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Inspection Summary


Overall summary & rating

Good

Updated 16 November 2016

The Circle Reading hospital is one of three hospitals provided by the Circle group in England. It is located on the outskirts of Reading, Berkshire. On-site facilities include inpatient beds, comprising 29 inpatient bedrooms (one bedroom is a double) and 20 day case ‘Pods’. The hospital has five operating theatres, three of which have laminar flow. There is an endoscopy suite within the theatre complex, as well as a suite of consulting and treatment rooms, and an imaging department offering x-ray, ultrasound and scans. The hospital also has a pharmacy on site.

The Circle Reading hospital provides a range of medical, surgical and diagnostic services to patients who pay for themselves, are insured, or are NHS funded patients. Services offered by the hospital include orthopaedics, spinal, general surgery, gynaecology, ENT, ophthalmology, endoscopy, physiotherapy and diagnostic imaging.

The Circle Reading hospital was selected for a comprehensive inspection as part of our routine inspection programme. The inspection was carried out using the Care Quality Commission’s new inspection methodology.

The announced inspection took place on 15 and 16 August 2016, followed by a routine unannounced visit on the 25 August 2016. This was an inspection of all core services provided at the hospital, surgery and outpatients/diagnostic imaging. The endoscopy service was inspected under the surgical core service.

Our key findings were as follows:

Are services safe at this hospital?

By safe, we mean that people are protected from abuse and avoidable harm.

  • Patients were protected from the risk of abuse and avoidable harm across all inspected services.

  • Staff reported incidents and openness about safety was actively encouraged.

  • Incidents were monitored and reviewed and staff could demonstrate learning from these.

  • Clinical areas were visibly clean and tidy.Hospital infection control and prevention policies were followed and these were regularly monitored, to reduce the risk of spread of infections.

  • Staff received appropriate training to be able to safely undertake their roles, and were supported in keeping their skills up to date.Staff received regular appraisals and were supported to undertake further learning.

  • Equipment was maintained and tested, in line with manufacturer’s guidance.There were appropriate checks and maintenance on the hospital building and plant.

  • Medicines were stored securely.

  • There was regular monitoring of patient records for accuracy and completeness.Patient records were stored securely and were available when needed.

  • Staffing levels and skill mix were planned, implemented and reviewed to keep patients’ safe at all times. There was a resident medical officer in the hospital 24 hours a day seven days a week.

  • When things went wrong patients were given a full apology.However, not all steps of the duty of candour legislation were always carried out.

Are services effective at this hospital?

By effective, we mean that people’s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence.

  • There was a lack of evidence based care and use of national guidelines around the starving of surgical patients.Staff did not have access to national guidance around this to enable them to advocate for patients.

  • Although staff demonstrated understanding of consent, and the implications of the Mental Capacity Act, they sometimes had limited understanding of the deprivation of liberty safeguards (DoLS).

  • There was evidence of local and national audits, including clinical audits and other monitoring activities such as reviews of services.However, WHO checklist audits had not been completed in the radiology department.

  • Information about patient’s care and treatment, and their outcomes, was routinely collected and monitored.

  • Patient outcomes were in line with the national average, and there were a low number of patients that required to be transferred to other hospitals. There were low numbers of unplanned readmission of patients.

  • The staff were competent to carry out their roles.Staff were given time to undertake training, and their competence was checked.

  • The hospital submitted data to the National Joint Registry and information to NHS England surgical site infection surveillance.

  • Practicing privileges were reviewed robustly and regularly: they were removed from consultants who did not provide suitable assurance of revalidation.

Are services caring at this hospital?

By caring, we mean that staff involve and treat people with compassion, kindness, dignity and respect.

  • Staff provided care that was compassionate and treated patients with dignity and respect at all times.Feedback we received from patients and those close to them was positive.

  • Staff spoke about developing and promoting good relationships with patients and having the time to care for them to a high standard.

  • Patients anxious about surgery were given time and information, and their individual needs and preferences were always taken into consideration. Patient’s family’s needs were also considered.

Are services responsive at this hospital?

By responsive, we mean that services are organised so they meet people’s needs.

  • Services were planned and delivered in ways which met the needs of the local population. Patients told us that there was good access to appointments, and these were at times which suited their needs.

  • Waiting times, delays, and cancellations were minimal and managed appropriately. Facilities and premises were suitable for the services being delivered.

  • Patients were given written information to support them through the pre and post-operative period.However, these were not available for any patients whose first language was not English.

  • Patients discharge was planned for as soon as they were admitted to hospital, and the length of stay was flexible if required.

  • The hospital monitored patient waiting times; these showed that 90% of patients began treatment within 18 weeks of referral.

  • The hospital had a robust system for learning from complaints and concerns. However, patient information on how to make a complaint was not readily available on the wards.

  • There was openness and transparency in how complaints were dealt with.

Are services well led at this hospital?

By well-led, we mean that the leadership, management and governance of the organisation assures the delivery of high-quality person-centred care, supports learning and innovation, and promotes an open and fair culture.

  • There was a supportive culture and staff felt empowered to raise concerns to keep patients safe.

  • Visions and values of the hospital were devised in partnership with staff.Staff could talk about the values and ethos of the hospital and were proud to work there.

  • The culture was open and staff felt that they had the ability to prevent harm to patients through the use of ‘Stop the Line’; this was a mechanism by which staff could stop a procedure for immediate review by a senior member of staff. Staff said they did not feel that there would be any repercussions for using this mechanism.

  • There were robust systems in place for identifying and managing risk.Risks were recorded and mitigations put in place.

  • Staff were encouraged to escalate concerns around patient safety using ‘Stop the Line’, we were given several examples of this in action.

Our key findings were as follows:

  • The hospital was well led by managers that fostered an open culture among staff to report risks to patient safety.

  • The hospital was clean and well maintained, staff followed infection control procedures and this was checked regularly.

  • There were an appropriate number of suitably qualified staff to look after patients safely.

  • Patients were given food and drinks when they wanted them, and as appropriate to their specific needs.

We saw several areas of outstanding practice including:

  • Privacy and dignity arrangements for patients undergoing endoscopy were excellent offering them a ‘pod’ with ensuite facilities.

  • There was a domiciliary food delivery service for patients that had undergone surgery.

However, there were also areas of where the provider needs to make improvements.

Importantly, the provider must:

  • Ensure that statutory notifications are always reported to the Care Quality Commission in a timely way.

  • Ensure that the Duty of Candour process is fully completed after an incident involving patient harm.

In addition the provider should ensure:

  • Resuscitation equipment for use with children should be removed from trolleys, as there is a risk of confusion about what equipment to use in an emergency.

  • Checks of defibrillators should include a record of a shock test in case the equipment should fail to self-record this.

  • Fluid balance charts for patients, especially those having intravenous fluids, should always be accurately completed.

  • WHO checklist audits in the radiology department are completed.

  • Staff are trained in Duty of Candour and the application of this duty is monitored.

  • Patient leaflets are available in the imaging and diagnostic department.

  • The space in the imaging and diagnostic department is reviewed for bed patients, and a standard operating procedure is in place.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Good

Updated 16 November 2016

We found that patients were protected from the risk of abuse and avoidable harm across all inspected services. Staff reported incidents and there was an open culture that encouraged staff to report safety incidents. Incidents that occurred were monitored and reviews carried out, this allowed staff to learn from these events. This learning was shared across teams and departments.

The hospital was visibly clean, tidy and well maintained. Staff followed the hospital infection control and prevention policies, and senior staff monitored compliance against these, to reduce the risk of spread of infections.

Staff received the training they needed to be able to safely undertake their roles, managers supported staff in keeping their skills current. All staff received a regular appraisal, and were supported to undertake further learning.

The hospital’s equipment was clean, maintained and tested. There were appropriate checks and maintenance on the hospital building and environment. We found that medicines were stored securely and appropriately across all departments.

The hospital could demonstrate there was regular monitoring of patient records to ensure high standards of accuracy and completeness. Confidential patient records were available when needed and were stored securely.

There were sufficient planned staffing levels and skill mix to keep patients’ safe at all times. There was a resident medical officer in the hospital 24 hours a day, seven days a week.

When things went wrong patients were given a full apology. However, not all steps of the duty of candour legislation were always carried out.

Effective

Requires improvement

Updated 16 November 2016

We found there was a lack of evidence based care and use of national guidelines around the starving of patients prior to surgery. Staff did not have access to appropriate national guidance about pre-operative starving to enable them to advocate for patients.

Staff demonstrated understanding of consent, and the implications of the Mental Capacity Act. However, some staff had a limited understanding of the deprivation of liberty safeguards (DoLS).

We found evidence of a local audit programme and the hospital contributed to national audits. This included clinical audits and monitoring activities such as reviews of services. However, five steps to safer surgery (WHO) checklist audits were not completed in the diagnostic imaging department.

The hospital collected and monitored information about patient’s outcomes, care and treatment. Patient outcomes were in line with the national average. There were a low number of patients that needed to be transferred to NHS hospitals after treatment. There were also low numbers of patients that required to be readmitted to the hospital.

We found evidence that staff were competent to carry out their roles. Staff were given time to undertake training. After they had been trained staff competence was checked.

The hospital submitted data to the National Joint Registry about the outcome of operations, and information to NHS England about the incidence of surgical site infections.

The practicing privileges of consultants were reviewed regularly; these were removed from consultants who did not provide suitable assurance of revalidation.

Caring

Good

Updated 16 November 2016

Staff provided patients with compassionate care and always treated patients with dignity and respect. We received positive feedback from patients and those close to them about the care and treatment they had received at the hospital.

Staff told us about the importance for them of developing and promoting good relationships with patients. Staff felt they had the time to care for their patients to a high standard.

Patients that were anxious about surgery were given time and information by staff to reduce this. The patients’ individual needs and preferences were always taken into consideration. The needs of the patients' family were also taken into consideration.

Responsive

Good

Updated 16 November 2016

The hospital planned and delivered services in ways which met the needs of the local population. Patients told us that they had good access to appointments, and these were offered at times to meet their needs.

Waiting times, delays, and cancellations were minimal and were managed appropriately. The premises and facilities provided were suitable for the services being delivered.

Patients were given written information about care and treatment they could expect before treatment and afterwards. However, these were not available for patients whose first language was not English.

Planning for patients discharge was started as soon as they were admitted to hospital, the length of stay was flexible if needed.

The hospital monitored waiting times for all patients; data showed that 90% of patients began their treatment within 18 weeks of a referral.

The hospital had a robust system to ensure there was learning from complaints and concerns raised by patients. However, patient information on how to make a complaint was not readily available on the wards. Complaints were dealt with in an open and transparent way.

Well-led

Good

Updated 16 November 2016

The hospital was well led by managers that fostered an open culture among staff to report risks to patient safety; staff were empowered by this to raise concerns.

The vision and values of the hospital had been devised in partnership with the staff. Staff were able to talk about the values and ethos of the hospital, and told us they were proud to work there.

There was an open culture and staff felt that they had the ability to prevent harm to patients through the use of ‘Stop the Line’; this was a mechanism where any member of staff could stop a procedure to allow an immediate review by a senior member of staff. Staff told us there would be no repercussions for using this mechanism. During the inspection staff gave us several examples of where ‘Stop the Line’ had been used.

The hospital had robust systems in place for identifying and managing risk. Risks were recorded and these were effectively mitigated to keep patients safe.

Checks on specific services

Surgery

Good

Updated 16 November 2016

Overall we rated this service as good because:

Staff monitored patient safety; they investigated incidents and shared the learning to improve care.

All the areas we viewed were visibly clean and well maintained. Equipment was available for staff, and there were regular safety checks on equipment and the environment.

Consultants gained consent from patients during the initial consultation and again on the day of surgery. Patient records were well structured and staff completed all the relevant sections with few exceptions.

Staffing levels were sufficient to meet the needs of the patients. Doctors were available to provide care for patients 24 hours a day. The service had competent staff who worked well as a team to care for patients.

Staff told us training was available and they were given time to attend. Staff were up to date with their mandatory training and understood the safeguarding policies and procedures for adults. The hospital gave discharge information to patients when they went home and sent it to their GPs within 48 hours of discharge.

The service had policies and guidance to ensure staff provided care and treatment that took account of evidence based standards and procedures, except with regard to starving pre-operative patients.

The hospital reported, reviewed, and benchmarked patient outcomes against other hospitals within the Circle group.

Staff supported and treated patients with dignity and respect, and the patients were involved in decisions about their care and treatment.

Patients told us they received enough information and were satisfied with the care and treatment they received. Information leaflets were available about the hospitals services; however there was limited access to information for patients whose first language was not English.

There were appropriate governance structures in place with committees for clinical governance, health and safety, infection control, medicines management.

Outpatients and diagnostic imaging

Good

Updated 16 November 2016

Overall, this service was rated as good. We found outpatients and diagnostic imaging (OPD) was good for the key questions of safe, caring, responsive and well-led. We did not rate effective as we do not currently collate sufficient evidence to rate this.

There were appropriate systems in place to keep patients safe. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. There were well defined and embedded systems, processes and standard operating procedures to keep patients and staff safe and safeguarded from abuse. Staff received up-to-date training in all safety systems.

Patients’ care and treatment was planned and delivered in line with current evidence-based guidance, best practice and legislation. There was evidence of local and national audits, including clinical audits and other monitoring activities such as reviews of services. Staff were qualified and had the appropriate skills to carry out their roles effectively, and in line with best practice. Staff were supported to deliver effective care and treatment, through meaningful and timely supervision and appraisal.

We observed that staff were caring, kind, compassionate, and treated patients with dignity and respect. Feedback from people who use the service and those close to them was positive about the way staff treated them. Staff demonstrated they were passionate about caring for patients and clearly put the patient’s needs first, including their emotional needs. Patients were positive about the care they received from staff, access to appointments and the efficiency of the service as a whole.

Staff managed and scheduled clinics appropriately. This ensured good availability of appointments for patients across all specialities. Services were planned and delivered in a way which met the needs of the local population. Waiting times, delays, and cancellations were minimal and managed appropriately. There was openness and transparency in how complaints were dealt with.

There was a clear statement of vision and values, which was driven by quality and safety. Staff knew and understood the vision, values and strategic goals.

There was a culture of collective responsibility between teams and services. Information and analysis was used pro-actively to identify opportunities to drive improvements in care.