The Hampshire Clinic

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service had effective systems for recording safety incidents, supported by an incident reporting policy. Staff identified, reported and managed incidents in line with the provider’s incident reporting policy. Staff said they were encouraged to raise concerns and could easily access the electronic incident reporting system.

Staff could describe recent incidents and told us they had attended post incident huddles. These were held as soon as possible following the incident with a maximum delay of 24 hours. The huddles were attended by a whole multi-disciplinary team (MDT) for a broader scope of input. The MDT included nursing, medical and allied health professionals, together with hospital managers. This enabled them to reflect on the incident as a team and identify learning points without blame.

Managers shared incidents with staff at daily safety huddles and team meetings, which included incidents from the provider’s other hospitals. Theatre and ward team meeting minutes showed incidents had been recorded and discussed. This ensured staff learned from incidents or events at other hospitals to improve the patient experience at their hospital.

Serious incidents were reported centrally to the main provider and the service promptly reported notifiable incidents to CQC. Themes and trends were shared with staff electronically and through team meetings.

There had been no never events reported at the surgical service in the previous 12 months. A never event is a serious, preventable patient safety incident that should not occur if the available preventative measures have been implemented by healthcare providers.

Senior leaders described how they had worked with staff to improve the reporting culture. They were focused on supporting staff to maintain the quality and detail used when recording incidents on the reporting system. Incidents were investigated by senior staff with an appropriate level of training and expertise.

Staff at all levels demonstrated a good understanding of the duty of candour and we saw this was carried out when required. The duty of candour is the legal requirement for healthcare services to be open and honest when an unexpected or unintended incident leads to serious harm or death. The service had a duty of candour policy and staff followed this process for any incidents rated moderate harm and above.

The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service had effective systems for recording safety incidents, supported by an incident reporting policy. Staff identified, reported and managed incidents in line with the provider’s incident reporting policy. Staff said they were encouraged to raise concerns and could easily access the electronic incident reporting system.

Staff could describe recent incidents and told us they had attended post incident huddles. These were held as soon as possible following the incident with a maximum delay of 24 hours. The huddles were attended by a whole multi-disciplinary team (MDT) for a broader scope of input. The MDT included nursing, medical and allied health professionals, together with hospital managers. This enabled them to reflect on the incident as a team and identify learning points without blame.

Managers shared incidents with staff at daily safety huddles and team meetings, which included incidents from the provider’s other hospitals. Theatre and ward team meeting minutes showed incidents had been recorded and discussed. This ensured staff learned from incidents or events at other hospitals to improve the patient experience at their hospital.

Serious incidents were reported centrally to the main provider and the service promptly reported notifiable incidents to CQC. Themes and trends were shared with staff electronically and through team meetings.

There had been no never events reported at the surgical service in the previous 12 months. A never event is a serious, preventable patient safety incident that should not occur if the available preventative measures have been implemented by healthcare providers.

Senior leaders described how they had worked with staff to improve the reporting culture. They were focused on supporting staff to maintain the quality and detail used when recording incidents on the reporting system. Incidents were investigated by senior staff with an appropriate level of training and expertise.

Staff at all levels demonstrated a good understanding of the duty of candour and we saw this was carried out when required. The duty of candour is the legal requirement for healthcare services to be open and honest when an unexpected or unintended incident leads to serious harm or death. The service had a duty of candour policy and staff followed this process for any incidents rated moderate harm and above.

The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Patients told us they had not experienced any instances of abuse or neglect at the service.

The service provided safeguarding training in line with intercollegiate guidance and best practice. Although the hospital did not provide services for children and young people, it was recognised that patients may attend hospital with young family members. Staff were therefore required to complete level 2 children safeguarding training. Records for the current training year showed all theatre and ward staff had completed levels 1, 2, and 3 adults and children safeguarding training. Data showed safeguarding training compliance for all permanent hospital staff was at 100% for level 2 adults and children training and 98% for level 3 adults and children training.

However, some consultant doctors working under practicing privileges did not have the expected level of safeguarding adults training in line with the central provider policy and national guidelines. The Intercollegiate document for adult safeguarding recommends all registered staff are required to train to a minimum of level 3 to ensure they have the relevant skills, knowledge, and competence to protect vulnerable adults. Under provider policy, consultant doctors were expected to provide confirmation of their current and complete mandatory training records, at their primary site of employment. Records did not demonstrate discussion of absent mandatory training records before practicing privileges were renewed. For example, anonymised practicing privileges records showed some mandatory training, such as safeguarding adults' level 3 was not always clearly documented. When we raised concerns, senior leaders said they were assured consultants had the appropriate level of training, as they received copies of each consultant’s annual appraisal from their primary employment. This meant the responsible officer at their primary site of employment had approved consultant appraisals in line with NHS organisations. This included confirmation that consultants had completed safeguarding adults level 2 training.

The director of clinical services was the safeguarding lead. As safeguarding lead, they had completed the higher level of safeguarding training for children and adults, as did the hospital director. This meant there was always someone available to provide support to staff for safeguarding concerns.

Staff we spoke with were aware of the provider’s safeguarding policy. Staff could describe how to make a safeguarding referral and who to inform if they had concerns. They knew how to access support from the safeguarding team. The provider’s safeguarding policy instructed staff on how to identify and report any safeguarding concerns, including making referrals internally and to external agencies, such as the local authority safeguarding team.

Staff told us learning from any reported safeguarding incidents was shared as part of daily huddles and during routine staff meetings. Staff had safeguarding supervision with managers to discuss specific cases and to reflect on the actions and outcomes.

The evidence showed some shortfalls. The service did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We observed theatre teams undertake the NatSIPPS2 ‘8 steps to safer surgery’ safety checks, including the use of the World Health Organization (WHO) checklist. Although the theatre staff completed safety checks before, during and after surgery there was variation on adherence to provider policy. This indicated critical safety checks were not consistently performed before, during, and after surgical procedures. This was highlighted to the theatre and hospital management during the inspection. Immediate actions were taken by the management teams to improve compliance. These actions included urgent team meetings, increased local audit frequency and unannounced internal audits by the providers national lead for theatres.

Staff within the pre-assessment team screened patients based on their past medical history and escalated concerns in line with the admission criteria. We saw evidence of this and staff we able to give examples of following this process. Staff discussed support needs prior to admission to reduce risk depending on the type of surgery. For examples, during the assessment a patient was staying an additional night in hospital as there was no one to support them at home following surgery. This demonstrated the priority of patient safety.

Patients were reviewed by a consultant daily and were available for advice or further reviews throughout. In the event of a clinical concern that required escalation, staff were clear on how to access consultant advice and support from a senior nurse and theatre manager.

Staff said they used care plans and risk assessments to identify patient risk. Staff identified deteriorating patients using nationally recognised tools such as the National Early Warning Score (NEWS). All staff we spoke to during the assessment were able to tell us how they would escalate any deteriorating patient concerns. They described how they would escalate deteriorating patients, including patients with conditions such as venous thromboembolism (VTE), to the resident medical officer (RMO). The RMO was available 24 hours a day to support the nursing team and to provide immediate medical intervention as required.

Clinical staff received face to face training in basic life support to provide the skills to respond to life-threatening emergencies. Administrative staff only received online training due to a change made centrally by the provider. Staff knew how to call for emergency assistance if there was an emergency.

Patients told us staff explained any risks associated with their treatment and kept them up-to-date about any changes to their care and treatment. They told us they received post-operation phone calls within 24 hours of being discharged and had support if they needed it.

The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

During the inspection we found some corridors in the theatre suite were cluttered with equipment. This made it challenging for staff to effectively move equipment through the corridor and to be able to clean both the equipment and environment. The service immediately reviewed the amount of storage required in theatre areas. Service leads addressed issues raised regarding storage space by removing redundant items and ordering new racking. Information provided by the service following the inspection demonstrated how oversight and assurance meant the area was being managed safely. However, the preoperative assessment area, ward and theatre areas were visibly clean, well maintained and, with the exception of theatres, generally free from clutter.

Patients told us they felt the environment was safe, the design and condition of the rooms were good and met their needs. They said the hospital areas and inpatient rooms were clean and the equipment looked new.

Equipment was visibly clean and well maintained. Staff told us all items of equipment were readily available and any faulty equipment was repaired or replaced in a timely manner. Documentation showed the service recorded and monitored when equipment had been serviced and repaired. The service provided evidence of staff training in the use of clinical equipment and non-clinical equipment.

There were daily cleaning schedules and deep cleaning every 6 months.

Staff carried out daily safety checks of specialist equipment. Emergency resuscitation equipment was available in all areas. Daily and weekly equipment check logs were complete and up-to-date in those areas. All the emergency resuscitation trolleys we saw were tagged to minimise the risk of items being tampered with. Resuscitation trolley audits over the past three months showed consistent resuscitation trolley maintenance compliance.

We observed up-to-date risk assessments and associated action plans. This included fire safety, ventilation, legionella flushing of water outlets and environmental risk assessments for theatre and wards areas.

There were arrangements in place for the handling, storage, and disposal of clinical waste, including sharps. The service complied fully with the Control of Substances Hazardous to Health (COSHH) practices.

The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Patients told us there were enough staff during and after their procedures and they provided safe care and treatment. They spoke positively about the way staff communicated and interacted with them and told us staff responded quickly when they requested assistance.

Staff were available throughout the day to respond to patients in a timely manner. We observed how staff positively interacted with patients in a friendly and encouraging way.

Data from the staffing rota, and from our observations, showed staffing in both theatres and on the wards was sufficient and safe. Theatre staffing levels were in line with the Association for Perioperative Practice (AfPP) recommendations and ward staffing levels were based on the ‘safer staffing’ acuity tool. This meant staffing levels could be adjusted daily according to the number of patients and their needs. Enabling the service to provide a responsive service for patients and to support staff well-being.

The ward and theatre managers carried out daily staff monitoring and escalated staffing shortfalls as part of the daily hospital-wide and departmental huddles.

The vacancy rate was low and we heard that staffing was not an issue as managers planned ahead and were always approved by the leadership team to obtain extra staff when required.

The service had enough medical staff to keep patients safe. Surgical procedures were carried out by a team of consultant surgeons and anaesthetists who were mainly employed by other organisations (usually in the NHS) in substantive posts and had practising privileges with Hampshire Clinic Hospital. The process for review of practising privileges ensured consultants worked within an agreed scope of practice.

Staff received and kept up-to-date with their mandatory training. The mandatory training was comprehensive and met the needs of patients and staff. There was a practice-based educator who monitored compliance and supported staff with their training needs. Compliance with mandatory training was high. Data provided by the service showed at least 99% of all staff had completed mandatory training, with many modules achieving 100%.

Data provided showed 88% of all required staff had completed basic life support (BLS) and 96% had completed immediate life support (ILS).

All staff, including bank and agency staff received a full induction tailored to their role before they started work. Staff told us they received annual appraisals and the service monitored compliance. Data showed appraisals had either been completed or, where they may be overdue, they had been scheduled. The service recorded and monitored when doctors and consultants working under practicing privileges had completed appraisals with their own organisations (usually an NHS trust).

There was onsite medical cover for 24 hours a day, and a doctor could attend the ward quickly in an emergency. Anaesthetists and consultants were contactable in line with policy during the patient’s pathway and would support staff with concerns regarding their surgery.

Senior leaders reviewed practicing privileges for consultant doctors once every 2 years. Senior leaders followed a standardised review process set by the central provider and used data and insight dashboards effectively to monitor and manage this process. At the time of the inspection, all consultant doctors had received their practicing privileges review in the expected timeframe.

The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Staff within the theatre suite did not always adhere to effective infection control principles. including hand hygiene and following approved principles for the safe removal of personal and protective equipment (PPE).

We highlighted our concerns to the service during the inspection. The service implemented immediate actions to improve consistency in practice. For example, the provider’s national Infection Prevention and Control (IPC) Lead undertook a review. An action plan was developed following their recommendations. Information provided by the service following the inspection demonstrated improved oversight and compliance with IPC processes and policies.

Additionally, the hospital confirmed how they had strengthened their governance structure and quality assurance framework for accountability and assurance relating to infection prevention and control (IPC). This was overseen by the hospitals Director of Clinical Services. Further support was provided corporately by the provider’s national IPC lead.

Following the inspection, the service provided details of immediate training sessions, and subsequent regular sessions, with topics relating to theatre-specific IPC requirements and decontamination. These included training relating to effective cleaning of theatres, hand hygiene techniques and how to record and audit IPC effectiveness.

Staff generally maintained equipment well and kept it clean. ‘Clean’ stickers were visible on some equipment, but dates suggested cleaning had taken place some days previously. Staff we spoke with told us they would clean any equipment again prior to use if a sticker was not present or dated. We did not always see this being carried out during our assessment.

All ward areas were visibly clean, had required furnishings and were well-maintained. Hand gel dispensers were in the corridors of the ward outside patient rooms. Following the inspection, additional hand gel dispensers had been installed within the theatre suite to support effective hand hygiene. Staff advised they would use the sinks in the medication storage room or patient washrooms to wash hands with soap and water. Hand towels and soap was available.

Cleaning records within clinical areas such as ward and theatres were up to date and demonstrated the ward areas were cleaned regularly. Staff told us there was a robust room cleaning process following the discharge of patients from the ward.

Patients were routinely screened for infections such as MRSA at pre-assessment and there was a process in place to report surgical site infections (SSI). In the 12 months prior to our assessment there were no reportable infections.

Cleaning agents and equipment were safely stored in a locked cupboard when not in use. This was in line with the provider and service COSHH (Control of Substances Hazardous to Health) policy.

The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happen.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

The service had systems in place to support the safe prescribing, administration and storage of medicines. Medicines reconciliation is the process of gathering accurate information about a person’s prescribed medicines. These were completed on admission and pharmacy staff clinically reviewed prescriptions to ensure patients received appropriate treatment. Staff were knowledgeable about the medicines they administered and had access to pharmacy support throughout the day.

Medicines were stored securely and checked regularly, including controlled drugs which were audited routinely. Patients were supported with clear discharge counselling, including explanations of medicines and timetables for when to take medications. Discharge medicines were prepared early to support timely discharge.

Staff were allocated roles for medical emergencies during the daily handover. This ensured staff were aware of their role prior to any event taking place. Staff completed training and competency checks, including annual intravenous (IV) training and peer assessments around medicines optimisation.