All inspections: Practice Plus Group Hospital - Ilford

North East London NHS Treatment Centre is operated by Care UK. The service has six operating theatres, one endoscopy suite, 22 bedded inpatient ward (Kingfisher), two post anaesthetic care units consisting of five recovery bays, day surgery unit with 23 patient bays, onsite pharmacy and outpatients department (eight consulting rooms).

The service provides surgery, outpatients and diagnostic imaging. We inspected surgery and services for outpatients and diagnostic imaging. Although the service did provide some diagnostic services such as ultrasound on site, the bulk of the diagnostic service is outsourced to other external providers and was therefore not included in this inspection.

We inspected this service using our comprehensive inspection methodology, which we carried out on an unannounced inspection on 22 and 23 January 2019.

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.

Our rating of this hospital/service improved. We rated it as Good overall.

We found good practice in relation to outpatient care and surgery:

The service had taken action to ensure that the World Health Organisation’s Five Steps to Safer Surgery checklist was embedded in the theatre routine.
There was a positive learning culture throughout the service. Staff were encouraged to report incidents and near misses. Learning from incidents was cascaded to staff both within the service and across the provider as a whole. The service reported no never events and had minimal serious incidents.
All staff had up to date mandatory training.
Cleanliness and infection control policies and controls were in place, including for the environment.
Patient records were completed consistently and to a high standard.
Safeguarding processes and training were in place and staff demonstrated good knowledge of these.
The service demonstrated effective internal and external multidisciplinary (MDT) working.
The service benchmarked patient outcomes to ensure the best standards of care. Outcomes were in line with national expectations. We saw procedures had been developed in line with national guidance and staff were aware of how to access them on the shared drive and intranet.
Staff were competent to carry out the role for which they were employed and were supported to do so. The service developed staff with specialist skills to enable them to provide nurse led clinics. All staff had completed their appraisals and performance development plans.
Most specialities offered evening and weekend clinics which facilitated patient access to appointments at times which suited their needs. The service offered patients 24 hours seven days a week advice line.
All staff including consultants demonstrated empathy and compassion with patients in the context of the sensitive nature of many of the procedures carried out and provided emotional support. Staff spoke about patients with care and compassion, demonstrating genuine concern for their wellbeing.
Patients told us they felt listened to by health professionals, and felt informed and involved in their treatment and plans of care.
Access and flow through the service was generally highly effective.
The service reflected and responded to the needs of local people through the provision of information in a range of languages and the use of face-to-face interpreters.
The service worked collaboratively with the CCG and the local trust next door to reduce waiting times. Services were planned and delivered in a way that met the needs of the local population.
The service had reduced their ‘do not attend’ rates by implementing a pre-appointment call in addition to text reminders.
There was a clear vision and strategy for the service of which staff were aware.
The leadership team recognised areas for improvement since the inspection of September 2016 and had taken proactive steps to address them. The leadership team continued to recognise the need for improvement and was working to deliver this.
Generally there was a positive culture throughout the service. We found highly dedicated staff who were positive, knowledgeable and passionate about their work.
Although some members of the senior leadership team were relatively new, senior leaders told us the team felt more stable.
The centre suspended cinical activity bi-monthly for quality governance and assurance meetings and all staff were invited to attend.
Staff we spoke with said, they felt they could raise concerns and were confident that they would be dealt with appropriately.
We saw evidence of public and staff engagement. The centre demonstrated and confirmed that patient experience was the key factor for their service development.

We found areas of practice that require improvement in relation to outpatient care and surgery:

There were communication issues between the bookings team and the theatre team as well as between the theatre team and the recovery team which had the potential to impact on the delivery of an effective service.
The risk register was not always directly related to specific risks within the service itself, but reflected generic or specultative risks.
Due to patients sometime undergoing surgery with a different consultant than the one who had undertaken their consultation, difference of clinical opinion had the potential to impact on whether a patient received the same treatment for which they had initially been booked, or was treated at all.
The fridge log was not completed regularly and we found several omissions.
Although the service had an Infection Prevention and Control policy for Carbapenamase producing Enterobacteriaceae (CPE), staff awareness was inconsistent.
Although the service had made some improvements to friends and family test scores, further improvement was required to increase the response rate.
Although most staff we spoke with demonstrated awareness of the senior leadership team, some staff were not aware of the senior leaders’ names or roles.

Nigel Acheson

Deputy Chief Inspector of Hospitals (London and South East)

North East London NHS Treatment Centre (NELTC) opened in March 2007 . NHS treatment centres are private-sector owned and are contracted to treat NHS patients free at the point of use. In 2014, the Treatment Centre was acquired by Care UK Clinical Services Ltd, the largest independent provider of NHS services in England.

The Treatment Centre provided inpatient and day case elective surgery with associated outpatient and diagnostic clinics across five disciplines: orthopaedics, general surgery, ophthalmology, oral surgery and endoscopy. It provided services to people living in North East London and Essex. The model of care focuses on treating adults who are generally healthy and who do not have significant co-morbidities. It did not provide treatment to and care to children, nor did it provide treatment for 16 – 18 year old young adults.

The Treatment Centre had 21 bed inpatient facilities and 24 day case beds. There were six theatres that operate Monday to Saturday.

We carried out a comprehensive announced inspection of North East London NHS Treatment Centre on 21 and 22 September 2016, and an unannounced inspection on 18 October as part of our second wave of independent healthcare inspections.

We inspected the following two core services:

• Surgery

• Outpatients department.

The diagnostics service is supplied by another provider and was therefore not included in this inspection.

Our key findings were as follows:

Are services safe?

The surgery service used the Five Steps to Safer Surgery checklist; however despite this, there were three serious incidents that had occurred in theatre between April 2015 and March 2016.
Resuscitation training compliance was low for clinical staff.
Controlled drugs were managed appropriately, but we found medication pre-prepared was left unattended or in an unlocked cupboard within an unattended room.
When reviewing patient records, we found some consent forms were missing patient identification details.
In endoscopy there was currently no scope guide available for colonoscopy and no paediatric scope ready for use with narrow structures such as with diverticular disease.
There was currently no security presence in the outpatients department during the day and a risk assessment of the situation had not been undertaken.
Staff understood their responsibilities for reporting incidents and were confident in using the system. Learning was appropriately shared with all staff.
Standards of cleanliness were maintained. Consultation and clinic rooms were observed to be uncluttered.
Staff undertook mandatory training. At the time of our inspection nearly all staff were up to date with this.

Are services effective?

There were good patient outcomes in surgical specialities.
There were short length of stay and low readmission rates.
The hospital demonstrated effective evidence based care and treatment and published or researched guidance that related to good practice
NELTC had achieved Joint Advisory Group (JAG) accreditation for endoscopy provision over the past three years
All nurses and health care assistants completed job related competency frameworks as part of their induction and staff were supported to keep their qualifications and skills up to date.

Are services caring?

We observed staff taking time to interact with patients in a respectful and considerate manner.
Patients commented on how helpful and kind staff had been in providing support.
Overall staff respected patients’ privacy and dignity.
The surgical service received consistent positive feedback from the Friends and Family test.

Are services responsive?

Referral to treatment time standards were being met across the service, with the surgery service meeting the NHS standard of providing treatment for all surgical pathways within 18 weeks of referral
One-stop clinics in outpatients enabled patients to see the consultant, have assessments, diagnostic tests and receive a date for surgery all on the same day. However, this meant that waiting times could be long, and were one of the main issues raised in patient feedback.
Evening clinics were offered in orthopaedics, and ophthalmology and endoscopy clinics took place on Saturdays when waiting lists developed. Patients were able to choose dates and times which suited their needs.
Leaflets were available in the waiting areas offering patient advice and information about the hospital.
The service had not responded to more than half of all complaints within a 20 day target set out by Care UK in the last 12 months.

Are services well-led?

There was not sufficient oversight or risk management in place for patients coming from the local NHS acute hospital for treatment. Many staff we spoke with stated this was due to unclear communication and difference in operating procedures
Staff in outpatients were generally positive about the leadership of the service and were able to articulate the fundamentals of the strategy and vision. However, staff we spoke to in the surgery service were not aware of the future plans or strategic vision for that service.
Risks we identified on inspection were not reflected on the risk register.
Managers told us that staff were encouraged to be open and transparent. Staff we spoke to in outpatients felt that despite the immediate manager and head of nursing being approachable, senior managers were not visible. However, staff in surgery we spoke with stated that the senior leadership team were visible around the service and had an open door policy for any staff members needing to access them.
Staff had felt that job security had recently been at risk following a delay in the renewal of the hospital’s main contract. However, morale was improving at the time of our inspection.
Some staff we spoke with stated they had experienced or seen instances of bullying and harassment of staff while working with the service.
All staff were encouraged to attend the monthly Quality Governance and Assurance meeting that took place one afternoon a month, and were given time away from clinic and patient duties.
The service had a patient forum; however this group met infrequently and did not have much input from patients other than the representatives who did not gather patient feedback as part of their roles.

Importantly, the provider must ensure that:

Identified risks are reported and reviewed within the agreed timescales; and there is clinical oversight, governance structures, and risk management of patients coming from other healthcare providers that utilise the theatre services. (Regulation 17) (2) (b)

The provider should also ensure that:

All clinical staff are competent in basic life support and have the required level of resuscitation training for their role
Proposed changes to Resident Medical Officer working patterns comply with the European working time regulations.
Structures which support staff learning from incidents are reviewed.
The Workforce Race Equality Standard (WRES) is effectively implemented, and there is continued work towards improving culture within the service.
Temperature checks on medicine fridges are routinely carried out on the weekend to help maintain safe levels.
All staff are aware of the major incident management and escalation procedure, and business continuity plans.
Current security systems in place to protect staff and patients are reviewed, and make improvements where gaps have been identified.
Adequately risk assess the need for a continuous daytime security presence in outpatient areas.
Provision and additional support available for patients with learning disabilities are reviewed, and develop a policy to formalise any arrangements.

There is a scope guide available for colonoscopy and that a paediatric scope is available for use with narrow structures such as with diverticular disease.
That equipment failure in ophthalmology is logged and responded to.
That staff in Barley Court cannot be overheard through a shutter that separates the waiting area and the staff kitchen.
Audits and quality monitoring is appropriate for the service and actioned accordingly.
Continued progress is made on increasing the number of Friends and Family responses it receives.
Ways of reducing waiting times during the one stop clinics are explored, and that patients are kept fully informed of waiting times when they attend.

Professor Sir Mike Richards

Chief Inspector of Hospitals

People we spoke with were very positive about the care being provided and the service they had received. One person told us "all staff from those behind the scenes to the medical staff, nurses and ward staff were very approachable. Spotlessly clean and efficient.' Another person said 'I am very impressed with this place really fantastic.They explained everything step by step and they have answered everything.'

We observed that before people underwent treatment their consultant would explain the procedure to them, including the risks and benefits.They were asked to sign forms to indicate this had taken place and that they consented to the proposed course of treatment.

Appropriate checks took place before, during and after treatment to ensure that people were safe and well. People we spoke with confirmed that details about their medical history had been taken prior to treatment taking place.On the day of the inspection the centre was clean and tidy.There was an appropriate infection control policy and procedure in place which was adhered to. Staff told us they received appropriate training and support from the management team to carry out their roles. We also found that the service listened to comments and complaints and used these to improve the service.

People told us that they felt happy with service provided by the North East London NHS Treatment Centre. People told us that staff were polite and respectful, that they were happy with the treatment they had received and that the staff worked hard to meet their needs. One person said 'so far everyone has been great. I've seen the consultant and my treatment is going well'. Another person said 'I can't complain. They are top staff. I saw a surgeon who was really nice and the nurses are good to me too'.

We found that people were cared for with dignity and respect and according to assessed need. The environment in which they were cared for was clean and there were sufficient checks in place to effectively monitor the quality and safety of the service provided to people.

Practice Plus Group Hospital - Ilford

All Inspections

22 - 23 January 2019

During a routine inspection

21 & 22 September 2016

During a routine inspection

Professor Sir Mike Richards

Chief Inspector of Hospitals

18 November 2013

During a routine inspection

27 November and 3 December 2012

During a routine inspection