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Inspection Summary


Overall summary & rating

Good

Updated 31 May 2019

This service is rated as Good overall.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We carried out an announced comprehensive inspection at the Harley Street Hospital on 3 April 2019. This inspection was undertaken as part of our programme of inspecting independent doctor services registered with the Commission. This inspection was the first rated inspection of this service.

The Harley Street Hospital is a private hospital located on Harley Street in London. The service offers a range of specialist treatments which include orthopaedic care, non-surgical and rehabilitation services, spinal care, a range of exam services including cardio exam and full health checks.

The service manager is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Our key findings were:

  • The service assessed need and delivered care in line with current legislation, standards and evidence-based guidance.
  • The service organised and delivered services to meet patients’ needs.
  • Actions identified on the most recent external health and safety evaluation of the service had been completed.
  • The service treated patients with kindness, respect and compassion.
  • User feedback was used to improve on services provided.
  • The service had the capacity and skills to deliver quality care

The areas where the provider

should

make improvements are:

  • Evaluate processes to enable regular dissemination of patient medicine and safety alerts.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Updated 31 May 2019

We rated safe as Good

 because:

  • The provider had systems and procedures which ensured that users of the service and information relating to service users were kept safe. Medicines at the service were kept securely and regularly monitored to ensure that they were fit-for-purpose. A health and safety evaluation of the service had been completed by an external contractor. All actions identified as a result of the evaluation had been actioned by the provider. 

Safety systems and processes

The service had clear systems to keep people safe and safeguarded from abuse.

  • The provider conducted safety risk assessments. It had appropriate safety policies, which were regularly reviewed and communicated to staff including locums. They outlined clearly who to go to for further guidance. Staff received safety information from the service as part of their induction and refresher training. The service had systems to safeguard children and vulnerable adults from abuse.
  • The service had some systems in place to assure that an adult accompanying a child had parental authority. This was usually through verification of the patient via their parent’s health insurance. The service had a low number of patients under the age of 18.
  • The service worked with other agencies to support patients and protect them from neglect and abuse. Staff took steps to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect.
  • The provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate. Disclosure and Barring Service (DBS) checks were undertaken where required. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).

  • All staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns. Staff who acted as chaperones were trained for the role and had received a DBS check.
  • The service had employed an external company to conduct a Health and Safety evaluation of the service. This evaluation was completed in October 2018. Whilst the overall summary of the evaluation was that the service’s health and safety management was satisfactory, there were some actions necessary to improve safety management at the site. We noted that there were no completion dates on the action plan provided to the service to comply with the areas identified by the external contractor as requiring action within an agreed timescale. Subsequent to the inspection, we received evidence in the form of completion certificates and invoices for work completed, that outstanding actions identified had been completed.
  • There was an effective system to manage infection prevention and control. The service conducted weekly infection control audits. Any issues regarding infection control were taken forward by the hospital co-ordinator to resolve the issue. The service’s building had undergone a legionella risk assessment in July 2018 and weekly monitoring of water temperatures was conducted by the service.
  • The provider ensured that facilities and equipment were safe, and that equipment was maintained according to manufacturers’ instructions. There were systems for safely managing healthcare waste.
  • The provider carried out appropriate environmental risk assessments, which took into account the profile of people using the service and those who may be accompanying them. We saw evidence of the latest fire assessment which was conducted in June 2018.

Risks to patients

There were systems to assess, monitor and manage risks to patient safety.

  • There were arrangements for planning and monitoring the number and mix of staff needed.
  • Staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention. They knew how to identify and manage patients with severe infections, for example sepsis.
  • When reporting on medical emergencies, the guidance for emergency equipment is in the Resuscitation Council UK guidelines and the guidance on emergency medicines is in the British National Formulary (BNF).
  • When there were changes to services or staff the service assessed and monitored the impact on safety.
  • There were appropriate indemnity arrangements in place to cover all potential liabilities.

Information to deliver safe care and treatment

Staff had the information they needed to deliver safe care and treatment to patients.

  • Individual care records were written and managed in a way that kept patients safe. The care records we saw showed that information needed to deliver safe care and treatment was available to relevant staff in an accessible way.
  • The service had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.
  • Clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance.

Safe and appropriate use of medicines

The service

had reliable systems for appropriate and safe handling of medicines.

  • The systems and arrangements for managing medicines, including vaccines, controlled drugs, emergency medicines and equipment minimised risks. The service employed a pharmacist who ensure that medicines kept on site were done so in accordance with legislation and manufacturers guidance. The service kept prescription stationery securely and monitored its use.
  • Staff prescribed, administered or supplied medicines to patients and gave advice on medicines in line with legal requirements and current national guidance. Processes were in place for checking medicines and staff kept accurate records of medicines.

Track record on safety and incidents

The service had a good safety record.

  • There were comprehensive risk assessments in relation to safety issues.
  • The service monitored and reviewed activity. This helped it to understand risks and gave a clear, accurate and current picture that would lead to safety improvements.

Lessons learned, and improvements made

The service learned and made improvements when things went wrong.

  • There was a system for recording and acting on significant events. Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • There were adequate systems for reviewing and investigating when things went wrong. The service learned, and shared lessons identified themes and took action to improve safety in the service. The service spoke to us about an incident where a service user leaving the building during winter tripped on the outside step. Service staff based on reception went to assist the service user was not hurt. As a result of this incident, additional lighting was placed outside the building to highlight the step and if a member of staff saw older service user approaching the building they would go outside and assist the service user into the building.
  • The provider was aware of and complied with the requirements of the Duty of Candour. The provider encouraged a culture of openness and honesty. The service had systems in place for knowing about notifiable safety incidents

When there were unexpected or unintended safety incidents:

  • The service gave affected people reasonable support, truthful information and a verbal and written apology
  • They kept written records of verbal interactions as well as written correspondence.
  • The service told us that it acted on and learned from external safety events as well as patient and medicine safety alerts. However, the service did not have in place a process for receiving and disseminating safety alerts to relevant personnel within the service. We asked how the service assured itself that care was being provided in line with current safety alerts advice and was told that several clinical staff were able to access the alerts through external sources.

Effective

Good

Updated 31 May 2019

We rated effective as

Good

because:

  • The provider had systems and procedures which ensured clinical care provided was in relation to the needs of service users. Staff at the service had the knowledge and experience to be able to carry out their roles.

Effective needs assessment, care and treatment

The provider had systems to keep clinicians up to date with current evidence-based practice. We saw evidence that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance (relevant to their service)

  • The provider assessed needs and delivered care in line with relevant and current evidence-based guidance and standards such as the National Institute for Health and Care Excellence (NICE) best practice guidelines.
  • Patients’ immediate and ongoing needs were fully assessed. Where appropriate this included their clinical needs and their mental and physical wellbeing.
  • Clinicians had enough information to make or confirm a diagnosis
  • We saw no evidence of discrimination when making care and treatment decisions.
  • Arrangements were in place to deal with repeat patients. If a service user required a follow-up consultation, an appointment suitable with the service user was made by service staff to ensure the continuity of on-going treatment.
  • Staff assessed and managed patients’ pain where appropriate.

Monitoring care and treatment

The service was involved in quality improvement activity.

  • The service had been registered with the Commission from November 2018 and therefore had conducted a limited number of audits. There was no evidence of a plan of how often quality improvement and clinical audits would be undertaken by the service. We viewed an audit of post operation service users and their experiences following surgery whilst still at the hospital. As a result of the audit, the service has introduced an extended period monitoring service user (including provision of fluids) within the service before allowing them to leave the service. The service made improvements through the use of completed audits. There was clear evidence of action to resolve concerns and improve quality.

Effective staffing

Staff had the skills, knowledge and experience to carry out their roles.

  • All staff were appropriately qualified. The provider had an induction programme for all newly appointed staff.
  • Relevant professionals (medical and nursing) were registered with the General Medical Council (GMC and were up to date with revalidation
  • The provider understood the learning needs of staff and provided protected time and training to meet them. Up to date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop.

Coordinating patient care and information sharing

Staff worked together, and worked well with other organisations, to deliver effective care and treatment.

  • Patients received coordinated and person-centered care. Staff referred to, and communicated effectively with, other services when appropriate.
  • Before providing treatment, doctors at the service ensured they had adequate knowledge of the patient’s health, any relevant test results and their medicines history.
  • All patients were asked for consent to share details of their consultation and any medicines prescribed with their registered GP on each occasion they used the service.
  • The provider had risk assessed the treatments they offered. They had identified medicines that were not suitable for prescribing if the patient did not give their consent to share information with their GP, or they were not registered with a GP. For example, medicines liable to abuse or misuse, and those for the treatment of long-term conditions such as asthma. Where patients agreed to share their information, we saw evidence of letters sent to their registered GP in line with GMC guidance.
  • Patient information was shared appropriately (this included when patients moved to other professional services), and the information needed to plan and deliver care and treatment was available to relevant staff in a timely and accessible way. There were clear and effective arrangements for following up on people who had been referred to other service. 

Supporting patients to live healthier lives

Staff were consistent and proactive in empowering patients and supporting them to manage their own health and maximise their independence.

  • Where appropriate, staff gave people advice, so they could self-care.
  • Risk factors were identified, highlighted to patients and where appropriate highlighted to their normal care provider for additional support.
  • Where patients needs could not be met by the service, staff redirected them to the appropriate service for their needs.

Consent to care and treatment

The service obtained consent to care and treatment in line with legislation and guidance

.

  • Staff understood the requirements of legislation and guidance when considering consent and decision making.
  • Staff supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.
  • The service monitored the process for seeking consent appropriately.

Caring

Good

Updated 31 May 2019

We rated caring as

Good

because:

  • The service sought to treat service users with kindness, respect and dignity. The service involved service users in decisions about their treatment and care.

Kindness, respect and compassion

Staff treated service users with kindness, respect and compassion.

  • Feedback from patients was positive about the way staff treat people. This was obtained through post-treatment questionnaires. In addition, the service had an in-house system which allowed service users to give on the day feedback about their experience of the service through a short questionnaire.
  • Staff understood patients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all patients.
  • The service gave patients timely support and information.

Involvement in decisions about care and treatment

Staff helped service users to be involved in decisions about care and treatment.

  • Interpretation services were available for patients who did not have English as a first language. Service users were informed that this service was available when they completed the pre-treatment questionnaire. Service users were also told about multi-lingual staff who might be able to support them. Information leaflets were available in easy read formats, to help patients be involved in decisions about their care.
  • Service users told us through comment cards, that they felt listened to and supported by staff and had sufficient time during consultations to make an informed decision about the choice of treatment available to them. We received nine comment cards, all of which were positive about their experience at the service.
  • Staff communicated with people in a way that they could understand, for example, easy read materials were available. The service also had a hearing loop for service users who may have hearing difficulties.

Privacy and Dignity

The service respected service users privacy and dignity.

  • Staff recognised the importance of people’s dignity and respect.
  • Staff knew that if patients wanted to discuss sensitive issues or appeared distressed they could offer them a private room to discuss their needs.

Responsive

Good

Updated 31 May 2019

We rated responsive as

Good

because:

  • The provider was able to provide all service users with timely access to the service. The service had a complaints procedure in place and it used service users’ feedback to tailor services to meet user needs and improve the service provided.

Responding to and meeting people’s needs

The service organised and delivered services to meet patients’ needs. It took account of patient needs and preferences.

  • The provider understood the needs of their patients and improved services in response to those needs.
  • The facilities and premises were appropriate for the services delivered. The service building had a lift which had access to the floors that the service operated from.
  • Reasonable adjustments had been made so that people in vulnerable circumstances could access and use services on an equal basis to others. Although the service did not have a ramp for wheelchair users outside the building, staff at the service told us that they would be on hand to escort patients with physical disabilities into (and leaving) the building.
  • The service told us that following service user feedback that they had introduced staggered appointment times so that service users would not encounter long waits before being seen by a member of the clinical team.

Timely access to the service

Service users were able to access care and treatment from the service within an appropriate timescale for their needs.

  • Service users had timely access to initial assessment, test results, diagnosis and treatment.
  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • Service users with the most urgent needs had their care and treatment prioritised.
  • Referrals and transfers to other services were undertaken in a timely way.

Listening and learning from concerns and complaints

The service took complaints and concerns seriously and told us they would respond to them appropriately to improve the quality of care.

  • Information about how to make a complaint or raise concerns was available. Staff treated service users who made complaints compassionately.
  • The service informed service users of any further action that may be available to them should they not be satisfied with the response to their complaint.
  • The service had complaint policy and procedures in place. Due to the length of time the service had been operating, the service had not yet received any complaints. The service was able to talk to us about what they would do in the event of a complaint and tell us that if the complaint was not able to be resolved in-house, that it would be referred to the Independent Healthcare Sector Complaints Adjudication Service (ISCAS).

Well-led

Good

Updated 31 May 2019

We rated well-led as

Good because:

  • The service leaders were able to articulate the vision and strategy for the service. Staff worked together to ensure that service users would receive the best care that the service could provide. The provider was able to provide all service users with timely access to the service. The service had a complaints procedure in place and it used service users’ feedback to tailor services to meet user needs and improve the service provided.

Leadership capacity and capability

Leaders had the capacity and skills to deliver high-quality, sustainable care.

  • Leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them.
  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.
  • The provider had effective processes to develop leadership capacity and skills, including planning for the future leadership of the service.

Vision and strategy

The service had a clear vision and strategy to deliver high quality care and promote good outcomes for patients.

  • There was a clear vision and set of values. The service had a realistic strategy and supporting business plans to achieve priorities.
  • The service developed its vision, values and strategy jointly with staff and external partners (where relevant).
  • Staff were aware of and understood the vision, values and strategy and their role in achieving them
  • There was no indication that the service monitored its progress against delivery of the strategy.

Culture

The service had a culture of high-quality sustainable care.

  • Staff felt respected, supported and valued. They were proud to work for the service.
  • The service focused on the needs of patients.
  • Leaders and managers acted on behaviour and performance inconsistent with the vision and values.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. For example, when a service user tripped on the step outside of the service building, they were apologised to by staff and brought back into the service so that a member of clinical staff could make sure that they did not sustain an injury. In addition, the service contacted the service user by telephone the following day to ensure that they were ok after the accident. The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.
  • Staff told us they could raise concerns and were encouraged to do so. They had confidence that these would be addressed.
  • There were processes for providing all staff with the development they need. This included appraisal and career development conversations. As a new provider, the service had not yet commenced regular annual appraisals in the last year. We were told that these would commence later in the year. Staff were supported to meet the requirements of professional revalidation where necessary. Clinical staff were considered valued members of the team.
  • There was a strong emphasis on the safety and well-being of all staff.
  • The service actively promoted equality and diversity. It identified and addressed the causes of any workforce inequality. Staff had received equality and diversity training. Staff felt they were treated equally.
  • There were positive relationships between staff and teams. We noted that the service had staff meetings on a regular basis.

Governance arrangements

There were clear responsibilities, roles and systems of accountability to support good governance and management.

  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective. The governance and management of partnerships and joint working arrangements promoted interactive and co-ordinated person-centred care.
  • Staff were clear on their roles and accountabilities. The service had appointed members of staff as leads for specific roles such as safeguarding, infection and prevention control and managing complaints.
  • Leaders had established policies, procedures and activities to ensure safety and assured themselves that they were operating as intended. However, we noticed that the service business continuity policy had not been fully completed to include a risk score for the identified hazards to the business.

Managing risks, issues and performance

There were clear and effective clarity around processes for managing risks, issues and performance.

  • There was a process to identify, understand, monitor and address current and future risks including risks to patient safety, however this was not always acted upon. This was evidenced through non-completion of several actions of the most recent health and safety evaluation audit.
  • The service had processes to manage current and future performance. Performance of clinical staff could be demonstrated through audit of their consultations, prescribing and referral decisions. Leaders had oversight of safety alerts, incidents, and complaints.
  • As the service had not conducted any clinical audits, there was no evidence to measure that clinical audits had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to change services to improve quality via the audit conducted on post-operative service users experiences.
  • The provider had plans in place and had trained staff for major incidents.

Appropriate and accurate information

The service acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance. Performance information was combined with the views of service users.
  • Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information.

  • The service used performance information which was reported and monitored, and management and staff were held to account.
  • The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses.
  • The service submitted data or notifications to external organisations as required.
  • There were robust arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems. The service had its own bespoke records system to keep service users records. This system was backed up regularly. The system could only be access with a unique user ID. All staff at the service had been given a user id and dependant on the role performed, was given restricted or all access to records held. The system was able to provide an audit trail of who had accessed records on the system.

Engagement with patients, the public, staff and external partners

The service involved service users, staff and external partners to support high-quality sustainable services.

  • The service encouraged and heard views and concerns from service users, staff and external partners and acted on them to shape services and culture.
  • Staff could describe to us the systems in place to give feedback. The service told us that service users could provide feedback on the day of their appointment using the electronic feedback system located at the reception desk. In addition, the service sent service users a feedback form shortly after their attendance at the service, which gave users the chance to give in-depth feedback about their experience at the service. We saw evidence of feedback opportunities for staff and how the findings were fed back to staff. We also saw staff engagement in responding to these findings.
  • The service was transparent, collaborative and open with stakeholders about performance.