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Inspection carried out on 19 - 21 July 2016

During a routine inspection

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 carried out on 29 October 2013

During a routine inspection

There were two patients admitted to the in-patient ward on the day of our visit and we were able to speak with one of them. We also spoke with several patients who were attending out-patient appointments. Everyone told us they were happy with the care and treatment provided. For example, one patient told us they had been �treated perfectly.� In the out-patient department a patient told us their treatment had been explained clearly and they felt �comfortable asking questions.� Patients told us they felt safe using the service and had confidence in the staff. Everyone said they would recommend the hospital to others.

Patients considered the service was clean and hygienic. For example, one patient described the hospital as �spotless.� There had been no cases of hospital acquired infection in 2013. There were effective systems in place to reduce the risk of infection.

There was an effective system in place for assessing and monitoring the quality of the service patients received. Records kept by the service were accurate and fit for purpose.

Inspection carried out on 25 January 2013

During a routine inspection

We spoke with patients and relatives about the care and treatment they had received in the hospital. One patient told us �this is the best care I have ever had� and another said, "anything I need I get and always with a smile." Patients were confident in the skills of staff. For example, one patient said of staff, "they are brilliant I cannot fault them.�

Patients told us their medicines had been explained to them and they knew what they were for. Medicines were stored securely and administered to patients safely. Patients told us their pain was managed effectively.

Staff were suitably qualified and received appropriate training to enable them to provide safe care and treatment. The provider regularly monitored the service to make sure services were safe and an appropriate standard of care and treatment provided.

Inspection carried out on 25 January 2012

During a routine inspection

We spoke with patients who had undergone surgical procedures at the hospital. Patients told us they were happy with the quality of care and treatment provided to them. For example, one patient said, �the level of care is second to none�. Another patient said, �it�s fantastic here, everything you would expect�. Staff were described as �very good and very helpful in every way�. Treatment had been explained in a way that they understood and patients had been asked to give their consent to treatment. Patients knew how to complain if they needed to and were confident concerns and complaints would be taken seriously by staff.

Reports under our old system of regulation (including those from before CQC was created)