the level of patient satisfaction and in the period April 2014 and March 2015 the percentage of NHS-funded patients with improved outcomes following groin hernia, hip replacement and knee replacement procedures was similar to the England average

  • Renacres was part of a standard NHS contract with two other North West Hospitals in the Ramsay group. There were commissioning for quality and innovation commissioning (CQUIN) targets in place. The results enabled them to monitor performance compared to the other two local Ramsay hospitals. e.g. advancing quality audits for hips and knee joint replacements. There were low rates of unplanned readmissions to theatre within 28 days of discharge; there had been four in the period April 2015 to March 2016. There had also been two unplanned returns to the operating theatre in the same period.

  • There was a recently established continuous improvement working group. This multi-disciplinary group had representation from across the hospital with a focus on quality improvement, performance monitoring and improving the patient experience.

  • Multi-disciplinary working was good and there was effective communication between different staff groups. There were good consent processes in place and staff were aware of the policies and processes of the mental capacity act and best interest meetings were used as appropriate.

  • The copy of the consent policy that we reviewed expired in January 2016.



Updated 28 December 2016

We found services to be caring at Renacres hospital,

  • this was because we observed that patients were treated with kindness and compassion by all staff. Feedback from patients was very positive and they informed us that they were fully involved in their care and that staff explained procedures to them. Patients told us that they were treated with kindness and compassion by all staff and spoke positively about the care they received and were fully involved in their care and staff explained procedures to them. Privacy and dignity was respected at all times. Patient’s relatives and carers were involved in consultations when appropriate.

  • In the friends and family test in the period October 2015 to June 2016 the hospital frequently scored 100% with responses above the England average, these ranged between 55% and 96%. In the hospitals own patient satisfaction survey over the past year the lowest score was 93.9% and the highest was 100% for two months.

  • Healthwatch had undertaken a patient experience survey in November 2015 and the hospital had scored highly for care and compassion, 4.8 out of 5. A patient said it was an excellent service another said the service was fantastic.

  • There were examples where staff had gone the extra mile for patients; taking medicines to patient’s homes on the day of discharge so that they would not have to wait for them and also taking items that patients had left at the hospital to their homes to prevent an additional trip to the hospital. The catering team would go onto the ward if patients had not eaten their meals to find out if there was anything that they could make for the patient and if so this would be prepared for them.



Updated 28 December 2016

We found services to be responsive at Renacres hospital,

  • this was because the hospital was meeting national referral to treatment targets in OPD and surgery. No NHS patients were waiting longer than six weeks for magnetic resonance imaging (MRI), computerised tomography (CT) scanning, non-obstetric ultrasound, colonoscopy, flexible sigmoidoscopy and gastroscopy OPD diagnostic investigations between April 2015 and March 2016.

  • Services were planned and delivered to take account of the needs of vulnerable people and reasonable adjustments were made as necessary. Chaperones were available as necessary and there were posters informing patients of the availability of chaperones

  • Waiting times at the hospital were very short and patients were seen very quickly, following arrival. Did not attend rates were very low and very few clinics were cancelled. Complaints about the services were resolved in a timely manner and information about complaints was shared with staff to support learning. Translators were accessible and information leaflets were available in large print, in other languages and in braille.

  • There was a dementia champion and the hospital had introduced training for staff. The hospital was participating in a Commissioning for Quality and Innovation (CQUIN) with the other local sites, regarding dementia friendly care.

  • There will be three inpatient rooms that will be dementia friendly; the hospital was working with the Alzheimer’s society to provide guidance on how to do this.



Updated 28 December 2016

We found services to be well-led at Renacres hospital,

  • this was because there was an annual corporate strategy for the hospital with local actions. The staff knew the corporate provider’s ‘Ramsay’ way values which related to being caring and progressive, taking pride in achievements, recognising and encouraging staff, building constructive relationships and maintaining a sustainable and profitable organisation.

  • There were good governance structures in the organisation with an effective MAC chair and MAC committee, there were committees for medicines management, infection control and health and safety feeding into the clinical governance committee and medical advisory committee (MAC).

  • There were robust procedures in place for the monitoring, agreeing and reviewing of practising privileges and the performance of the consultants.

  • There was a comprehensive audit programme at the hospital. Results were discussed at the relevant committees and any risks arising from these were put on the risk register

  • There was a corporate risk register and risk registers for each clinical area. Risk management was an agenda item on the health and safety committee however as the MAC chair did not sit on the health and safety committee there was no clear clinical ownership of risk.

  • There was an open culture at the hospital and the staff were happy to work there, this was demonstrated through the staff survey as results were very positive and Renacres had scored better than the other Ramsay hospitals.

  • Patient engagement was good. Managers were very visible and the matron and the registered manager did a walk round of the hospital every morning.

  • All staff had completed their appraisals at the time of the inspection; appraisals had to be completed by July as salary increases were dependent on a completed appraisal.

  • The hospital was completing the workforce race equality standard (WRES) reporting template.

  • The hospital wanted to improve on what they did and was not looking to provide additional services that carried more risk due to their rural location.

Checks on specific services

Outpatients and diagnostic imaging


Updated 28 December 2016

People who used the services were protected from abuse and avoidable harm and staff were aware of the processes and reporting systems for recording incidents and safeguarding concerns. Staffing levels were sufficient to provide care in a safe way and staff appropriately responded to changing risks. Hygiene and infection control practices were followed. Patient records were held securely.

The care and treatment provided to people was evidence based and in line with relevant standards and legislation, including National Institute for Health and Care Excellence (NICE) and professional organisational guidelines.

Staff provided care and treatment to people who used the services in a caring and compassionate way and people were involved in decisions about their care. Translation services were available to people as necessary

The hospital planned the services to meet the needs of the local population. Waiting times for initial assessment, and treatment, following referral were low, and the services met the waiting time targets. Staff treated people as individuals, and made appropriate adjustments as necessary.

There was a robust governance framework and strong management and leadership within the hospital. A comprehensive audit programme and a risk register were in place.

There was good staff engagement within the services and staff felt supported by the management team.



Updated 28 December 2016

Patient safety at the hospital was monitored, incidents were reported and the learning from incidents was used to improve patient care. Staffing levels met the patients’ needs and there was good multi-disciplinary team working. Medicines were stored safely and the environment was clean and records were stored securely.

Patients received care and treatment according to national guidelines such as National Institute for Health and Clinical Excellence (NICE) and the Royal Colleges. Surgery services participated in national audits.

Patients spoke positively about their care and all patients were treated with privacy and dignity.

The hospital was meeting national targets for referral to treatment times and processes were in place to support vulnerable patients. Complaints were dealt with efficiently.

Governance structures were good and there was effective teamwork with visible leadership within the services. Staff were positive about the culture within the surgical services and the level of support they received from their managers.