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CESP (Dorset & New Forest) @ Nuffield Health Bournemouth Good

Inspection Summary


Overall summary & rating

Good

Updated 12 March 2018

Inspection areas

Safe

Good

Updated 12 March 2018

We rated safe as Good because:

  • There were no serious incidents and healthcare associated infections reported in the last 12 months.

  • Infection control processes and practices promoted safe care. The environment was clean and personal protective equipment was readily available.

  • Equipment including emergency resuscitation equipment was well maintained and checks were completed. .

  • Risk assessments were completed prior to lasers being operated and local rules were followed for the safety of patients and staff.

  • There were adequate number and skilled staff to provide care and treatment.

  • Policies and procedures were in place to ensure people were safeguarded from the risk of abuse.

  • The duty of candour was understood by staff and included their responsibilities in evoking this as needed.

  • There was a process in place for access to medical input out of hours and a service level agreement with the local trust for emergency transfer of patients as required.

  • Records of patients undergoing surgical procedures were detailed and contained risk assessments, pre and post op checks and notes.

    However, we also found the following issues that the service provider needs to improve:

  • There was no competency framework in place to assess staff’s competency and for the healthcare staff who were administering eye drops as an ‘extended’ role.

  •   Patients’ records such as risk assessments in the outpatients department were not stored safely and securely.

Effective

Good

Updated 12 March 2018

We rated effective as good because:

  • Staff followed professional guidance such as the Royal College of Ophthalmology, surgical pathways including the five steps to safer surgery were completed.

  • The process for granting practicing privileges was adhered to and the

  • Consent to care and treatment ensured that patients were involved and informed consent gained.

  • Patients were given information about pain relief and this included administration of anaesthetic eye drops prior to surgery or procedures.

Caring

Good

Updated 12 March 2018

We rated caring as good because:

  • Patients said they were treated with care and compassion and their privacy and dignity were maintained when receiving care and treatment. The patients were fully involved in their care and were supported in the management of long term conditions.
  • Patients were overwhelmingly positive about the care they received. We observed staff providing reassurance to patients in a calm manner ensuring they felt well-supported.

Responsive

Good

Updated 12 March 2018

We rated responsive as good because:

  • There was a robust process for investigations of complaints. Information on how to raise a concern or complaint was available to people using the service.

  • Access to care and treatment was well managed, and patients were seen within two to three weeks from referral times.

Well-led

Good

Updated 12 March 2018

We rated well-led as good because:

  • CESP was proactive in seeking patients’ views and their experience of care and treatment they had received in order to improve the service.

  • The provider’s vision and strategy was to provide care and treatment tailored to patients individual needs.

  • The governance process included the medical advisory committee to monitor practices and share learning from incidents.

  • CESP and the host hospital had recently developed terms of reference for a joint governance committee. The aim of this committee was to facilitate implementation of governance processes which would include risk management.

    However-

  • CESP did not have a surgical risk register. CESP process for assessing risks was not fully developed in order to mitigate risks associated with carrying on the regulated activities.

Checks on specific services

Services for children & young people

Updated 12 March 2018

Children and young people’s services were a small proportion of this service activity. The main service was surgery. Where arrangements were the same, we have reported findings in the surgery section of the report.

We have not rated services for children and young people as we do not have enough evidence to rate this service.

Outpatients and diagnostic imaging

Good

Updated 12 March 2018

Surgery and outpatients and diagnostics were activities undertaken at this service.  Where our findings also apply to both activities, we do not repeat the information but cross-refer to the surgery section of the report.

We rated outpatients and diagnostic as good overall because it was safe, caring, responsive and well led. We currently do not rate Effective for Outpatients and diagnostic.

Surgery

Good

Updated 12 March 2018

Surgery, and outpatients and diagnostics were activities undertaken at this service. Surgery was the main activity at the service. Where our findings also apply to both activities, we do not repeat the information but cross-refer to the surgery section of the report.

We rated surgery as good overall because it was safe, effective, caring, responsive and well -led