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Inspection Summary


Overall summary & rating

Outstanding

Updated 8 August 2017

Claremont Hospital is operated by Aspen Healthcare Limited. Claremont Hospital has 42 beds, three laminar flow theatres, 13 consulting rooms, a static MRI and CT scanner, and plain and digital X-ray. The hospital provides surgery and outpatients with diagnostic imaging services and we inspected both of these services.

We inspected this hospital using our comprehensive inspection methodology. We carried out the announced part of the inspection on 20 to 21 February 2017 with an unannounced visit to the hospital on 3 March 2017.

We rated the hospital as outstanding overall, with surgery rated as outstanding and outpatients and diagnostics rated as good.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so, we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate. Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

The main services provided by this hospital were surgery, outpatients and diagnostics. Where our findings on surgery, for example, management arrangements, also apply to other services, we do not repeat the information but cross-refer to the surgery core service.

We rated this hospital as outstanding overall because:

  • We saw excellent leadership from managers who were passionate about patient care and staff welfare. They were visible to all levels of staff and patients.

  • There were robust governance structures and reporting mechanisms in place where performance and the quality of the service was reviewed and changes made. Actions were monitored through audit processes and reported to leadership and governance committees.

  • We saw a service wide vision and strategy that was embedded across the organisation.

  • Patient care was at the heart of the service and the priority for staff. We saw several areas of outstanding caring practice.

  • Staff were trained in a nationally recognised accreditation programme in customer care. Following this staff completed a Values Partners programme which is a workshop to explore values and behaviours between staff and towards patients and aims to create a positive working culture.

  • The hospital took part in a recognised comprehensive observational study process to consider the approach by staff to the general care of patients, the level of patient/visitor engagement, and the environmental factors within patient reception areas. We saw an example of one survey in July 2016 and there had been an overall high score of 97%.

  • There were effective systems to keep people safe and to learn from critical incidents.

  • The hospital environment was visibly clean and there were measures to prevent the spread of infection.

  • There were adequate numbers of suitably qualified, skilled, and experienced staff (including doctors and nurses) to meet patients’ need.

  • There were arrangements to ensure staff had and maintained the skills required to do their jobs.

  • There were arrangements to ensure people received adequate food and drink that met their needs and preferences.

  • Care was delivered in line with national guidance and the outcomes for patients were good when benchmarked.

  • Robust arrangements for obtaining consent ensured legal requirements and national guidance were met.

  • The individual needs of patients were met including those in vulnerable circumstances, such as those with a learning disability or dementia.

  • Patients could access care when they needed it.

However:

  • We observed some environmental concerns in theatre areas. There was a refurbishment plan in place.

  • Surgical safety checklists were not completed consistently.

  • Not all checks had been completed in theatre for controlled drugs, drug fridges and warming cabinets. Some cleaning checks in the theatre areas had not always been completed daily.

  • Not all eligible staff had received an appropriate level of safeguarding training to allow them to recognise any issues of concern.

  • Mandatory training figures did not reach Aspen Healthcare Ltd targets.

Following this inspection, we told the provider that it should make some improvements, even though a regulation had not been breached, to help the service improve. Details are at the end of the report.

Ted Baker

Chief Inspector of Hospitals

Inspection areas

Safe

Good

Updated 8 August 2017

We rated safe as good because:

  • The hospital promoted a culture of reporting and learning from incidents. Incidents were fully investigated with actions for improvement identified and put into place.

  • There were sufficient staffing levels in place to meet patient’s needs.

  • Nursing records had been completed appropriately and in line with each individual patient’s needs.

  • A modified early warning score system was in place to support staff to recognise a deteriorating patient.

  • There was an out of hours on call system. There was a senior manager on call rota in place seven days per week. This rota was circulated and all staff were aware of the senior contact for the hospital each week.

  • Each  Resident Medical Officer (RMO) on duty was Advanced Life Support (ALS) and Paediatric Advance Life Support (APLS) trained and was available for assistance 24 hours per day, seven days per week.

However,

  • Surgical safety checklists were not completed consistently.

  • There were defects in the theatre environment and some equipment which were a potential infection risk. There were plans in place to address these.

  • Not all checks had been completed in theatre for controlled drugs, drug fridges and warming cabinets.

  • Not all eligible staff had received an appropriate level of safeguarding training to allow them to recognise any issues of concern.

Effective

Good

Updated 8 August 2017

We rated effective as good because:

  • Patient’s care and treatment was planned and delivered in line with current evidence-based guidance, standards, and best practise legislation. Adherence to evidence-based practice was monitored as part of the annual audit plan to ensure a consistent approach to care and to monitor patient outcomes.

  • Policies and procedures used within surgery and theatres followed evidence based practice. For example, the surgical site infection monitoring in orthopaedics was followed in accordance with guidance from the National Institute for Health and Care Excellence (NICE) for prevention and treatment of surgical site infection (SSI) clinical guideline number 74 (CG74).

  • There were a range of clinical pathways and protocols for the management and care of a range of surgical interventions which were based on best practice and NICE guidelines. We observed a range of surgical management pathways in the patient medical records which were easy to follow and were fully completed.

  • Staff used a pain-scoring tool to assess patient’s pain levels; staff recorded the assessment on paper records.

  • The hospital participated in those national audits relevant to the services they provided. This included the patient reported outcomes measures (PROMS) for NHS funded patients and the National Joint Registry. The hospital had scored highly in the assessment for health gain using the Oxford hip score and was in the top fifty providers.

  • Anaesthetists had a 24-hour post anaesthetic responsibility for the care of their patients and were available 24 hours a day for any deviation or concern with patient’s health progress.

  • Staff skills and competence were examined and staff were trained to ensure they were competent to provide the care and treatment needed. Staff were supported to obtain new skills and share best practice. Staff appraisal was ongoing.

  • Consent to care and treatment was discussed and obtained in line with legislation and guidance.

  • Patients had good outcomes as they received effective care and treatment to meet their needs.

  • High quality performance and care were encouraged and acknowledged and all staff were engaged in monitoring and improving outcomes for patients.

  • Children and young people’s needs were assessed and care and treatment was delivered in line with legislation, standards, and evidence-based guidance.

Caring

Outstanding

Updated 8 August 2017

We rated caring as outstanding because:

  • Patient care was at the heart of the service and the priority for staff. We saw several areas of outstanding practice.

  • The hospital had been accredited with a recognised customer service programme. This meant that staff had training to offer patients respect and courtesy.

  • Patients had their privacy and dignity maintained at all times.

  • Patients were listened to and actively involved in their care and treatment. Staff were committed to working in partnership with the patients and making this a reality for each person.

  • People’s social and emotional needs were highly valued by staff and we were given examples of how these needs were met.

  • The emotional needs of young people were embedded in the care provided. Parents were able to accompany their child to theatre and be present in recovery to give extra emotional support.

  • Patients felt staff went the extra mile and the care they received exceeded their expectations.

  • Theatre recovery nurses visited the young people on the ward prior to surgery so they would see a face they recognised and be less anxious after their surgery.

  • There was an emphasis on the family as a whole and ensuring that parents were put at ease as much as the young people.

  • Nursing staff could provide emotional support to patients receiving bad news and psychiatric support was available for patients receiving cosmetic, bariatric or breast cancer treatment.

Responsive

Good

Updated 8 August 2017

We rated responsive as good because:

  • Services were planned to meet patients’ needs. The flow of patients through the hospital was well organised.

  • An average of 95% patients were treated within 18 weeks of referral between the time frame September 2015 to October 2016.

  • There were facilities for those patients who had a disability including sensory impairments.

  • In the inpatient and theatre areas, we saw that the Aspen Healthcare Limited dementia strategy had been rolled out and there were five dementia champions in place.

  • Patients felt well informed about the procedure and what to expect during their recovery. Patients received “going home packs”. These packs contained information relating to the type of anaesthetic the patient would receive the surgical procedure, VTE information, booklets for cardiac patients and National Joint Registry (NJR) consent forms for patients who agreed to contribute to the hip and knee NJR.

  • Services were tailored to meet the needs of individual patients and were delivered in a flexible way.

  • Complaints were responded to in a timely manner and any learning was taken forward to develop future practice.

  • Staff actively invited feedback from patients and their relatives and were very open to learning and improvement.

  • There was access into the building and a passenger lift to all floors ensuring patients could move around the building.

  • The service provided mostly inpatient care for NHS funded patients who would attend on contract through the local commissioning groups (CCG’s). The hospital worked closely with the local NHS providers and CCG’s to ensure that services were planned to meet the needs of the local population.

  • We saw that clinics were flexible to meet the needs of patients. There were a small number of satellite clinics which meant, for some patients, this minimised travel.

  • New self-funded and insured patients could be seen in some cases within 24 hours.
  • There was a discharge co-ordinator in place to ensure there were minimal delays and that services were in place at home.

Well-led

Outstanding

Updated 8 August 2017

We rated well-led as outstanding because:

  • There were robust governance structures and reporting mechanism in place where performance and the quality of the service was reviewed and changes made. Actions were monitored through audit processes and reported to leadership and governance committees.

  • We saw a service wide vision and strategy that was embedded by staff in both inpatient wards and in the

  • Staff were very proud of their service and felt as though their managers and senior managers were very approachable and caring.

  • There was a learning culture within the hospital. Staff were encouraged and supported to further their skills and knowledge.

  • There was strong local leadership of the service from the hospital director supported by the matron and heads of departments. Senior staff provided visible leadership and support to staff on a daily basis. Staff had confidence in leadership at each level and felt they would be listened to.

  • Staff were very proud of the job they did and without exception, the staff we spoke with enjoyed working at the hospital. We found morale to be universally positive.

  • Staff demonstrated a strong belief in delivering high quality service in their individual role and as a team, felt supported by management and were committed to striving for the best patient experience.

  • Leaders ensured that employees involved in the performance of invasive procedures were given adequate time and support to be educated in good safety practice, to train together as teams and to understand the human factors that underpin the delivery of safer patient care.

  • Risks were identified and ways of reducing the risk investigated. Any changes in practice were introduced, shared throughout the hospital, and monitored for compliance.

  • The leadership, governance, and culture were used to drive and improve the delivery of high-quality care. The clinical managers were committed to the patients in their care, their staff, and the unit.

  • Frontline staff and managers were passionate about providing a high quality service for patients with a continual drive to improve the delivery of care.

  • There was a high level of staff satisfaction with staff saying they were proud of the departments as a place to work. They showed commitment to the patients, their responsibilities and to one another. All staff were treated with respect and their views and opinions heard and valued.

  • Patients were able to give their feedback on the services they received; this was recorded and acted upon where necessary

  • The service ensured they were using skills and experience of organisations and specialists independent of the hospital.

  • The development of the new endoscopy suite was in progress at the time of our inspection. This was on target for opening. There were associated plans to become JAG accredited.

Checks on specific services

Outpatients and diagnostic imaging

Good

Updated 8 August 2017

We rated this service as good. Safe, responsive and well-led were rated as good. Caring was rated as outstanding. We did not rate effective as we are currently not confident that we are collecting sufficient evidence to rate effectiveness for outpatients & diagnostic Imaging.

The service had reported no never events or serious incidents and one incident had been reported to the CQC in accordance with the Ionising Radiation (Medical Exposure) Regulations 2000 (IR (ME) R). Staff were encouraged to raise concerns and report incidents. We saw evidence of lessons learnt from safety incidents and changes to clinical practice.

Medications in radiology were stored securely in appropriately locked rooms and fridges. There was an effective process in place for monitoring the use of prescription charts.

Policies and procedures were accessible to staff and had been developed and referenced to the National Institute for Health and Care Excellence (NICE) and national guidance.

Staff knew how to report incidents and there was good evidence of sharing and learning from incidents.

All areas were clean, organised, and well equipped. Staff complied with ‘arms bare below the elbows’ policy, correct handwashing technique, and use of hand gels.

Staff we spoke who were aware of their roles and responsibilities in relation to safeguarding. They were able to identify different types of abuse and were aware of how to escalate concerns.

Staffing levels were good with no vacancies in the outpatients and physiotherapy departments. One vacancy in the radiology department was in process of being filled.

The culture across the hospital was replicated in outpatients and diagnostic services. Patients told us they were treated with kindness, dignity, and respect. We observed staff interacting with patients and their families in a respectful and considerate manner. Reception staff were welcoming and friendly and patients told us they were courteous.

All patients we spoke with said they felt informed about their care and treatment. They said staff had time to explain things fully and to answer any questions they had.

Nursing staff could provide emotional support to patients receiving bad news and psychiatric support was available for patients receiving cosmetic, bariatric or breast cancer treatment.

Referral to treatment time (RTT) for patients on incomplete pathways waiting 18 weeks or less at this hospital, was consistently 95% or higher.

Patients were seen promptly and able to access appointments at a date and time to suit them. Outpatient clinic cancellations were low.

Staff in outpatient and diagnostic imaging services met the individual needs of patients. Waiting areas had been improved for patients with dementia and telephone and face to face interpretation services were available for patients whose first language was not English.

Patients were made aware of how to complain and staff dealt with patient concerns immediately to prevent them escalating. The outcome of formal complaints was shared with staff at team meetings, which included feedback and learning.

Staff spoke highly of both local and senior leaders. They said they were accessible and approachable. There was a positive culture with good staff morale. Staff felt able to raise concerns and said they felt listened to and valued.

Risks were managed well and there was a clear mechanism for escalating risks when necessary.

Outpatients and radiology departments were continually seeking to improve services for patients.

Surgery

Outstanding

Updated 8 August 2017


Surgery was the main activity of the hospital.

Where our findings on surgery also apply to other services, we do not repeat the information but cross-refer to the surgery section.

We rated this service as outstanding overall. We rated caring and well-led as outstanding. We rated safe, effective and responsive as good.

The service had reported no never events and two serious injuries between October 2015 and September 2016. There had been one never event, involving wrong site surgery, that had been reported in January 2017 prior to our inspection. We saw that this was being investigated and an action plan developed.

Learning was cascaded via the governance committees and received at staff team meetings.

Internal patient satisfaction surveys indicated 98% satisfaction for cleanliness and the service had a low rate of hospital acquired infection.

The hospital training performance for the surgical services showed mandatory training completion results were predominantly above the hospital target of 85%.

Integrated care records covered the entire patient pathway from pre-operative assessment to discharge and included comprehensive care plans for identified care needs.

We reviewed 11 sets of medical and nursing care records whilst on site and records were legible, complete, and contemporaneous.

We saw excellent individualised care which was delivered by highly motivated staff.

The surgery service at the hospital had a good overall safety performance and patients were protected from harm.

We found good processes for reporting and escalating incidents and good sharing of learning from incidents.

There was a good understanding of the duty of candour regulation and major incident policies amongst clinical staff.

There were good patient outcomes across surgical specialties and care was delivered in line with relevant national guidelines.

The hospital performed well in national clinical audits.

Staffing needs were based on acuity of patients and reviewed daily to ensure safe staffing.

Patients had effective and timely pain relief.

Staff felt supported with training opportunities to fulfil their role

There was effective multidisciplinary team (MDT) working between doctors, nurses and allied health professionals and local NHS hospitals.

Staff across the surgery service were caring and professional and patients were treated with dignity. Staff often went ‘the extra mile’ to ensure that patient needs were met and patients were comfortable and informed about their treatment and care.

Patients that we spoke to consistently highly praised staff of all levels, in particular their caring attitude.

Patient flow from admissions, through theatres and onto to surgery wards was smooth and bed availability was managed effectively.

We saw leadership from staff who were passionate about patient care and staff welfare. They were visible to all levels of staff and patients.

There were comprehensive and robust governance and risk management processes in place.

During the inspection, we observed warm, open, and positive interactions between staff and patients. All patients we spoke with were happy with the care they received and we received universally positive written feedback from patients during the inspection.