Archived: Shepton Mallet Health Partnership

Shepton Mallet NHS Treatment Centre is an independent hospital run by Care UK, providing NHS elective surgical and outpatient services to patients across Somerset and North Dorset. Surgical specialities include: general surgery; orthopaedics, endoscopy, gynaecology, urology, ear, nose and throat and ophthalmology. Children are not treated at this site. It opened in 2005 as part of the wave 1 procurement of NHS services from the independent sector.

The hospital has 34 inpatient beds and 18 day-case beds, although only a maximum of 26 inpatient beds were available for use at the time of our inspection, as the remainder of the beds had been converted into areas for use by the resident medical officer and patients attending the falls and stability outpatient service.

We carried out this comprehensive inspection as part of our wave 1 pilot of in-depth reviews of independent hospitals. Our inspection was carried out in two parts: the announced visit, which took place on 9 and 10 December 2014; and the unannounced visit, which took place on 14 December 2014.

As with other services inspected as part of the wave 1 pilot programme we did not rate this service. We did however, find the centre provided safe, effective, caring, responsive, and well led services to patients.

Our key findings were as follows:

Safety:

• There was a good safety culture within the hospital. Staff throughout were aware of how to report incidents. There were low levels of incidents and, for any that did happen, a thorough investigation was carried out with clear actions and learning undertaken.
• The hospital was clean and there was a clear focus on infection prevention and control. There had been no instances of MRSA, Clostridium difficile or other reportable hospital acquired infections within the hospital within the 12 months prior to our inspection. There were cleaning schedules in place and these were audited and monitored regularly.
• There had been one Never Event in the hospital in the 12 months prior to our inspection. Never events are serious, largely preventable patient safety incidents. These should not occur if the available, preventative measures have been implemented. This had been thoroughly investigated, with human factors in mind. Actions and learning had been identified and carried out as a result of the incident to reduce the risk of reoccurrence.
• There were clear processes for assessing and responding to patient risk. Clear admission criteria were in place (identified both by the provider and through commissioning contracts). This ensured the hospital only admitted patients who they had the facilities to provide care and treatment to as there were no intensive care or high dependency facilities. There were effective processes in place to monitor patients for deterioration in their condition.
• There were suitable numbers of nursing staff within the hospital. On the implementation of the safer staffing initiative by the Department of Health there had been no need to amend the staffing levels in the hospital. The hospital routinely had staffing levels which met or exceeded the safer staffing requirements.

Effective:

• Patients received effective care from the hospital. There was a holistic approach to assessing, planning and delivering care within the hospital. An individual approach to patients’ needs was adopted throughout the patient pathway. Discharge was planned prior to admission. Care and treatment was provided in line with national guidelines, including those of the National Institute for Health and Care Excellence, and Royal Colleges.
• Patients receiving hip and knee operations had a lower (better) length of stay, following their operation, than the NHS national average for England.
• There were low rates of post-operative infection, venous thromboembolism (VTE) and no unexpected cases of mortality.
• Patients received effective pain relief. They were assessed for their pain needs in their outpatient pre-operative assessment and throughout their hospital stay.
• Patients nutritional and hydration needs were met. The chef visited the ward and spoke to a number of patients each day. Dietary needs were accommodated with, for example, fresh gluten free bread being made on site.
• Staff were actively engaged in activities to monitor and improve the quality of care and patient outcomes. There was an audit cycle which reviewed clinical practice by clinician and by procedure. This allowed benchmarking both internally and externally.
• Staff were proactively supported to acquire new skills. A large number of staff were funded by the provider to engage in further training to develop in their roles either at degree or masters’ degree level.
• There were systems in place to ensure patients received the treatment and care they needed seven days a week. Although operating theatres were only open on six days of the week, physiotherapy was provided on seven days. Where an operation had occurred on a Saturday which required the patient to receive a scan or X-ray on a Sunday (in line with the patient treatment pathway), a radiographer would attend the hospital to ensure this occurred.

Caring:

• Without exception we saw staff acting in a kind, compassionate and caring manner with patients.
• Staff all talked enthusiastically of the ‘patients first’ ethos and this was evident in all engagements we observed. We saw patients’ dignity promoted within the hospital with staff working together to ensure patients were supported through procedures and treatments.
• Feedback from all patients we spoke with was positive. They spoke of staff going the extra mile with many saying that they felt staff always provided what they needed and nothing was too much bother. They were actively involved in decisions around their care.
• Patients’ emotional and social needs were highly valued by staff. We saw examples of staff providing support to patients to ensure they felt safe and secure.

Responsive:

• Patients’ individual needs and preferences were central to the planning and delivery of the service provided. Treatment plans and pathways were tailored to individual needs where necessary. This included, for example, providing additional support and appointments for patients requiring imaging scans (which might cause patients to feel claustrophobic) rather than cancelling the scan and delaying or preventing treatment.
• There were systems in place to ensure patients could access outpatient services at their convenience. Referral to treatment times for surgery were consistently below the Department of Health 18 week target. There had only been three breaches in referral to treatment times for outpatient appointments in the previous year. Patients were given the opportunity to choose an appropriate time and date for their outpatient appointment. Outpatient clinics offered a ‘one-stop shop’ approach, enabling patients to have all diagnostic tests and to leave with a date for surgery if required.
• Times for admission for surgery were allocated in line with the patient’s position on the theatre list. Patients who were identified as being first on the operating list were contacted to ensure they were able to get to the hospital early in the morning. If this was not possible then they would be allocated another slot on the list in order to meet their needs.
• There were low numbers of complaints made about the hospital. There were clear processes in place for investigating and responding to complaints and information was accessible to patients about making a complaint.
• There were processes in place to ensure rapid engagement with patients’ GPs and other specialist providers where an unexpected diagnosis of a cancer was found.
• The service was responsive to patients’ cultural, religious, language and dietary needs. Translation facilities were available and the chef proactively engaged with patients to ensure that any special dietary needs were met.

Well Led:

• The hospital was well led. Strong leadership, governance and culture were used to drive and improve the delivery of high quality patient-centred care.
• There was a clear vision and strategy within the hospital. This focused on three core areas of Quality (clinical excellence), People (developing people, leadership and culture) and Business (growing the business). Each department and team had been empowered to develop their own vision and strategy aligned to that of the hospital. This was to ensure that there was engagement with all staff.
• Governance and performance management arrangements were proactively reviewed and reflected best practice. There were clear governance arrangements in the hospital. Data on performance was collated monthly and reviewed in an open governance meeting each month which all staff were encouraged to attend.
• There was a positive working relationship with the commissioners of the service at the hospital. There were quarterly reports produced and meetings held regarding performance by the hospital. Services had been developed with commissioners to meet the needs of the local community, for example, running satellite outpatient clinics in community hospitals, and there was a view to develop this further. During our visit the hospital director told us how they were engaged with clinical commissioners and NHS trusts about how the service could support winter pressures initiatives.
• The hospital did not have a policy regarding the duty of candour at the time of our inspection. However, evidence seen of the engagement with patients regarding complaints and where care had not gone as planned, demonstrated a candid approach.
• There were high levels of staff satisfaction within the hospital. Staff were proud to work there and spoke highly of the leadership. Staff felt they were able to raise concerns within the hospital.
• The culture of ‘patient first’ was clear throughout the hospital. Staff demonstrated the values of the hospital and the provider organisation. They were proud of their work and service they provided to patients.
• Innovation was ongoing within the hospital. A physiotherapy “App” had been developed to provide support to patients undergoing joint replacement surgery. There was also a falls prevention programme in place. This supported patients through their surgical pathway from prior to surgery right through to a year following their operation. This was to prevent patient falls in hospital but also following discharge from hospital. Both had won awards.

We saw several areas of outstanding practice including:

• Staff were able to prepare for any patient being admitted with a diagnosis of dementia. One to one nursing support was provided and equipment made available to promote independence. When required, relatives had been able to stay with the patient overnight.
• Length of stay for both hip and knee surgery was significantly below the NHS England average. Length of stay for hip replacement surgery was 2. 7 days (NHS England average 4 days) and for knee replacement surgery 2.8 days (NHS England average 5 days). This was made possible by the pre-operative preparation of the patient including delivery of equipment into the home; physio therapy assessment; pain relief including discussing and preparing of medicines for discharge; seven day working of physiotherapists and radiographers; and intensive physiotherapy with the provision of equipment to take home to continue rehabilitation.
• Multidisciplinary team working and approach to all aspects of the patient care pathway. Multidisciplinary agreement prior to cancelations on the day of surgery as Multidisciplinary ward rounds with all involved in determining when a patient was fit for discharge.
• The service was highly responsive to patient needs at all stages through the patient pathway including discharge.
• There was a clear patient focus by both clinical and non-clinical throughout the hospital. This included the chef who visited patients on the ward each day to ensure that their dietary choices were being met.
• There was a high level of patient satisfaction reported across all areas of the treatment centre.
• There were very low levels of operations being cancelled on the day of surgery for non-clinical reasons.
• Patients were at the centre of care. Staff were empowered to make decisions in the best interests of the patient.
• There was a highly visible management team.
• The governance systems were exceptionally well organised, monitored and kept under regular review. Records were accessible and defined planning, actions taken and how learning was to be disseminated. Staff at all levels demonstrated an understanding of the governance structure and processes. These effective systems helped minimise risks to patients and promoted quality care.
• There was clear leadership at all levels within the hospital; from housekeeping and kitchens, through to the ward and departments. This was supported by the senior leadership in the hospital.
• The imaging department had an excellent track record for effective and safe care, with no reportable radiation incidents. The service employed an external consultant radiologist to regularly assess the quality of randomly selected imaging results. This promoted effective diagnoses and appropriate treatment plans for patients.

• The physiotherapy staff were proactive in their approach to providing person centred and effective care. The department worked flexibly to meet patient needs and at the time of our visit there was no wait to see a physiotherapist.
• The physiotherapists ran a ‘falls and stability’ outpatients program open to anyone who had been seen at the treatment centre.
• The outpatient department proactively looked for ways to improve their services and patient outcomes. This included the developed of a ‘Pocket Physio App’. This free resource for patients provided both video and text instructions on pre-operative and post-operative physiotherapy exercises.
• Patients were advised to contact the treatment centre with any concerns regarding their treatment for up to one year post surgery.

However, there were also areas of practice where the provider should make improvements:

• The provider should ensure safer storage of anaphylaxis boxes in theatre and on the ward as these boxes did not have a tamper proof seal.

Professor Sir Mike Richards

Chief Inspector of Hospitals