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Inspection Summary


Overall summary & rating

Good

Updated 10 January 2017

We inspected the hospital on 19, 20 and 21July 2016 as part of our independent hospital inspection programme. The inspection was conducted using the CQC’s comprehensive inspection methodology. It was a routine planned inspection. We inspected the following three core services at the hospital: medicine, surgery and outpatients and diagnostic imaging.

We rated the hospital as good overall.

Our key findings were as follows:

Are services safe at this hospital?

We rated safe as requires improvement because:

  • At the time of our inspection 88.68% of staff completed their mandatory training. This was below the hospitals target of 100%.
  • Staff were not following the appropriate guidance and not separating clinical and non-clinical waste.
  • Some of the inpatient patient rooms required to be redecorated to ensure facilities met appropriate standards.
  • Colour coded cleaning equipment was not used in theatres and there was no protocol on which cleaning products should be used where. 
  • The ward environment was not suitable for the care of patients living with dementia.
  • The consulting room in the new ophthalmic clinic had no hand basin and the hand basin in the mammography room was removed and not replaced for over three months.
  • The plaster room was used for plastering as well as wound dressing and this potentially exposed patients to cross infection in the event of an infected wound.
  • The outpatients department was in need of refurbishment.
  • Most sinks in the theatre suite were not compliant with suitable building regulations.
  • Learning from incidents was not always shared with all staff.
  • Maintenance requirements noted in the validation report for the theatre ventilation system were not completed.
  • Controlled drugs were not always disposed of correctly.
  • Patients’ clinical records were sometimes left unattended in an unlocked drawer. 
  • In the physiotherapy department, the cryotherapy pod was not in service and there was no timeline as to when the ownership and the contractual issues would be resolved.
  • There were no timelines for replacing the MRI scanner and the ultrasound machine.
  • Some managerial posts were vacant for some time, which has had an impact on both the managerial and clinical work of the departments.

Are services effective at this hospital?

We rated effective as good overall because:

  • The hospital had an audit calendar which set out the audits to be undertaken across the hospital over the 12 month period for 2015/2016.
  • Theatre staff used the five steps to safer surgery in line with guidance from the National Patient Safety Agency (NPSA).
  • The hospital carried out regular audits including use of the World Health Organisation (WHO) safety checklist.
  • We found good multidisciplinary team (MDT) working between nurses and consultants.
  • Patients’ pain was assessed and managed appropriately.
  • The hospital followed national guidelines in its policies and procedures, which were kept updated.
  • The work of the departments was audited thoroughly, and found to be generally of a high standard. There were regular clinical audits. 
  • Agency nurses underwent hospital orientation and induction.

Are services caring at this hospital?

We rated caring as good because:

  • Patients gave positive feedback about the care and service provided. They reported that staff were reassuring, approachable and very professional.
  • Patients said they were well informed and confirmed they were given time to read the various forms before signing them.
  • We observed that staff were friendly and interacted well with patients. Staff provided compassionate, patient-centred care.
  • The hospital scored above the national average in the NHS Friends and Family Test.

Are services responsive at this hospital?

We rated responsive as good overall because

  • Patients had single rooms that provided privacy and comfort with ensuite facilities and there was no restricted visiting times for patients.
  • The hospital had monthly compliments and complaints meeting for staff to receive and give feedback and to facilitate discussion on how to improve patients’ experiences.
  • Patients referred by their GP could book a convenient date and time for their appointment through NHS ‘choose and book’ electronic booking system.
  • All patients were admitted under the care of a named consultant. The consultants reviewed patients prior to commencement of each treatment.
  • Services were planned to meet the needs of patients and to ensure contractual requirements were met.
  • The hospital met the referral to treatment target (RTT) of 90% for NHS admitted patients waiting less than 18 weeks from the time of referral to treatment. They achieved 98% in April 2016, 100% in May and 98.8% in June.
  • Any radiology required was arranged, usually on the same day as the appointment with the consultant.
  • The flow of patients through the various clinics was well organised.
  • There was a wide range of physiotherapy treatments available. Interpreters were provided when needed.
  • Staff felt they worked well with NHS providers and GPs to meet the needs of local people.
  • Complaints were handled and resolved appropriately and quickly.

Are services well led at this hospital?

We rated well led as good overall because:

  • Governance and risk management processes were in place.
  • The hospital risk register included corporate and clinical risks
  • Patient satisfaction was monitored and reported on monthly through the patient satisfaction dashboard.
  • Safety outcomes were measured and monitored.
  • There was good teamwork and staff enjoyed working there.
  • The hospital had an open and transparent culture. The executive team was supportive of their staff; the E

    executive D

    director was visible daily and was involved in staff meetings.

  • There was an open door policy and staff felt comfortable to speak with the executive director or the clinical director if they had any issues.
  • There was good clinical governance and a good quality and risk management process. This ensured patients received safe care and treatment.

We also said that the provider must:

  • Carry out remedial work in the sluice where there is exposed plaster and pipes and a hole in the wall from the recent removal of decontamination equipment.
  • Ensure that all remedial action highlighted in the theatre ventilation servicing report is completed.
  • Ensure that the facilities are in compliance with Department of Health guidelines HBN26 ‘facilities for surgical procedures’.
  • Ensure confidential patient information is stored in accordance with the Data Protection Act 1998.
  • Ensure there are an adequate number of hand basins in the consultation and treatment rooms to minimise the risk of cross-infection.
  • Ensure there is an adequate facility for wound dressing to prevent cross infection.

In addition the provider should:

  • Improve communication of shared learning from incidents so that all staff are aware and involved.
  • Ensure that all staff have the skills needed to fulfil their roles and are supported to develop.
  • Ensure staff complete their mandatory training.
  • Ensure that the resident medical officer RMO’s has regular clinical supervision.
  • Improve communications between the theatre and other departments.
  • Ensure waste management meets best practice guidelines for the segregation and indication of clinical and non-clinical waste
  • Ensure there is oversight of infection prevention and control across all departments including theatres.
  • Ensure that inpatient rooms are compliant with HBN00-09.
  • Ensure that thermostatically taps are installed in the hand washing basins.
  • Ensure disabled shower room facilities are safe and fit for purpose.
  • Improve the environment in patient’s rooms and bathrooms.
  • Ensure the decor of the outpatients department is well maintained.
  • Ensure the MRI scanner and the ultrasound machine are replaced in a timely manner.
  • Ensure the vacant manager posts for both departments are filled without further delay.
  • Undertake audits of national early warning score (NEWS) systems to identify deteriorating patients
  • Ensure action plans are in place for high MUST scores

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 10 January 2017

  • At the time of our inspection 88.68% of staff completed their mandatory training. This was below the hospitals target of 100%.
  • Staff were not following the appropriate guidance and not separating clinical and non-clinical waste.
  • Some of the inpatient patient rooms required to be redecorated to ensure facilities met appropriate standards.
  • Colour coded cleaning equipment was not used in theatres and there was no protocol on which cleaning products should be used where.
  • The ward environment was not suitable for the care of patients living with dementia.
  • The consulting room in the new ophthalmic clinic had no hand basin and the hand basin in the mammography room was removed and not replaced for over three months.
  • The plaster room was used for plastering as well as wound dressing and this potentially exposed patients to cross infection in the event of an infected wound.
  • The outpatients department was in need of refurbishment.
  • Most sinks in the theatre suite were not compliant with suitable building regulations.
  • Learning from incidents was not always shared with all staff.
  • Maintenance requirements noted in the validation report for the theatre ventilation system were not completed.
  • Controlled drugs were not always disposed of correctly.
  • Patients’ clinical records were sometimes left unattended in an unlocked drawer.
  • In the physiotherapy department, the cryotherapy pod was not in service and there was no timeline as to when the ownership and the contractual issues would be resolved.
  • There were no timelines for replacing the MRI scanner and the ultrasound machine.
  • Some managerial posts were vacant for some time, which has had an impact on both the managerial and clinical work of the departments.

Effective

Good

Updated 10 January 2017

  • The hospital had an audit calendar which set out the audits to be undertaken across the hospital over the 12 month period for 2015/2016.
  • Theatre staff used the five steps to safer surgery in line with guidance from the National Patient Safety Agency (NPSA).
  • The hospital carried out regular audits including use of the World Health Organisation (WHO) safety checklist.
  • We found good multidisciplinary team (MDT) working between nurses and consultants.
  • Patients’ pain was assessed and managed appropriately.
  • The hospital followed national guidelines in its policies and procedures, which were kept updated.
  • The work of the departments was audited thoroughly, and found to be generally of a high standard. There were regular clinical audits.
  • Agency nurses underwent hospital orientation and induction.

Caring

Good

Updated 10 January 2017

  • Patients gave positive feedback about the care and service provided. They reported that staff were reassuring, approachable and very professional.
  • Patients said they were well informed and confirmed they were given time to read the various forms before signing them.
  • We observed that staff were friendly and interacted well with patients. Staff provided compassionate, patient-centred care.
  • The hospital scored above the national average in the NHS Friends and Family Test.

Responsive

Good

Updated 10 January 2017

  • Patients had single rooms that provided privacy and comfort with ensuite facilities and there was no restricted visiting times for patients.
  • The hospital had monthly compliments and complaints meeting for staff to receive and give feedback and to facilitate discussion on how to improve patients’ experiences.
  • Patients referred by their GP could book a convenient date and time for their appointment through NHS ‘choose and book’ electronic booking system.
  • All patients were admitted under the care of a named consultant. The consultants reviewed patients prior to commencement of each treatment.
  • Services were planned to meet the needs of patients and to ensure contractual requirements were met.
  • The hospital met the referral to treatment target (RTT) of 90% for NHS admitted patients waiting less than 18 weeks from the time of referral to treatment. They achieved 98% in April 2016, 100% in May and 98.8% in June.
  • Any radiology required was arranged, usually on the same day as the appointment with the consultant.
  • The flow of patients through the various clinics was well organised.
  • There was a wide range of physiotherapy treatments available. Interpreters were provided when needed.
  • Staff felt they worked well with NHS providers and GPs to meet the needs of local people.
  • Complaints were handled and resolved appropriately and quickly.

Well-led

Good

Updated 10 January 2017

  • Governance and risk management processes were in place.
  • The hospital risk register included corporate and clinical risks
  • Patient satisfaction was monitored and reported on monthly through the patient satisfaction dashboard.
  • Safety outcomes were measured and monitored.
  • There was good teamwork and staff enjoyed working there.
  • The hospital had an open and transparent culture. The executive team was supportive of their staff; the executive director was visible daily and was involved in staff meetings.
  • There was an open door policy and staff felt comfortable to speak with the executive director or the clinical director if they had any issues.
  • There was good clinical governance and a good quality and risk management process. This ensured patients received safe care and treatment.
Checks on specific services

Medical care (including older people’s care)

Requires improvement

Updated 10 January 2017

  • At the time of our inspection 88.68% of staff completed their mandatory training. This was below the hospitals target of 100%.
  • The ward environment was not suitable for the care of patients living with dementia and not all the staff on the ward received dementia training.
  • There was no audit of national early warning score (NEWS) systems to identify deteriorating patients which meant the hospital was unable to identify if improvements in practice and outcomes were required.
  • Action plans were not always in place for high MUST scores where an intervention was required.
  • It was not clear who was responsible for providing the resident medical officer RMO’s with clinical supervision.
  • Waste paper bins were in patient rooms and pedal bins used in bathrooms did not meet the waste management guidelines for segregated waste bins.
  • Staff were not following the appropriate guidance and not segregating clinical and non-clinical waste.
  • One hand basin for staff use outside of patient rooms had no thermostatically controlled tap and an open bin stored in the recess stored under the sink. The waste management did not follow the correct classification for offensive/non-infectious waste.
  • The disabled shower room had a shower chair with a missing caster from one of the legs and a leg was rusty.
  • In patient rooms patient lockers were damaged with wood exposed on most of the edges on the tops of the lockers, some fabric chairs had staining on the seat cushions and there were some gaps in between the en-suite flooring and the room carpet.
  • In patient bathrooms some of the Formica tops were stained, tiles were coming away from the walls and sealant around the sinks and toilets were in a poor condition.

Outpatients and diagnostic imaging

Good

Updated 10 January 2017

  • The hospital had good leadership through the executive director and there was good clinical governance.
  • The hospital’s policies and procedures were in accordance with national guidelines.
  • Patients received good care and treatment. They were respected and well supported. Patients were seen by a specialist consultant within days of being referred.
  • Patients said they were well informed and involved in making decisions with their consultant.
  • Staff of all disciplines worked well together to ensure patients received good care and treatment. They demonstrated an open and transparent culture and felt comfortable to raise concerns and report incidents.
  • There was good multidisciplinary working within the hospital services and externally with other healthcare providers. The hospital made thorough checks on consultants before awarding practising privileges.
  • Staff followed the escalation policy when a patient was clinically unwell. 
  • The x-ray machines were checked regularly and regular monitoring was carried out when using contrast agents.
  • The staffing number and skill mix of staff was adequate to keep patients safe. All staff had competency assessments before carrying out clinical tasks and all staff completed mandatory training.

Surgery

Good

Updated 10 January 2017

  • Care and treatment was delivered in line with evidence-based guidance. Surgical staff used the five steps to safer surgery in line with guidance from the National Patient Safety Agency (NPSA). The hospital carried out regular audits to monitor performance, including use of the World Health Organisation (WHO) safety checklist.
  • There was good communication and team-working between nurses and consultants.
  • Staff were compassionate and caring towards patients, and patient feedback was positive about staff.
  • The hospital scored highly in the NHS Friends and Family Test.
  • The hospital met the referral to treatment target (RTT) of 90% for NHS admitted patients waiting less than 18 weeks from the time of referral to treatment. They achieved 98% in April 2016, 100% in May and 98.8% in June.