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Winfield Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 30 May 2018

Winfield Hospital is operated by Ramsay Health Care UK. The hospital provides surgery for adults, outpatient care and diagnostic imaging.

We completed a comprehensive inspection in August 2016 as part of our national programme to inspect and rate all independent hospitals. We returned to the hospital on 27 February 2018 when we conducted a focused inspection on surgical services. This was an unannounced inspection (they did not know we were coming) which enabled us to observe routine activity. We did not inspect outpatients and diagnostic imaging on this occasion. We carried out this focused inspection to follow-up on the areas that had been identified as requiring improvement at the last inspection and in response to concerns raised with us about surgical services and intelligence we hold through ongoing monitoring.

We asked two questions of the service during this focused inspection: are they safe and are they 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.

We found the following areas of good practice:

  • The service had a good reporting culture and learned from things that went wrong, they reported and investigated incidents and made recommendations for improvements.
  • There were good infection control procedures. Staff and premises were clean and regular checks ensured standards were maintained.
  • Medicines were managed in a way to ensure patients were safe. They were stored securely, controlled drug records were regularly audited and charts were checked daily to ensure medicines were correctly administered.
  • There were effective safeguarding processes helping to protect people from abuse.
  • There was a well-defined strategy and vision for the service prioritising high quality care. There was also a well-embedded set of organisational values so staff knew what was expected.
  • There was a comprehensive audit programme to ensure quality was routinely monitored.
  • Managers had the skills and experience to lead effectively; there was a desire to continuously improve and there was a respectful culture between managers and staff.
  • The hospital sought feedback from patients and staff to learn how they could improve the service. We saw staff were consulted over changes and had the opportunity to contribute when things affected them.

We found areas of practice that required improvement in services:

  • The way the hospital applied duty of candour did not meet the regulatory requirements. Where the relevant person had not been notified in line with the regulatory requirements for specific reasons, there was no audit trail that explained why this was the case. The hospital did not always provide an apology and some records were not held in a place where they were accessible.
  • There was no evidence that the hospital had monitored actions following serious incident investigations to ensure improvements had been completed.
  • The audit programme was not always delivered in line with the company's expectations.  Some audits had been missed and it was not always clear what action was going to be taken, by whom and when it was due to be completed.
  • Risk registers were not used effectively to monitor and escalate risks. The hospital had not been following the company’s processes to manage risk, although they had started to address this.
  • Compliance with mandatory training was poor in some subjects, particularly for face to face training.

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. Details are at the end of the report.

Amanda Standford

Deputy Chief Inspector of Hospitals, on behalf of the Chief inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 30 May 2018

We rated safe as requires improvement because:

The documentation we reviewed to understand how the hospital delivered duty of candour did not demonstrate that they were meeting the regulatory requirements. This was a concern at the previous inspection and, although improvements had been made to this process, some elements still did not meet the regulatory requirements.

Where actions were identified following investigation of incidents, these were not being monitored consistently and senior managers did not always receive assurance that actions had been completed.

Staff attendance at face to face mandatory training modules was poor. Out of 19 modules, staff compliance had reached the hospital target in only five of the modules for theatre staff and six of the modules for ward staff.

However:

The service ensured staff were able to report incidents and investigations took place in order to learn and improve services.

The hospital monitored and compared its results with other hospitals in the Ramsay Group using the information to identify areas where practice needed to be improved.

Hygiene and infection control was a priority for the service and staff compliance with hospital policies was monitored. Investigations were undertaken if a higher number of patient infections were found.

Premises and equipment were suitable for their intended purpose. They were monitored for any risk and maintenance actions were taken to ensure equipment was safe for patient use.

Medicines, medical gases and contrast media were managed safely at the correct temperatures. Stocks were regularly checked. Staff used a systematic approach to highlight when medicine expiry dates were due and audit processes ensured that safe standards were maintained.

Record keeping processes helped to keep patients safe. A full patient record was available for staff to use and was kept up to date. Quality of records was audited by the hospital and, where errors were reported; improvements were identified and shared with staff.

Safeguarding processes were followed by staff to keep patients free from abuse. Policies supported staff in their actions and advice was available from staff with additional skills in safeguarding.

Staff told us there had been an increase in staffing numbers over the previous 12 months and although they were busy staff felt their caseloads were manageable. Temporary staff were used less than 25% of the time and induction processes supported them to familiarise themselves with their area of work.

The hospital reviewed qualifications of medical staff and only allowed consultants to work in the hospital once the standards had been met. Registered medical officers were supplied by a medical agency and cared for patients’ day to day needs. Their agency supported RMOs if any concerns were raised by hospital staff.

Effective

Good

Updated 30 May 2018

This was a focused inspection which did not include this question.

Caring

Good

Updated 30 May 2018

This was a focused inspection which did not include this question.

Responsive

Requires improvement

Updated 30 May 2018

This was a focused inspection which did not include this question.

Well-led

Requires improvement

Updated 30 May 2018

We rated well-led as requires improvement because:

Although we saw that many audits had been completed, we found that some key audits had been missed and there were some occasions when poor compliance had been identified, but there was no clear improvement actions, no person responsible for the improvement and no timescale for completion.

Risk registers were not used effectively to monitor and escalate risks. There was limited discussion and oversight of new risks in relevant committees and risk assessments were not always completed in line with the company’s process.

There was sometimes poor monitoring of actions from governance processes. Staff reporting risks and incidents did not always receive feedback, there was no system for monitoring to ensure actions from serious incident investigations were completed and audits did not always identify specific actions and identify who would be responsible for improvements and when they should be completed.

However:

There was a well-defined vision and strategy for the hospital and for surgical services. Senior managers had set their key priorities and understood where they needed to improve to meet the hospital’s business and clinical goals.

There was an effective governance structure with clear lines of accountability. Staff, department leads and managers understood their roles in relation to quality and there was a collective sense of responsibility for providing high quality care.

There was a comprehensive audit programme and outcomes were reviewed to identify where improvements were needed. Issues were addressed and actions were discussed with the departmental teams.

There was an open culture where information about quality was shared with staff, patients and local stakeholders.

Although there were historic problems with the leadership in theatres during the previous 12 months, there was now effective leadership in theatres and on the ward with the necessary skills and experience lead services.

There was an open and respectful culture amongst staff and managers, and across the disciplines. Staff were comfortable challenging each other and relationships were positive and supportive.

The hospital had improved how it engaged with staff. Meetings that had been infrequent or had stopped had re-commenced. Staff views were sought; they received information to help them in their role and staff said they felt consulted about changes affecting them.

The hospital sought feedback from patients and used their views to shape services.

Checks on specific services

Outpatients and diagnostic imaging

Requires improvement

Updated 18 January 2017

We have rated outpatients and diagnostic imaging as requires improvement overall because:

  • Staff did not always receive feedback following adverse incidents.

  • Medicines were stored in the diagnostic imaging department at temperatures which were above recommended levels.

  • There were inadequate systems in place to track medicines and prescription pads in outpatients in order to prevent theft or misuse.

  • The imaging table in the X-ray room was not height- adjustable. Staff had to use portable steps to assist post-operative patients on to the table, posing the risk of injury to staff and patients.

  • The provider was unable to provide us with accurate and up-to-date information in respect of staff compliance with mandatory training. We could not therefore be assured that staff had the required knowledge of safety systems, processes and practices. Staff in outpatients and physiotherapy were not up-to-date with role-specific competencies.

  • The hospital had taken few steps to support people in vulnerable circumstances, such as patients living with dementia or patients with a learning disability. Staff in outpatients were not able to describe any examples of support which may be provided to such patients.

  • Patient information leaflets relating to surgical procedures did not indicate that they could be made available in languages other than English or other formats, such as large print, braille or easy read. Staff told us they had never been asked for information in other formats and they were not aware of any facility to provide this.

  • Information on how to access the complaints system was not well publicised and patients were not offered support with their complaint.

  • Patients attending the diagnostic imaging department, who were required to undress, were not offered sufficient privacy while waiting for their treatment.

  • Governance and reporting processes were not fully effective to ensure effective communication ‘from ward to board’ and ‘from board to ward’.

  • There was insufficient evidence that managers had oversight of all performance, including risks to quality and safety. The recent provider visit had highlighted weakness in governance processes which still needed to be improved. For example, there was insufficient oversight of mandatory staff training and little evidence that audits were consistently taking place as planned or learning was taking place following these audits.

  • The management team had suffered from a period of instability with a significant number of management changes. There had been a difficult transition period while managers settled in. Staff meetings did not occur regularly and some staff consequently felt they did not a have a voice.

  • The recent staff survey had a disappointing response and highlighted some worrying themes. Staff engagement and involvement needed to improve to address issues which affected staff morale and make them feel more valued.

However,

  • Staff understood their responsibilities to report incidents and were encouraged to do so.

  • Risks to patients were assessed and their safety was monitored and maintained.

  • There was evidence of learning and improvement following two incidents in diagnostic imaging and an incident in the physiotherapy department.

  • Departments were mostly clean and tidy. Staff observed standard infection control precautions and disposed of waste appropriately.

  • Premises and equipment were designed and maintained to keep people safe.

  • Staff treated people with compassion, kindness, dignity and respect.

  • We observed staff interact with patients in a respectful and considerate manner.

  • Patient satisfaction survey results showed consistently high levels of satisfaction.

  • Staff took steps to ensure that patients’ privacy and dignity were protected, including during physical and intimate examinations and treatment.

  • Patients were involved as partners in their care. Patient satisfaction survey results showed that patients were well informed about their care and treatment and knew how and when they would receive test results.

  • Patients received timely access to care and treatment. The hospital consistently met the NHS standard which measures the time that people wait from referral by their GP to consultant-led treatment.

  • Outpatients’ clinics took place so that, as far as possible, patients were able to access care and treatment a time that suited them. Clinics mostly ran to time so that people were not inconvenienced and cancellations rarely occurred.

  • Premises were mostly appropriate for the services that were planned and delivered. There was ample free car parking, good signage and waiting areas were light, airy and comfortable.

  • The hospital had a clear strategy and had developed a vision statement with involvement and engagement from staff. Not all staff felt engaged in this and not all staff could articulate the vision statement but they all expressed with passion their desire to provide the best patient-centred care.

  • The senior management team was now established and from October 2016, all heads off department posts would be filled.

  • The senior management team were respected; in recent months they had become more visible and most staff told us they were accessible and supportive.

  • The senior management team were working on a new staff engagement strategy, responding to the themes highlighted in the staff survey. Daily huddles had been introduced to help inter-departmental working and heads of department were engaged in team building and looking at ways to better support each other and work cohesively.

  • Most staff told us they enjoyed working at Winfield Hospital. Teamwork and camaraderie were cited by many as being the best thing about working there.

  • The hospital had recently appointed a quality lead who would have oversight of the clinical audit programme.

Surgery

Requires improvement

Updated 30 May 2018

Surgery was the main activity of the hospital.

We did not rate this service because we conducted a focused inspection on only two key areas. We did not collect sufficient evidence for us to give an overall rating for this core service.