Archived: Transform Hospital Group Dolan Park Hospital

Transform Hospital Group Dolan Park Hospital is operated by Transform Hospital Group Limited . The hospital has 30 en-suite bedrooms which can accommodate 31 patients. Facilities include four operating theatres, and outpatient facilities.

The service provides cosmetic and weight loss surgery for adults from 18 years old to over 74 years of age. We inspected cosmetic and weight loss surgical services.

We inspected this service using our comprehensive inspection methodology. We carried out the unannounced part of the inspection on 14 - 15 January 2020, along with a further unannounced visit to the hospital on 28 January 2020.

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 service provided by this hospital was cosmetic surgery. Where our findings on surgical services – for example, management arrangements also apply to other services, we do not repeat the information but cross-refer to the main surgical service level.

The location was known as Dolan Park Hospital locally. We will refer to this name in the body of the report.

Services we rate

We rated this hospital as Requires improvement overall.

• The hospitals governance processes did not always operate effectively. There were not consistently effective governance processes to ensure that actions identified from the internal audit programme were monitored and completed. There were risks highlighted during our inspection that had not been recognised by leaders or included on a risk register, such as the management of medicines on the ward. Staff were not aware of how safety data was used to further improve services.
• There was no specific senior nurse leadership role, such as a matron or clinical services manager. The ward manager post was vacant, being actively recruited to and temporarily covered. We found there was no formal workforce plan for the hospital. Staff satisfaction was mixed. There was no staff forum, staff union support or monitoring of staff’s wellbeing through, for example staff surveys. The culture did not always support an open approach, for example, not all staff felt comfortable challenging consultants to comply with the arms bare below the elbow policy.
• The service did not have effective processes in place to safely prescribe, administer, record and store medicines. The design, maintenance and use of facilities, premises and equipment did not always keep people safe.
• The hospital did not always control infection risks well. While the service had enough staff; staffing within theatres did not always meet national guidelines.
• Participation in external audits and benchmarking was limited. Patients’ outcomes were not always compared to those from similar services. They did not always use the findings of local audits to make improvements to achieve good outcomes for patients. Data or notifications were not consistently submitted to external organisations as required. For example, the hospital did not submit all required data to the Private Healthcare Information Network.

However;

• The hospital had enough staff to care for patients and keep them safe. Staff had training in key skills and understood how to protect patients from abuse. The service managed safety incidents well and learned lessons from them. The hospital introduced a morning huddle meeting to enable a better flow of information, communication and engagement with staff.
• Staff provided good care and treatment, patients and visitors had access to hot and cold drinks, and staff gave patients pain relief when they needed it. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available to meet the needs of patients.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
• The hospital planned care to meet the needs of most people accessing the service, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with four requirement notices that affected the location. Details are at the end of the report.

Heidi Smoult

Deputy Chief Inspector of Hospitals