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Archived: BMI The Esperance Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 6 September 2017

At our inspection in June 2016, we rated safety as ‘requires improvement’ for surgery, although safe was found to be good in outpatients and medicine. We cannot re-rate these services due the time elapsed since the comprehensive inspection, Therefore the rating for safe for remains ‘requires improvement’. However, during this inspection we were assured that the hospital had met all the required improvements, and was no longer in breach of two regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. In addition, the hospital had made additional improvements.

During this inspection, we found that infection control practices had improved and the management of medicines met national guidance. There had been improvements in systems for managing and minimising risks to patients, including fire safety risks. Mandatory training and appraisal rates for staff were good, and staff reported confidence in their leaders.

Inspection areas

Safe

Requires improvement

Updated 6 September 2017

Are services at this hospital safe?

At our inspection in June 2016, we rated safety as ‘requires improvement’ for surgery, although safe was found to be good in outpatients and medicine. We cannot re-rate these services due to the time elapsed since the comprehensive inspection, Therefore the rating for safe for remains ‘requires improvement’. However, during this inspection we were assured that the hospital had met all the required improvements, and was no longer in breach of two regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. In addition, the hospital had made additional improvements.

Cleanliness, infection control and hygiene

  • During our last inspection, we found that poor infection control practices were going unchallenged which could indicate that staff did not feel empowered to challenge poor practice when they saw it. During this inspection, we saw the majority of staff adhered to good infection control practices. However, we saw five members of housekeeping, facilities and portering staff who entered clinical areas who were not “bare below the elbows” (BBE). For example, we saw a porter taking a patient to theatre who was not BBE. When we raised this with the staff there was confusion regarding the interpretation of the BMI Healthcare Uniform and Dress code Policy, and the definitions of clinical roles and clinical areas.

  • Staff sought clarification on the policy from their line manager and informed us that they should be “bare below the elbows.” However, when we returned to the ward 30 minutes later the staff were still not BBE. We spoke to the ward manager who said they felt it was the responsibility of the staff members’ line manager to challenge the staff on not adhering to BBE.

  • We raised this with the leadership team who said they would take immediate action to ensure all staff were BBE. Since the inspection, we have been provided with evidence, which provides assurances that all staff will be BBE. For example, staff will be issued with fob watches as being able to tell the time was given as a reason for not being BBE.

  • Data provided to us by the hospital showed 100% (compliance in hospital wide hand hygiene audits undertaken in between January 2017 and June 2017.This showed an improvement from 70% compliance within theatres in October 2016 and 90% in November and December 2016.

  • Additional hand hygiene training sessions were undertaken by staff to ensure hand hygiene best practice.

  • Compliance of monthly observation hand hygiene audits was monitored through the infection control and clinical governance meetings, and we saw evidence of this in meeting minutes. This enabled clear oversite of the hospital’s Infection Prevention.

  • We saw examples of completed hand hygiene competency documents. These required another member of staff to observe their hand hygiene practice to ensure it was in line with national guidance.

  • We observed some examples of staff challenging poor practice in relation to infection control practices. For example, we saw a member of the estates team check with the theatre manager that it was appropriate to enter the theatre department. The theatre manager told us that previously visitors used to enter the department without seeking authorisation first.

  • We saw other changes within theatres that promoted good infection control practices. For example, there was now a red line in the entrance that visitors were not allowed to cross if they were not dressed appropriately and surgeons now had an allocated space to store their personal belongings so they were not taken into theatre.

  • We saw in the February 2017, head of department meeting minutes that visitors to the theatre department were requested to wait at reception and not enter the theatre.

  • Managers told us they supported staff to challenge poor infection control practices and staff told us they felt empowered to and gave examples of when they had challenged other staff members.

  • Infection prevention link nurses were in post in the surgery department and within outpatients. They attended monthly Infection Prevention team meetings and acted as a point of contact for staff within departmental teams. The role also included ensuring audits were completed in a timely way.

  • During our last inspection, we observed a single use item used for multiple patients this was contrary to BMI Healthcare single use policy and the manufactures guidelines. Since our last inspection, all clinical staff had been reminded of the BMI Healthcare policy on single use items and responsibilities in keeping patients safe. The single use item policy is now included as part of department induction for all new staff and agency staff before they could commence work. Sign off sheets were kept as part of evidence of staff learning. We saw in the October 2016 theatre meeting minutes staff were reminded to familiarise themselves with the BMI Healthcare single use policy and any deviations to the policy must be highlighted to the theatre manager immediately. During this inspection, we did not observe any single items being used on multiple patients.

  • We saw that personal protective equipment was being used appropriately; this was highlighted as a concern in the last inspection.

  • During our last inspection, in theatres, we observed staff placing surgical instruments outside of the laminar flow (clean air) area, this may compromise the sterility of instruments. During this inspection, we observed that the instruments were placed inside the laminar flow area. In addition, anaesthetic room doors were kept closed maximising the efficiency of the laminar flow. We saw doors were now clearly labelled to be kept shut.

  • During our last inspection, we saw that some of the patient bedrooms on Devonshire ward had carpets. There were no control measures on the risk assessment relating to carpet cleaning following a bodily fluid spillage. The hospital was unable to provide evidence of regular deep cleaning of carpets. This meant carpet on the ward may have posed an infection control risk to patients.

  • During this inspection, we saw evidence that a programme of three monthly cleaning had been put in place for carpet cleaning. We were told that this was supplemented by ad hoc cleans if required. We saw the programme and the invoices for both the programmed work and ad hoc work. We checked 12 invoices and these were consistent with the programme and the spillage record requesting ad hoc cleans.

  • We saw risk assessments for the carpet cleaning which provided assurances that there was an effective cleaning process in place.

  • We saw there was a carpet replacement programme planned for the rooms on Devonshire ward. This programme was due to start in August 2017 and would replace carpets with wipeable flooring that met national guidance. We saw the capital programme for these works, which confirmed the replacement programme and timescales.

  • During this inspection, we checked over 10 sharps bins all were labelled correctly to ensure tracking of waste material.

    Environment and equipment

  • During our last inspection, we had concerns regarding fire safety. The actions taken and the evidence we reviewed provided assurances that fire safety concerns had been addressed.

  • Within the outpatient department, there was a ground floor fire escape, which had no signage. It was obscured by plants, which were overgrown onto a poorly lit escape route. During this inspection, we saw that the fire escape had signage and the fire escape was free from obstructions.

  • Although, as it was light at the time of our inspection and we could not test the lighting however, we saw new lighting had been installed for the complete length of the escape route.

  • On our last inspection, there was confusion amongst staff and managers about procedures for evacuation of the theatres in the event of a fire.

  • During this inspection, staff were clear on the evacuation route and how they were protected from a fire in the main building. We reviewed the fire plan, which showed the theatre area was treated as one compartment. This compartment was protected from a fire in another part of the hospital by fire doors, which were adequately signed at the bottom of the stairwell leading from the hospital. The route of evacuation, if needed, was clear and two staff demonstrated to us that they knew the route and the evacuation procedures.

  • We saw in the June 2017 Fire Safety Meeting minutes that fire evacuations scenarios had been undertaken.

  • In addition, we saw a record, which showed East Sussex Fire and Rescue, had undertaken an inspection in November 2016 and no deficiencies were found.

  • We saw in theatres emergency escape signs directed staff and patients along the correct escape route. Fire signage, lighting and escape routes across the hospital now complied with the recommended Health Technical Memorandum 05-02: Firecode.

  • At the last inspection, concerns were raised about the high temperatures in the endoscopy suite, which could be uncomfortable for staff and patients. The temperatures were now recorded every day in all three areas, the procedure suite, the recovery area and the wash up area. Air-cooling had been installed in the procedure room to reduce the temperature. The temperature monitoring record showed the acceptable temperature range. We checked 19 records and all were recorded as within the correct range. We were told that the main area of concern was the wash up area when all the machines were running. There were windows in this area that staff could open if required.

  • We checked over 20 items of electrical equipment and 19 of these had undergone electrical safety checks within the last year. The hospital now kept a central log of all equipment with servicing and electrical testing records. This meant there was now a system, which ensured all equipment was safe for use.

  • During our last inspection in theatres, we saw there was no checklist on the difficult airway trolley to provide assurance of regular checks. During the most recent inspection we saw there was a completed weekly checklist .This provided assurance that regular checks were undertaken which ensured all the equipment was in date and available for use.

Medicines

  • During our previous inspection, we found on Devonshire ward, there were no accurate records of the quantity of controlled drug prescriptions (FP10) or private prescriptions (SPF100). During this inspection, we found there was a system, which ensured security and monitoring and tracking of prescriptions.

Mandatory training

  • During our last inspection, mandatory training compliance was below BMI Healthcare targets. Data supplied to us by the hospital showed that 92% of all staff were compliant with mandatory training which was above the BMI Healthcare target (90%).This was an improvement from 87% on our last inspection. Staff confirmed they had access to mandatory training and had protected time to complete it.

Assessing and responding to patient risk

  • During our last inspection, we were not assured that there was an effective process, which checked the relevant female patients had their pregnancy status checked. At this inspection, we found pregnancy testing on relevant females was undertaken and recorded on a specific form within the patients’ notes. We reviewed 10 sets of notes and found nine had pregnancy status recorded. The one patient who did not have it recorded was not appropriate for testing but the ‘not relevant’ box had not been ticked.

  • During our previous inspection, we identified a number of issues which related to the completion of the WHO’ five steps to safer surgery’ checklist. The WHO checklist is a national core set of safety checks for use in any theatre environment. During this inspection, we observed the ‘five steps to safer surgery’ WHO checklist completed twice the checklist was fully completed both times in line with national guidance. In addition, we reviewed 10 sets of patient notes all had fully completed checklists. We were told any short falls in the process were highlighted through daily audits, which were monitored by the theatre manager who addressed any problems directly. Staff we spoke with said there was a much better engagement from staff around the importance of the ‘five steps to safer surgery’ WHO checklist.

  • During our last inspection, we saw that knowledge around venous thromboembolism (VTE) assessments within theatres was poor. During our most recent inspection, we saw staff discussed VTE assessment during the WHO process and implemented VTE prevention measures. For example, theatre staff checked that patients were wearing compression stockings. This showed that staff were considering VTE prevention and taking appropriate action. During the previous inspection, we saw staff ticked a box on the assessment form to indicate the VTE assessment had been undertaken. We reviewed 10 sets of patients’ notes and all had a fully completed VTE assessment.

  • There was now a VTE link nurse on Devonshire ward and we saw records of 13 staff members who had completed additional training. All staff had signed to confirm they had read the BMI Healthcare VTE policy. There was an audit of 20 randomly selected joint replacement patients a month undertaken. The audit looked at different aspects of VTE assessment and treatment for example if the VTE assessment had been completed on admission. We reviewed the audit results between January 2017 and June 2017, which showed all audits were complete. This provided assurances that national guidance and best practice was adhered to.

  • During our last inspection, we saw a safety briefing was not undertaken during the nursing handover to highlight patients who may have additional needs. In the most recent inspection, we saw evidence, which showed a daily 08:45am safety huddle was undertaken where patient needs were discussed. Observational audits were undertaken which ensured all relevant risks were highlighted.

Effective

Good

Updated 6 September 2017

  • During our last inspection, we saw there was a low rate of staff appraisals in theatres, and the theatre manager was taking action to address this. During our most recent inspection, data showed that 91% of staff had an appraisal undertaken in the last 12 months. This was a big improvement since the last inspection and higher than the BMI healthcare target of 90%.Only two members of theatre staff had not had an appraisal undertaken in the last 12 months, however we have seen the appraisal schedule and these are due to be undertaken in August.

  • We reviewed three appraisal records during this inspection and saw they were detailed with development opportunities discussed along with revalidation for qualified nurses.

  • During our last inspection, we saw agency staff records on Devonshire ward did not show that all staff had demonstrated competency in all required areas before being signed off as competent to work unsupervised. This meant the hospital might not have had assurance all agency staff had the necessary induction to enable them to work competently on the ward without direct supervision. During our recent inspection, we saw agency staff induction checklists had been introduced. These included relevant personal information, professional registration details, orientation to hospital and ward, completion of health and safety procedures including fire evacuation procedures. We reviewed three completed agency induction checklist, which were fully completed.

  • During our last inspection, we saw that cosmetic breast surgery patients were referred to the breast care nurse pre-surgery however, a record of this was not within the patients’ notes. During our recent inspection, we saw the notes from the breast care nurse consultation were integrated into the patients’ notes.

  • In addition, during our last inspection, we noticed that three patients undergoing cosmetic breast surgery were consented for their operation on the day of surgery; this was not in line with national guidelines. During this inspection, we saw a new system had been introduced and the patient’s consent was now usually taken at pre-assessment surgery. This ensured that the patient had sufficient time and information to make an informed decision. We saw this was explained within the patient information leaflet.

Caring

Good

Updated 6 September 2017

We did not inspect this area of the service, as this was a focused follow up inspection and there were no concerns raised about caring during the previous inspection.

Responsive

Good

Updated 6 September 2017

  • During our last inspection we saw that all written information, including pre-appointment

    information, leaflets, and signage, was in English. Staff were not aware there was a system available to print written information such as pre-appointment information and leaflets into other languages. During our recent inspection, staff were able to demonstrate how they would access these via a computer programme. Staff explained how information could be sent to patients in the post if they required it in a different language. This meant information was available for patients, relatives and carers in different languages. Staff explained how the information could be printed off at the pre-assessment appointment if required.

  • During our last inspection, we saw there were no level access showers for wheelchair users. During our most recent inspection, we saw there were refurbishment plans to address installing level access showers for wheelchair users.

Well-led

Requires improvement

Updated 6 September 2017

  • Although not specifically inspected during our most recent inspection, we observed some improvements.

  • Staff spoke positively regarding the theatre manager who had just come into post prior to our last inspection. Staff felt there had been improvements in the quality and safety of care delivered within theatres. For example, the theatre department was now clean, tidy and uncluttered. The inspection team saw a vast improvement in the environment within theatres.

  • Staff were positive about the leadership team and felt positive changes had been made since the Executive Director had been in post.

  • Staff said the leadership team were visible in the hospital and approachable.

Checks on specific services

Medical care (including older people’s care)

Good

Updated 6 September 2017

Outpatients and diagnostic imaging

Good

Updated 6 September 2017

Surgery

Requires improvement

Updated 6 September 2017