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BMI The Duchy Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 29 September 2017

Inspection areas

Safe

Good

Updated 29 September 2017

Are services safe?

We rated safe as good because:

  • The Duchy Hospital had improved the incident reporting process so they could track learning and outcomes of incidents. In addition to this, the new electronic system had made it easier for staff to report incidents.
  • Staffing levels in the theatre recovery had improved and were in line with national recommendations.
  • The five steps to safer surgery were now being consistently used and communication between staff at all of the stages of the operation had improved. There was now an opportunity for professional challenge between staff.
  • The refurbishment of patient’s bedrooms had commenced with carpets being replaced in 20 out of 27 bedrooms. There was a plan to have all bedrooms refurbished by the end of August 2017 which was on track.
  • The on-site decontamination of endoscopes had stopped and these were now being sent to a central decontamination hub. A system had been put in place to identify clean and dirty endoscopes which staff were following.
  • At our last inspection we raised concerns because we found not all patients attending the outpatient department for a minor procedure under local anaesthetic had their observations recorded before or after the procedure. We saw this had improved and all patients had their observations recorded pre and post procedure.
  • The use of the minor procedure room had been reviewed and it was no longer being used for treatments requiring specialist ventilation. Patients requiring procedures who would need this were being scheduled into the operating theatres where there was the appropriate theatre environment.

Effective

Updated 29 September 2017

Caring

Updated 29 September 2017

Responsive

Updated 29 September 2017

Well-led

Requires improvement

Updated 29 September 2017

Are services well-led?

We rated well-led as requires improvement because:

  • Although there were many improvements in governance, leadership, staff and public engagement and staff morale/culture many of the new processes and initiatives were still in their infancy. The hospital leaders knew they had more to do to ensure they were embedded and improvement sustained.
  • Improvements had been made in the hospitals approach to the Workforce Race Equality Standard (WRES) but the hospital leaders acknowledged they were not yet fully compliant with the requirements.

However, we also found the following areas of good practice:

  • The governance arrangements had been reviewed and a new structure had been put in place. The new structure was designed to give more assurance to the executive leadership team.
  • Staff morale had significantly improved since our last inspection and staff now told us they felt supported and could speak up without fear of retribution.
Checks on specific services

Outpatients and diagnostic imaging

Requires improvement

Updated 29 September 2017

During this focused inspection we inspected the safe and well led domains of the outpatient and diagnostic imaging core service.

We rated the outpatient core service as requires improvement because:

  • Although there were many improvements in governance, leadership, staff and public engagement and staff morale/culture, more time was needed to embed these improvements. Many of the new processes and initiatives were still in their infancy and the hospital leaders knew they had more to do to ensure they were embedded and improvement sustained.

However;

  • Improvements had been made in the use of the five steps to safer surgery, including the World Health Organisation (WHO) surgical safety checklist. During this inspection, nine out of the 10 cases we looked at were completed correctly. However, one WHO checklist was not completed correctly because we noted on a minor procedures column that not all of the boxes were initialled by the surgeon and the accompanying nurse. We escalated this to the person in charge who said they would address this.
  • At our last inspection we raised concerns because we found not all patients attending the outpatient department for a minor procedure under local anaesthetic had their observations recorded before or after the procedure. We saw this had improved and all patients had their observations recorded pre and post procedure.
  • The use of the minor procedure room had been reviewed and it was no longer being used for treatments requiring specialist ventilation. Patients requiring procedures who would need this were being scheduled into the operating theatres where there was the appropriate theatre environment.
  • Risks in the outpatient department were now on the departmental risk register and mitigating actions were appropriate and up to date.

Surgery

Requires improvement

Updated 29 September 2017

During this focused inspection we inspected the safe and well led domains of the surgery core service.

We rated the surgery core service as requires improvement overall because:

  • Although there were many improvements in governance, leadership, staff and public engagement and staff morale/culture, more time was needed to embed these improvements. Many of the new processes and initiatives were still in their infancy and the hospital leaders knew they had more to do to ensure they were embedded and improvement sustained

However;

  • The hospital had improved the incident reporting process so they could track learning and outcomes of incidents. In addition to this, the new electronic system had made it easier for staff to report incidents.
  • Staffing levels in the theatre recovery had improved and were in line with national recommendations.
  • The five steps to safer surgery were now being consistently used and communication between staff at all of the stages of the operation had improved. There was now an opportunity for professional challenge between staff.
  • The refurbishment of patient bedrooms had commenced with carpets being replaced in 20 out of 27 bedrooms. There was a plan to have all bedrooms refurbished by the end of August 2017 which was on track.
  • The on-site decontamination of endoscopes had stopped and these were now being sent to a central decontamination hub. A system had been put in place to identify clean and dirty endoscopes which staff were following.
  • The governance arrangements had been reviewed and a new structure had been put in place. The new structure was designed to give more assurance to the executive leadership team.
  • Staff morale had improved since our last inspection and staff now told us they felt supported and could speak up without fear of retribution.