spire washington hospital · spire washington hospital is operated by spire healthcare limited. the...

This report describes our judgement of the quality of care at this location. It is based on a combination of what wefound when we inspected and a review of all information available to CQC including information given to us frompatients, the public and other organisations

Ratings

Overall rating for this location Good –––

Are services safe? Good –––

Are services effective? Good –––

Are services caring? Good –––

Are services responsive? Good –––

Are services well-led? Good –––

Overall summary

Spire Washington Hospital is operated by SpireHealthcare Limited. The hospital had 47 beds, howeverthe hospital provided information stating there werecurrently 36 beds operational.

The hospital provides a range of inpatient and outpatientelective services. We inspected surgery, termination ofpregnancy, outpatients and diagnostic imaging.

We carried out the unannounced visit to the hospital on 4and 5 December 2019 and inspected the diagnosticimaging service on the 7 February 2020.

To get to the heart of patients’ experiences of care andtreatment, we ask the same five questions of all services:are they safe, effective, caring, responsive to people'sneeds, and well-led? Where we have a legal duty to do sowe rate services’ performance against each key questionas outstanding, good, requires improvement orinadequate.

SpirSpiree WWashingtashingtonon HospitHospitalalQuality Report

Picktree LaneRickletonWashingtonNE38 9JZTel: 0191 415 1272Website: www.spirehealthcare.com

Date of inspection visit: 4 December 2019 to 5December 2019 and 7 February 2020Date of publication: 08/05/2020

1 Spire Washington Hospital Quality Report 08/05/2020

Throughout the inspection, we took account of whatpeople told us and how the provider understood andcomplied with the Mental Capacity Act 2005.

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

Services we rate

Our rating of this hospital stayed the same. We rated it asGood overall.

• The service provided mandatory training in key skillsto all staff and made sure everyone completed it.Staff understood how to protect patients fromabuse. Staff had training on how to recognise andreport abuse and they knew how to apply it.

• The service controlled infection risk well. Staff usedequipment and control measures to protect patients,themselves and others from infection. They keptequipment and the premises visibly clean. Thedesign, maintenance and use of facilities, premisesand equipment kept people safe. Staff managedclinical waste well.

• Staff identified and acted upon patients at risk ofdeterioration. The service had enough staff with theright qualifications, skills, training and experience.Managers regularly reviewed and adjusted staffinglevels.

• The service used systems and processes to safelyprescribe, administer, record and store medicines.The service managed patient safety incidents well.Staff recognised and reported incidents and nearmisses. Managers investigated incidents and sharedlessons learned with the whole team and the widerservice.

• The service provided care and treatment based onnational guidance and evidence-based practice. Theservice made sure staff were competent for theirroles. Managers appraised staff’s work performanceand held supervision meetings with them to providesupport and development.

• Doctors, nurses and other healthcare professionalsworked together as a team to benefit patients. They

supported each other to provide good care. Staffsupported patients to make informed decisionsabout their care and treatment. They followednational guidance to gain patients’ consent.

• Staff treated patients with compassion and kindness,respected their privacy and dignity, and tookaccount of their individual needs. Staff providedemotional support to patients, families and carers tominimise their distress. Staff supported and involvedpatients, families and carers to understand theircondition and make decisions about their care andtreatment.

• The service planned and provided care in a way thatmet the needs of local people and the communitiesserved. It also worked with others in the widersystem and local organisations to plan care.

• The service was inclusive and took account ofpatients’ individual needs and preferences. Staffmade reasonable adjustments to help patientsaccess services. They coordinated care with otherservices and providers.

• People could access the service when they needed itand received the right care promptly. Waiting timesfrom referral to treatment and arrangements toadmit, treat and discharge patients were in line withnational standards.

• It was easy for people to give feedback and raiseconcerns about care received. The service treatedconcerns and complaints seriously, investigatedthem and shared lessons learned with all staff.

• Leaders understood and managed the priorities andissues the service faced. They were visible andapproachable in the service for patients and staff.They supported staff to develop their skills and takeon more senior roles.

• The service had a vision for what it wanted toachieve and a strategy to turn it into action,developed with all relevant stakeholders. The visionand strategy were focused on sustainability ofservices and aligned to local plans within the widerhealth economy. Leaders and staff understood andknew how to apply them and monitor progress.

• Staff felt respected, supported and valued. Theywere focused on the needs of patients receiving care.

Summary of findings


Leaders operated effective governance processes,throughout the service and with partnerorganisations. Staff at all levels were clear abouttheir roles and accountabilities and had regularopportunities to meet, discuss and learn from theperformance of the service.

• Leaders and teams used systems to manageperformance effectively. They identified andescalated relevant risks and issues and identifiedactions to reduce their impact.

• The service collected reliable data and analysed it.Staff could find the data they needed, in easilyaccessible formats, to understand performance,make decisions and improvements.

• Leaders and staff actively and openly engaged withpatients, staff, and local organisations to plan andmanage services. All staff were committed tocontinually learning and improving services.

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

• Staff did not always keep detailed records ofpatients’ care and treatment in the outpatientdepartment.

• We observed some inconsistencies in executing theWHO checklist which was not implementedconsistently across each operating theatre.

• Recruitment and retention of orthopaedic scrub stafffor theatres required some development to alleviateshortages.

• Some items of equipment were overdue for servicewhich did not comply with documentation.

• Staff used personal protective equipment with oneexception we observed following which immediateaction was taken to remedy practice.

• Some key positions were filled on an interim basisand the hospital identified recruitment to keyleadership roles in clinical areas as an area fordevelopment.

• Consultation appointments were available on onlyone weekday in the termination of pregnancyservice.

Following this inspection, we told the provider that itshould make other improvements, even though aregulation had not been breached, to help the serviceimprove. Details are at the end of the report.

Ann Ford

Deputy Chief Inspector of Hospitals (North Region)

Summary of findings


Our judgements about each of the main services

Service Rating Summary of each main service

Surgery

Good –––

Summary of serviceSurgery was the main activity of the hospital. Whereour findings on surgery also apply to other services, wedo not repeat the information but cross-refer to thesurgery section.We rated this service as good because it was safe,effective, caring, responsive and well-led.The service used a nationally recognised tool toidentify deteriorating patients and escalated themappropriately.Detailed records of patients’ care and treatment wereclear, up-to-date and easily available to all staffproviding care. The service had systems in place toidentify and manage adults and children at risk ofabuse.Systems were in place for reporting, monitoring andlearning from incidents. The service contributed to theNHS Safety Thermometer to support monitoring ofpatient harm incidents and promote harm-free care.The hospital consistently achieved positive patientoutcomes including low rates of surgical site infectionand positive patient reported outcome measureresults. The hospital held a number of nationalaccreditations which demonstrated the hospital metnational quality markers.Staff supported patients to make informed decisionsabout their care and treatment and followed nationalguidance to gain patients’ consent.The hospital promoted privacy and dignity for patientsand the provider’s value statement was ‘Caring is ourpassion’.Staff were compassionate, discreet and responsivewhen caring for patients. Staff took time to interactwith patients and those close to them in a respectfuland considerate way.The service was inclusive and took account of patients’individual needs and preferences. Staff madereasonable adjustments to help patients accessservices.

Summary of findings


Special arrangements were made for bariatric patientsrequiring surgery including holding a multidisciplinarymeeting prior to surgery.The service supported patients living with dementia bymaking suitable arrangements for their stay inhospital.Patients were not discharged on the day of theirsurgery if they lived alone and their circumstanceswere checked at the pre-operative stage so thatovernight accommodation was pre-arranged.The hospital had a stable leadership structure with anexperienced hospital director and registered managerand a leadership team of 12 senior managers andmanagers. Consultant staff we spoke with told us theirengagement with the hospital leadership team waspositive.The service had a vision for what it wanted to achieveand a strategy to turn it into action, developed with allrelevant stakeholders. The vision and strategy werefocused on sustainability of services and aligned tolocal plans within the wider health economy.Staff were consistently positive about the culture theyexperienced in the hospital. Staff felt well supportedand morale was high. A robust procedure was in placefor challenging consultant behaviours andperformance. Any staff issues were dealt withsupportively.The service had in place clear and well-establishedgovernance structures and leaders operated effectivegovernance processes. An established clinicalgovernance team was in place with robustarrangements for clinical governance. The servicemanaged risks proactively and used systems tomanage performance effectively.

Outpatients

Good –––

We rated this service as good because it was safe,caring, responsive and well led.We do not rate effective for outpatients.The service provided mandatory training in key skillsto all staff and made sure everyone completed it.The service controlled infection risk well. Staff usedequipment and control measures to protect patients,themselves and others from infection. They keptequipment and the premises visibly clean. The design,maintenance and use of facilities, premises andequipment kept people safe. Staff managed clinicalwaste well.

Summary of findings


The service planned and provided care in a way thatmet the needs of local people and the communitiesserved. It also worked with others in the wider systemand local organisations to plan care.Leaders understood and managed the priorities andissues the service faced. They were visible andapproachable in the service for patients and staff.

Diagnosticimaging

Good –––

We rated this service as good because it was safe,caring, responsive and well led.We do not rate effective for diagnostic imaging.The service provided mandatory training in key skillsto all staff and made sure everyone completed it.The service controlled infection risk well. Staff usedequipment and control measures to protect patients,themselves and others from infection. They keptequipment and the premises visibly clean. The design,maintenance and use of facilities, premises andequipment kept people safe. Staff managed clinicalwaste well.The service planned and provided care in a way thatmet the needs of local people and the communitiesserved. It also worked with others in the wider systemand local organisations to plan care.Leaders understood and managed the priorities andissues the service faced. They were visible andapproachable in the service for patients and staff.

Terminationof pregnancy

Good –––

Spire Washington provides medical termination ofpregnancy up to 16 weeks gestation and surgicaltermination of pregnancy up to 19 weeks gestation.The service provides a vasectomy service.We rated this service as good because it was safe,effective, responsive and well led.We rated safe as good, because the service hadenough staff to care for patients and keep them safe.Staff had training in key skills, understood how toprotect patients from abuse, and managed safety well.The service controlled infection-risk well. Staffassessed risks to patients, acted on them and keptgood care records. They managed medicines well. Theservice managed safety incidents well and learnedlessons from them. Staff collected safety informationand used it to improve the service.Training was up-to-date. Staff were aware of theirresponsibilities is respect of safeguarding. Staffcomplied with best practice regarding cleanliness andinfection control, and the environment was

Summary of findings


appropriate for the service. Risks were assessed andmanaged appropriately. Nursing and medical staffnumbers were sufficient and appropriate to meet theneeds of patients in their care. Medicines were storedand prescribed safely. Medical records werecomprehensive and clear. There was a process forreporting incidents, staff understood when and how touse it, and there was a process for cascading lessonslearned and actions to be taken to front-line staff.We rated effective as good, because staff providedgood care and treatment, gave patients enough to eatand drink, and gave them pain relief when theyneeded it. Managers monitored the effectiveness ofthe service and made sure staff were competent. Staffworked 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.There were processes for implementing andmonitoring the use of evidence-based guidelines andstandards to meet patients’ care needs. Patientoutcomes were monitored. Pain relief was prescribedpre and post-procedure, and women’s pain levels wereassessed following both medical and surgicalterminations. Staff were competent in general nursingpractice, and additional, informal training in caring forwomen undergoing termination of pregnancy wasprovided by appropriate consultant staff. Informedconsent was obtained in all cases, and staffunderstood their responsibilities under the MentalCapacity Act 2005We had insufficient evidence to rate ‘caring’ within thisservice.It was evident that staff treated patients withcompassion and kindness, respected their privacy anddignity, took account of their individual needs, andhelped them understand their procedure. Theyprovided emotional support to patients, families andcarers.There were no women attending clinics or theatres forthis service during our inspection. We were thereforeunable to observe the way patients were treated bystaff. However, staff described to us how they treatedwomen with compassion, kindness, dignity, andrespect. They told us how they explained the different

Summary of findings


methods of termination and options available towomen attending the service. Should a woman needtime to make a decision, staff told us how they wouldsupport her.Post-termination counselling was offered to all womenusing the service.We rated responsive as good, because the serviceplanned care to meet the needs of local people, tookaccount of patients’ individual needs, and made iteasy for people to give feedback. Women did not haveto wait too long for treatment.The service was responsive to the needs of women.Pre and post-procedure checks and tests were carriedout at the hospital, and waiting times wereconsistently within guidelines set by the Departmentof Health and Social Care. Interpreting and counsellingservices were available to all women using the service,and information and advice were available to womenat all stages of their episode of care. Foetal remainswere disposed of sensitively, and choice was available.There were appropriate systems for managingcomplaints should they arise.Leaders ran services well, using reliable informationsystems, and supported staff to develop their skills.Staff felt respected, supported, and valued. They werefocused on the needs of patients receiving care. Staffwere clear about their roles and accountabilities. Allstaff were committed to improving servicescontinually.There was strong leadership of the service. Qualitycare and patient experience were regarded as theresponsibilities of all staff members, and staff feltproud of the service they provided. Clinicalgovernance and risks were managed well. Staff feltsupported to carry out their roles and were confidentto raise concerns with managers.

Summary of findings


Contents

PageSummary of this inspectionBackground to Spire Washington Hospital 11

Our inspection team 11

Information about Spire Washington Hospital 11

The five questions we ask about services and what we found 14

Detailed findings from this inspectionOverview of ratings 20

Outstanding practice 83

Areas for improvement 83

Summary of findings


Spire Washington Hospital

Services we looked atSurgery; Outpatients; Diagnostic imaging; Termination of pregnancy;

SpireWashingtonHospital

Good –––


Background to Spire Washington Hospital

Spire Washington Hospital is operated by SpireHealthcare Limited. The hospital/service opened in 1988.It is a private hospital in Washington, Tyne and Wear. Thehospital was located two miles from Chester-Le-Streetand Washington, and 11 miles south of Newcastle uponTyne. The hospital primarily serves the communities ofSunderland, Durham and Gateshead. It also acceptspatient referrals from outside this area. It was registeredas an acute hospital with 47 beds.

The Hospital Director has been the CQC registeredmanager since 25 July 2013. The hospital was previouslyinspected on the 5th, 6th and 18th August 2015 andreceived an overall rating of good. There was noenforcement associated with the previous inspection.

The service was inspected on the 4th and 5th ofDecember 2019 and diagnostic imaging was inspected onthe 7th February 2020.

The hospital had not taken part in any special reviews orinvestigations by the CQC during 2019/2020.

The inspection team inspected the following four coreservices:

• Surgery

• Termination of Pregnancy

• Outpatients

• Diagnostic Imaging

Our inspection team

The team that inspected the service comprised CQCinspectors and specialist advisors with expertise insurgery, termination of pregnancy, outpatients anddiagnostic imaging. The inspection team was overseen bySarah Dronsfield, Head of Hospital Inspection.

Information about Spire Washington Hospital

The hospital has two wards and is registered to providethe following regulated activities:

• Diagnostic and Screening Procedures

• Surgical Procedures

• Treatment of disease, disorder or injury

• Services in slimming clinics

• Termination of pregnancies

• Family planning

During the inspection, we visited surgery, outpatients, thetermination of pregnancy service and the diagnosticimaging department. We spoke with 40 staff includingregistered nurses, health care assistants, reception staff,

medical staff, operating department practitioners, andsenior managers. We spoke with 19 patients and onerelative. During our inspection, we reviewed 40 sets ofpatient records.

The two wards were the Lambton ward and Sunnisideward.

The hospital provides a range of inpatient and outpatientelective services including orthopaedics, general surgery,oncology, cardiology, endoscopy, gynaecology, urology,termination of pregnancy services, outpatient services forchildren and young people, outpatients and diagnosticimaging. We inspected surgery, termination of pregnancy,outpatients and diagnostic imaging.

There are three operating theatres with laminar flow, andan endoscopy suite providing day case care. There wasan extended recovery where level 1 was provided and the

Summaryofthisinspection

Summary of this inspection


hospital had on site pathology and pharmacy services.There was a diagnostic imaging department equippedwith static MRI and CT and the service offered ultrasoundand mammography services.

In the previous 12 months to the inspection there were44,171 outpatient appointments of which 0.5% of thetotal appointments were for patients under the age of 18.

Diagnostic imaging facilities included a CT scanner,mammography, an MRI scanner, a ultrasound scanner,fluoroscopy services and x-ray. Diagnostic imagingprovided services to adults and children and had awaiting room for patients and visitors to wait.

The diagnostic imaging department completed 3794scans between February 2019 and January 2020. Ofthese, the department saw 32 children between the ageof 16 and 18. The percentage of patients scannedbetween the age of 16 and 18 was 0.8%.

Procedures included approximately 257 CT examinations,2585 MRI examinations, 347 plain film x-rays, 532ultrasound scans and 73 fluoroscopy’s.

There were no special reviews or investigations of thehospital ongoing by the CQC at any time during the 12months before this inspection. The hospital/service hasbeen inspected once, and the most recent inspectiontook place in August 2015, which found that the hospital/service was meeting all standards of quality and safety itwas inspected against.

Activity (July 2018 to June 2019)

• In the reporting period July 2018 to June 2019. Therewere 7,904 inpatient and day case episodes of carerecorded at The Hospital; of these 64% wereNHS-funded and 36% privately funded.

• 23% of all NHS-funded patients and 30% of allprivately funded patients stayed overnight at thehospital during the same reporting period.

• There were 37,499 outpatient total attendances inthe reporting period; of these 19,239 were privatelyfunded and 18,260 were NHS-funded.

169 doctors worked at the hospital under practisingprivileges. Two regular resident medical officer (RMO)worked on a seven-day rota. Spire Washington employed30.6 whole time equivalent registered nurses, 23.7 whole

time equivalent care assistants 113 other whole timeequivalent hospital staff, as well as having its own bankstaff. The accountable officer for controlled drugs (CDs)was the registered manager.

Track record on safety

• No Never events between July 2018 and June 2019.

• Clinical incidents 390 no harm, 65 low harm, 45moderate harm, two severe harm, Zero deathsbetween July 2018 and June 2019.

• Seven serious injuries between July 2018 and June2019.

• No incidences of hospital acquiredMeticillin-resistant Staphylococcus aureus (MRSA)between July 2018 and June 2019.

• No incidences of hospital acquiredMeticillin-sensitive staphylococcus aureus (MSSA)between July 2018 and June 2019.

• No incidences of hospital acquired Clostridiumdifficile (c.diff) between July 2018 and June 2019.

• No incidences of hospital acquired E-Coli betweenJuly 2018 and June 2019.

There had been 63 complaints between August 2018 andJuly 2019.

Services accredited by a national body:

• SGS Accreditation for Sterile Services Department

• Joint Advisory Group on GI endoscopy (JAGS)accreditation

• UKAS – Pathology

• BUPA accredited bowel and breast services

Services provided at the hospital under service levelagreement:

• Clinical and or non-clinical waste removal

• Cytotoxic drugs service

• Interpreting services

• Grounds Maintenance

• Laser protection service

• Laundry




• Maintenance of medical equipment

• Pathology and histology

• RMO provision




The five questions we ask about services and what we found

We always ask the following five questions of services.

Are services safe?Our rating of safe stayed the same. We rated it as Good because:

• The service provided mandatory training in key skills to all staffand made sure everyone completed it. The service controlledinfection-risk well. Staff assessed risks to patients, acted onthem and kept good care records.

• Staff complied with best practice regarding cleanliness andinfection control, and the environment was appropriate for theservice. Risks were assessed and managed appropriately.

• The service used a nationally recognised tool to identifydeteriorating patients and escalated them appropriately.

• Detailed records of patients’ care and treatment were clear,up-to-date and easily available to all staff providing care. Theservice had systems in place to identify and manage adults andchildren at risk of abuse.

• Systems were in place for reporting, monitoring and learningfrom incidents. The service contributed to the NHS SafetyThermometer to support monitoring of patient harm incidentsand promote harm-free care.

• The service had sufficient medical and nursing staff to keeppatients safe.

• The design of the operating theatres and the maintenance ofequipment was fit for purpose and in line with nationalguidance. The theatre department was very clean andorganised. Equipment available within theatres wasappropriate.

• Medicines were stored and managed safely and prescribingdocuments were prepared in line with the provider’s policy.

• The service managed safety incidents well and learned lessonsfrom them.

However, we found the following areas that the service providerneeded to improve:

• We observed some inconsistencies in executing the WHOchecklist which was not implemented consistently across eachoperating theatre.

• Recruitment and retention of orthopaedic scrub staff fortheatres required some development to alleviate shortages.

• Some items of equipment were overdue for service which didnot comply with documentation.

Good –––




• Staff used personal protective equipment with one exceptionwe observed following which immediate action was taken toremedy practice.

• Staff did not always keep detailed records of patients’ care andtreatment in the outpatient department.

Are services effective?Our rating of effective stayed the same. We rated it as Goodbecause:

• The hospital consistently achieved positive patient outcomesincluding low rates of surgical site infection and positive patientreported outcome measure results. The hospital held a numberof national accreditations which demonstrated the hospitalmet national quality markers.

• Managers monitored the effectiveness of the service and madesure staff were competent.

• Pain relief was prescribed pre and post-procedure, andwomen’s pain levels were assessed following both medical andsurgical terminations. Staff were competent in general nursingpractice, and additional, informal training in caring for womenundergoing termination of pregnancy was provided byappropriate consultant staff. Informed consent was obtained inall cases, and staff understood their responsibilities under theMental Capacity Act 2005.

• Staff supported patients to make informed decisions abouttheir care and treatment and followed national guidance togain patients’ consent.

• Staff followed up-to-date policies to plan and deliver highquality care and treatment according to best practice andnational guidance. Care pathways were used for all patientsundergoing surgical procedures.

• Staff assessed and monitored patients regularly to see if theywere in pain and gave pain relief in a timely way. The patient’spain score was assessed following guidelines.

• Adequate nutrition and hydration standards were maintainedin the theatres and ward areas. Staff followed nationalguidelines to make sure patients fasting before surgery werenot without food for long periods.

• The hospital held effective multidisciplinary meetings tosupport effective care for patients and staff worked acrosshealth care disciplines and with other agencies when required.

• The service helped to promote healthy lifestyles for patients.Staff assessed each patient’s health when admitted andprovided support for individual needs to promote healthyliving.

Good –––




• Key services were available seven days a week to supporttimely patient care.

• Staff were experienced, qualified and had the right skills andknowledge to meet the needs of patients. Managers supportedstaff, including consultant staff, with their development throughsix monthly or annual appraisals of their work performance.

• A clinical audit programme was in place which supported thehospital’s management of its policies.

Are services caring?Our rating of caring stayed the same. We rated it as Good because:

• The hospital promoted privacy and dignity for patients and theprovider’s value statement was ‘Caring is our passion’.

• Staff were compassionate, discreet and responsive when caringfor patients. Staff took time to interact with patients and thoseclose to them in a respectful and considerate way.

• Staff understood and respected the personal, cultural, socialand religious needs of patients and how they may relate to careneeds.

• Staff talked with patients, families and carers in a way theycould understand, using communication aids where needed.Staff gave informative explanations to the patient andcontinued to keep them informed.

• Staff gave patients and those close to them help, emotionalsupport and advice when they needed it.

• Each patient we spoke with (with one exception) was verypositive about their experience of the hospital and their careand treatment.

• There were no women attending clinics or theatres for thisservice during our inspection. We were therefore unable toobserve the way patients were treated by staff. However, staffdescribed to us how they treated women with compassion,kindness, dignity, and respect. They told us how they explainedthe different methods of termination and options available towomen attending the service. Should a woman need time tomake a decision, staff told us how they would support her.

• Post-termination counselling was offered to all women usingthe service.

However, we found the following area that the service providerneeded to improve:

• One patient had been disturbed by the noise of staff in thetheatre area.

Good –––




Are services responsive?Our rating of responsive stayed the same. We rated it as Goodbecause:

• The service planned and provided care in a way that met theneeds of local people and the communities served. It alsoworked with others in the wider system including primaryhealthcare and local organisations to plan care.

• The service was inclusive and took account of patients’individual needs and preferences. Staff made reasonableadjustments to help patients access services.

• Special arrangements were made for bariatric patientsrequiring surgery including holding a multidisciplinary meetingprior to surgery.

• The service supported patients living with dementia by makingsuitable arrangements for their stay in hospital.

• Patients were not discharged on the day of their surgery if theylived alone and their circumstances were checked at thepre-operative stage so that overnight accommodation waspre-arranged.

• People could access the service when they needed it andreceived the right care promptly. Waiting times from referral totreatment and arrangements to admit, treat and dischargepatients were in line with national standards.

• One-stop clinics were used to reduce the need for patients toattend on several occasions.

• The service worked to ensure patients accessed services theyneeded promptly. Managers and staff worked to ensurepatients did not stay in hospital longer than necessary and tokeep the number of cancelled operations to a minimum.

• Discharge planning started as early as possible. Dischargeplanning was discussed at the patient’s pre-assessmentmeeting. Patients requiring assistance from other services atdischarge were identified at pre-assessment.

• The service was responsive to the needs of women. Pre andpost-procedure checks and tests were carried out at thehospital, and waiting times were consistently within guidelinesset by the Department of Health and Social Care. Interpretingand counselling services were available to all women using theservice, and information and advice were available to womenat all stages of their episode of care. Foetal remains weredisposed of sensitively, and choice was available.

• It was easy for people to give feedback and raise concernsabout care received. The service treated concerns andcomplaints seriously, investigated them and shared lessonslearned with all staff.

However:

Good –––




• Consultation appointments were available on only oneweekday.

Are services well-led?Our rating of well-led stayed the same. We rated it as Good because:

• The hospital had a stable leadership structure with anexperienced hospital director and registered manager and aleadership team of 12 senior managers and managers.Consultant staff we spoke with told us their engagement withthe hospital leadership team was positive.

• Leaders ran services well, using reliable information systems,and supported staff to develop their skills. Staff felt respected,supported, and valued. They were focused on the needs ofpatients receiving care. Staff were clear about their roles andaccountabilities. All staff were committed to improving servicescontinually.

• There was strong leadership of the services. Quality care andpatient experience were regarded as the responsibilities of allstaff members, and staff felt proud of the service they provided.Clinical governance and risks were managed well. Staff feltsupported to carry out their roles and were confident to raiseconcerns with managers.

• The service had a vision for what it wanted to achieve and astrategy to turn it into action, developed with all relevantstakeholders. The vision and strategy were focused onsustainability of services and aligned to local plans within thewider health economy.

• Staff were consistently positive about the culture theyexperienced in the hospital. Staff felt well supported andmorale was high. A robust procedure was in place forchallenging consultant behaviours and performance. Any staffissues were dealt with supportively.

• The service had in place clear and well-established governancestructures and leaders operated effective governanceprocesses. An established clinical governance team was inplace with robust arrangements for clinical governance. Theservice managed risks proactively and used systems to manageperformance effectively.

• Staff had access to up-to-date, accurate and comprehensiveinformation on patients’ care and treatment.

• The hospital could demonstrate high levels of patient and staffsatisfaction. Leaders and staff actively and openly engaged with

Good –––




patients, staff, equality groups, the public and localorganisations to plan and manage services. They collaboratedwith partner organisations to help improve services forpatients.

• The hospital was committed to continually learning andimproving services. It’s staff had an understanding of qualityimprovement methods and the skills to use them. Leadersencouraged innovation and participation in research.

However, we found the following area that the service providerneeded to improve:

• Some key positions were filled on an interim basis and thehospital identified recruitment to key leadership roles in clinicalareas as an area for development.




Overview of ratings

Our ratings for this location are:

Safe Effective Caring Responsive Well-led Overall

Surgery Good Good Good Good Good Good

Outpatients Good N/A Good Good Good Good

Diagnostic imaging Good N/A Good Good Good Good

Termination ofpregnancy Good Good Not rated Good Good Good

Overall Good Good Good Good Good Good

Detailed findings from this inspection


Safe Good –––

Effective Good –––

Caring Good –––

Responsive Good –––

Well-led Good –––

Are surgery services safe?

Good –––

Our rating of safe stayed the same. We rated it as good.

Mandatory training

The service provided mandatory training in key skillsto all staff and made sure everyone completed it.

Staff received and kept up to date with their mandatorytraining. The hospital used a system to ensure staffreceived annual mandatory training, comprised ofe-learning and face-toface training. The hospitalmandatory training system provided reminders to staff tocomplete the required mandatory training. The trainingsystem allowed staff to see what training they wererequired to complete and allowed managers to view overallcompliance, for their area.

Each member of staff we spoke with told us they hadcompleted their mandatory training including resuscitationtraining, or an arrangement was in place for them to attendtraining. Our review of mandatory training informationconfirmed this. 100% of contracted staff had receivedmandatory training against the hospital standard of 95%compliance. Bank staff were awarded similar mandatorytraining to permanent staff but some bank staff were due tocomplete their mandatory training which meant 90% oftheatre staff overall had completed their mandatorytraining at inspection. The deadline for outstanding staffwas March 2020.

The clinical governance lead provided oversight ofmandatory training compliance for all staff. The hospitalmonitored mandatory training compliance daily and

mandatory training compliance figures were reported tothe clinical governance meeting monthly. Results of auditabout staff training compliance were displayed in theseminar room.

Resident medical officers (RMOs) were employed through anational agency and completed mandatory training withthe agency. The hospital received confirmation of thetraining and kept a record of attendance.

Safeguarding

Staff understood how to protect patients from abuseand the service worked well with other agencies to doso. Staff had training on how to recognise and reportabuse and they knew how to apply it.

The service had systems in place for the identification andmanagement of adults and children at risk of abuse. Thehospital safeguarding policies for adults and children wereaccessible to staff and detailed the different types of abuseand issues which staff should report. A safeguarding leadwas in place for the hospital.

Staff we spoke with were aware of what concerns couldpotentially be a safeguarding concern and knew how toraise them. Staff we spoke with told us the safeguardinglead was accessible and supportive when staff neededadvice about safeguarding concerns.

The safeguarding lead and some senior managers hadcompleted safeguarding level four training including thehospital director and director of clinical services. 100% ofcontracted staff had received mandatory safeguardingtraining against the hospital standard of 95% compliance.Bank staff were awarded similar mandatory training topermanent staff but some bank staff were due to completetheir mandatory training which meant 79% of theatre staff

Surgery

Surgery

Good –––


overall had completed their mandatory training atinspection. The deadline for remaining training to becompleted was March 2020. Staff we spoke with confirmedthey had completed adult and children’s safeguardingtraining.

Female genital mutilation (FGM) was included in thehospital’s safeguarding training. Staff were aware of FGMand understood their responsibilities to report anyinstances.

We spoke with the safeguarding lead who described thesteps the hospital took when a safeguarding concern arose.A safeguarding concern had occurred during our inspectionand appropriate actions had been put in place. Theregistered manager also described the steps takenfollowing a recent safeguarding concern which led to themember of staff involved in raising the alert receiving aninternal award. We found evidence of learning from theinvestigation had been shared with external organisationswith an interest in the results of the investigation.

Cleanliness, infection control and hygiene

The service controlled infection risk well. The serviceused systems to identify and prevent surgical siteinfections. Staff used equipment and controlmeasures to protect patients, themselves and othersfrom infection. They kept equipment and thepremises visibly clean.

The hospital infection, prevention and control policy wassupported by an annual plan for infection control whichguided staff about cleaning, decontamination and personalprotective clothing and linked to related policies andprocedures.

An infection prevention and control lead for the hospitalwas in place and an infection prevention and controlcommittee was responsible for ensuring that the servicewas delivered in accordance with infection prevention andcontrol requirements.

We observed all areas of the hospital were clean and hadsuitable furnishings which were well-maintained. Thetheatre department was very clean and organised.

We observed processes for segregation of waste includingclinical waste. We observed within the operating theatre

waste disposal procedures were followed. Sharps disposalboxes were provided within the theatres. Also, within theoperating theatres cleanliness was maintained and laminarflow theatres were functioning appropriately.

Staff cleaned equipment after patient contact and labelledequipment to show when it was last cleaned. We inspectedreusable equipment stored in the department and all itemswere visibly clean and ready for use. Staff used a specificlabel to identify the equipment was clean and ready foruse.

Each member of staff completed infection prevention andcontrol training as part of their mandatory trainingprogramme. Training data provided by the hospital showed100% compliance.

Staff we spoke with including healthcare assistants andoperation practitioners confirmed they followed infectioncontrol policy and guidance strictly which confirmed ourobservation in theatres and wards.

Water flushing records were maintained which showedcompliance with water safety plans, supported by aseparate safety meeting for water matters.

Alcohol gel was provided at several areas in the corridorand while entering into operating theatre and also in therecovery area. We observed staff cleaning their handsbetween patient contact and staff were compliant with‘bare below the elbows’ policy. Staff used personalprotective equipment with one exception we observedfollowing which immediate action was taken to remedypractice.

The hospital audited hand hygiene compliance usingobservational hand hygiene audits, results we reviewedshowed a very high level of compliance. The results of thequarterly audits were displayed in the department andshared in monthly clinical governance and monthly theatremeetings.

Staff used records to identify how well the serviceprevented infections. The hospital screened surgicalpatients for methicillin-resistant staphylococcus aureus(MRSA) and some patients for methicillin-sensitivestaphylococcus aureus (MSSA) following practice guidance.Infection prevention and control was included in the healthand safety meeting agenda and shared with regional healthand safety leads.

Environment and equipment

Surgery

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The design, maintenance and use of facilities,premises and equipment kept people safe. Staffmanaged clinical waste well.

The design of the operating theatres and the maintenanceof equipment we found was fit for purpose and in line withnational guidance. The main hospital ward consisted ofsingle use rooms with suction equipment, piped oxygenand emergency call facilities. Within the theatre area fourbays were fitted with alarms, suction and monitors; a fifthbay was used for spare equipment. The service hadsuitable facilities to meet the needs of patients’ families.

The hospital had access to endoscopy and radiologyservices on site although no major endoscopic therapeuticinterventions were undertaken at this site. A small bloodstorage facility in the corridor of main theatres we foundwas locked and secured.

Equipment available within theatres was appropriate.Separate bins were used for domestic, contaminated andsharp disposal. A separate corridor was used for carryingwaste. Anaesthetic machines and cardiac arrest trolleyswere regularly checked with the time of next inspectionshown.

Resuscitation equipment was regularly checked and testedconsistently and in line with hospital policy. We observedclear signage for the location of emergency equipment.Equipment we reviewed was clean, tidy, ready for use andstaff had checked the equipment was in order. Trolleys weinspected were locked, appropriately stocked andequipment was in date.

We reviewed the equipment storage areas including thesterile equipment storage facility (instrument trays).Separate designated areas were used for storinginstrument trays. Staff carried out daily safety checks ofspecialist equipment. Electrical equipment portableappliance testing had been undertaken and labels were indate.

Sufficient suitable equipment was available to support thesafe care of patients. Staff we spoke with told us adequatestocks of equipment were available and we saw evidenceof stock rotation and equipment replacement. A hospitalsystem alerted essential maintenance when it was due andon-site engineers maintained equipment which provided

assurance equipment was fit for use. However, we found anitem of equipment was overdue for service which did notcomply with documentation. The hospital took immediateaction to remedy this.

Assessing and responding to patient risk

Staff completed and updated risk assessments foreach patient and removed or minimised risks. Staffidentified and quickly acted upon patients at risk ofdeterioration.

The hospital used a nationally recognised tool to identifydeteriorating patients and escalated them appropriately.Staff completed risk assessments for each patient on arrivaland updated them when necessary and used recognisedtools. Staff were aware what action to take to deal with anyspecific risk issues and took appropriate action.

Staff shared key information to keep patients safe whenhanding over their care to others. Shift changes andhandovers included all necessary key information to keeppatients safe.

A system of WHO checklist was in place and completed forevery procedure. However, we observed someinconsistencies in executing the checklist. The WHOchecklist was not implemented consistently across eachoperating theatre. Staff identified to us the application ofthe WHO process in the hospital was being reviewed toachieve consistency and ensure the safety of patients. Thisconfirmed our observation of the use of the surgicalchecklist.

Patient safety briefings were carried out pre-operatively.Briefings included introductions from the clinical team, theorder of the list, additional equipment anticipated and theaddition of emergency patients. We observed the briefcompleted with the whole surgical team present. Twobriefings were held daily to support the morning andafternoon theatre lists. We observed a stop before youcement safety process was followed and we observed thedaily cardiac arrest huddle documentation identificationby the crash team. We also spoke with staff about therelevance of NHS England’s Local Safety Standards forInvasive Procedures to promote safe practice. A surgicalsafety guardian was in role and we found evidence surgicalsafety was assured with processes compliant with theNational Safety Standards for Invasive Procedures(NatSSIPs).

Surgery

Surgery

Good –––


We observed the hospital used the national early warningscore tool (NEWS2). Staff received training in completingthe early warning score and the scores were audited eachmonth and submitted to the clinical governance lead forreview.

An escalation policy was in place in the event of adeteriorating patient or a seriously ill patient. Nursing staffwe spoke with could describe the deteriorating patientprotocol and were able to state when they would escalateto medical staff. In case of the particular surgeon not beingavailable, contact details were held for other surgeonswithin the same speciality who provide cross cover. Anescalation policy operated for patients with confirmed orpresumed evidence of sepsis.

No clinical care outreach team or HDU facility was availablewithin the hospital however the surgeon responsible for thepatient was contactable when necessary (including out ofhours).

To support a patient’s discharge, the hospital providedleaflets with contact details of the hospital and measures tobe taken at home and if the patient required emergencyassistance following their surgical procedure. The hospitaloperated an on-call service for unplanned returns totheatre. A team was available and would attend within 30minutes. The hospital had an agreement with an NHSambulance provider to transfer patients in the event of anemergency or if a deteriorating patient required anincreased level of care. We found unplanned returns totheatre were relatively infrequent, with nine in the previous12 months.

Staff we spoke with told us they had received sepsistraining. Staff could describe the signs of sepsis and wereaware of actions required for escalation and treatment. Wereviewed risk assessments including pressure damageacquisition, malnutrition, falls, bed rails, moving andhandling and we found these were completedappropriately.

Reception staff carried out a daily crash call test between8am and 9am for staff to respond to reception. Receptionstaff recorded who had not responded. We reviewed the logkept at reception which provided assurance a safe androbust mechanism to ensure the crash bleep was coveredand other issues were addressed.

Nursing and support staffing

The service had enough nursing staff with the rightqualifications, skills, training and experience to keeppatients safe from avoidable harm and to provide theright care and treatment. Managers regularlyreviewed staffing levels and skill mix, and gave bankand agency staff a full induction.

The service had in place sufficient nursing staff of all gradesto keep patients safe. Managers we spoke with told us theyhad no staffing concerns. Managers calculated andreviewed the numbers and grades of nurses and healthcareassistants needed for each shift, following nationalguidance.

The duty rota was planned in advance with patientdependency calculated according to the organisation’s safestaffing policy which took account of actual patientnumbers and the dependency of patients. The staffing toolcalculated a safe number of staff and was used on a shift byshift basis to provide assurance staffing levels were safe.The acuity score for each patient was reviewed three timesin the day to determine actual patient needs.

We observed the hospital including the theatre departmentwas adequately staffed. The ratio of nursing staff in thetheatre department and in the ward areas was appropriate.The hospital operated within Association for PerioperativePractice guidelines.

We found evidence of effective recruitment and retention ofstaff. The hospital had very low vacancy rates at ourinspection and expected to be fully established by January2020. Staff turnover rates and sickness rates were generallyvery low. Bank and agency staff were used infrequently butreceived a full induction when they were. There had beenno use of agency staff in the three months prior to ourinspection.

Staff worked flexible shifts depending on the service needand their own circumstances. Ahead of the inspection thefull-time equivalent staff numbers for the theatredepartments were: registered nursing staff: 12 FTE;operating department practitioners and health careassistants: 13.6 FTE.

Staff allocations to theatre lists were pre planned andallocations were the responsibility of the theatre manager.We reviewed the rota and allocation of theatre staff to eachtheatre.

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We observed the daily hospital safety meeting in whichstaffing was reviewed in detail to provide assurance thatthe department was operating safely. All departments werefully staffed. The meeting was minuted and sent to heads ofdepartment to share with staff.

We observed staff handover between patients followedrobust procedures which assured patient safety. Anadequate hand over between teams took place at shiftchange, when patient care was transferred from theatres torecovery and recovery to wards. We followed two casesfrom ward to operating theatres and from operating theatreto ward. The hand over between the teams at every stagewas adequate and detailed.

The hospital identified ahead of the inspection thatrecruitment and retention of orthopaedic scrub staff fortheatres required development. Staff we spoke withexplained there had been some sickness and vacancieswith scrub nurses which required bank and agency staff tobe used as a contingency. At the time of our inspectionthese posts had been filled and staff were being inductedto the team.

Medical staffing

The service had enough medical staff with the rightqualifications, skills, training and experience to keeppatient's safe from avoidable harm and to provide theright care and treatment.

The service had enough medical staff to keep patients safe.The hospital accessed locum doctors when the serviceneeded additional medical staff but we found this wasinfrequent. Managers made sure locums had a fullinduction to the service before they started work.

Each patient was admitted under the care of a namedconsultant. Consultants were responsible for the care oftheir patients from the pre-admission consultation until theconclusion of their episode of care.

The hospital required the consultant to review patientsevery day, including at weekends and to be accessible outof hours. Consultants nominated a colleague to providecover when they were not available. We observed the list ofconsultant cover arrangements.

Medical staff with practising privileges were required toprovide cross cover arrangements in the event they areunable to be contacted. The cross-cover information wasstored in the doctor’s profile and reviewed biennially. When

a surgeon was on annual leave and had recentlyundertaken a theatre list, they were required to inform thehospital of the cover arrangements in the event a patientneeded to be readmitted. Consultants were required toremain on call so long as they had a patient in the hospital.A hospital contact list was maintained for doctors withpractising privileges for staff use. Nursing staff contactedthe member of medical staff directly if they were requiredout of hours. It was the consultant surgeon’s responsibilityto arrange alternative anaesthetic cover if their regularanaesthetist was not available.

Two resident medical officers in the hospital provide a24-hour on call on a weekly basis. A resident medical officerwas on duty 24 hours a day, seven days a week to respondto any concerns arising as to a patient’s clinical condition.The resident medical officer attended a scheduled dailymeeting to discuss any patients with concerns.

Records

Staff kept detailed records of patients’ care andtreatment. Records were clear, up-to-date and easilyavailable to all staff providing care.

Paper records were available for each patient that attendedthe hospital. We observed patient records held the patient’sindividual plan of care. Patient notes were comprehensiveand all staff could access them easily. When patientstransferred to another department there were no delays instaff accessing their records.

Records were stored securely. Medical records were storedin locked cupboards in the ward areas with keys secured indigital key enabled boxes. A white dashboard in the wardarea identified patients’ details and location with roomnumbers and the members of staff who were assigned tothe care of the patient.

We reviewed patient documentation in the theatredepartment for a selection of records. We reviewed threemedical records in the theatre and ward areas. Patientidentifiers were present on each page of the case notes.Nursing records showed the same attention to detail.Checklists were completed in each set of case notes,particularly in the assessment of falls, alcohol consumptionhistory, moving and handling, pressure damage, MUSTscore and VTE prophylaxis. All entries were dated, timed

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and signed. All details were legible although blue ink hadbeen used on some occasions. Clinic letters were clearlydocumented with a care plan and actions. Patients werereviewed appropriately.

Verification forms for surgical site marking were completedaccurately. The surgical first assistant log book in thetheatre department was kept up to date and documentedclearly. Theatre documentation was completed at thecorrect times and found to be accurate. Traceability wasrecorded appropriately and National Joint Registry formswere completed as required. The theatre register wascompleted. All procedures were recorded in the register ofthe respective theatre. After each procedure accountableinstruments were cross-checked by other team membersincluding the swabs.

The hospital audited ten sets of randomly selected patientnotes each month and the audit showed a 96% level ofcompliance against the hospital’s standard.

Medicines

The service used systems and processes to safelyprescribe, administer, record and store medicines.

The hospital informed us ahead of the inspection thepharmacy department was under review to extend thefacility.

The hospital stored and managed medicines andprescribing documents in line with the provider’s policy.Medicine stocks were managed safely in theatre and wardareas. We checked a selection of medicines includingcontrolled drugs and medical gas cylinders and foundthese were consistently in date. We observed safe practicein the preparation of medicines for surgery.

Medicines including controlled drugs and fridge items werestored securely and monitored in line with the hospitalmedicine policy. Records we checked were correct andaudits were undertaken regularly.

We observed medicines were handled safely in theanaesthetic, theatre and ward areas. Staff followed currentnational practice to check patients had the correctmedicines. Medicines were prescribed in appropriate dosesand administered according to guidelines. Patient allergieswere documented appropriately and highlighted withdistinctive red labels. Nursing staff in the ward areas

followed appropriate guidelines and standards ofadministration for controlled drugs. Staff reviewed patients’medicines regularly and provided specific advice topatients and carers about their medicines.

The service had systems to ensure staff knew about safetyalerts and incidents, so patients received their medicinessafely. Decision making processes were in place to ensurepatient’s behaviour was not controlled by excessive andinappropriate use of medicines.

Incidents

The service managed patient safety incidents well.Staff recognised incidents and near misses andreported them appropriately. Managers investigatedincidents and shared lessons learned with the wholeteam and the wider service. When things went wrong,staff apologised and gave patients honest informationand suitable support. Managers ensured that actionsfrom patient safety alerts were implemented andmonitored.

The hospital had systems in place for reporting, monitoringand learning from incidents. The hospital had an incidentmanagement policy, which staff accessed through theintranet. This provided staff with information aboutreporting, escalating and investigating incidents.

Hospital staff knew the type of incidents they needed toreport and were familiar with how to do this. Staff reportedall incidents that they should report including reportingserious incidents clearly and in line with hospital policy.Incidents reports were sent to line managers and reportedincidents were reviewed in the daily safety meeting whereimmediate learning was shared.

Staff understood the duty of candour and were open andtransparent. Patients and families were given a fullexplanation if and when things went wrong.

The hospital had no never events in the reporting period.The hospital reported two severe clinical incidents in thereporting period. Managers investigated incidentsthoroughly. Patients and their families were involved inthese investigations. Managers debriefed and supportedstaff after any serious incident.

Staff received feedback from investigation of incidents,both internal and external to the service. Staff we spokewith told us if a serious incident occurred they would be

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involved in the root cause analysis process. Staff met todiscuss the feedback and look at improvements to patientcare, lessons learned and recommendations to preventreoccurrence of the incident.

We reviewed two completed incident investigation reports.The reports included: action already taken – high priorityactions, medical governance arrangements, patientsupport and involvement, staff support and involvement,lessons learnt, recommendations and shared learning.Monthly safety bulletins shared with staff included keylearning. The hospital also held an incident review workinggroup, linking with the investigation of incidents.

Safety Thermometer (or equivalent)

The service used monitoring results well to improvesafety. Staff collected safety information and shared itwith staff, patients and visitors.

The hospital contributed information to the NHS SafetyThermometer to support monitoring of patient harmincidents and harm-free care. The submission of safetythermometer information was monitored by the hospital’sdirector of clinical services.

The incidents of patient falls in the hospital had reducedand incidents that had occurred were categorised as of noharm. Falls management and VTE working groups metregularly. The hospital contributed to the provider levelfalls scrutiny panel. A revised falls policy for the providerwas due to be published in February 2020.

The hospital’s director of clinical services had led thereview of the provider’s national falls policy based on NICEand NHS improvement guidelines. This included an impactassessment for reducing the financial burden from falls andreduced falls decreasing the length of stay and morbidity.The director of clinical services was also assisting innational scrutiny panels for falls within the provider,recommending best practice principles which had shown areduction of falls at other hospitals where a higher rate offalls had been identified.

Are surgery services effective?

Good –––

Our rating of effective stayed the same. We rated it asgood.

Evidence-based care and treatment

The service provided care and treatment based onnational guidance and best practice. Managerschecked to make sure staff followed guidance. Staffprotected the rights of patients subject to the MentalHealth Act 1983.

Staff followed up-to-date policies to plan and deliver highquality care and treatment according to best practice andnational guidance including the National Institute of Healthand Care Excellence, the Association of Anaesthetists ofGreat Britain and Ireland and the Royal College ofSurgeons. We reviewed a selection of policies accessedthrough the hospital intranet and saw evidence clinicalpolicies were updated in 2019. A folder of updated policieswas available in the staff area and we saw evidence staffread and signed to confirm they had read the updatedpolicies.

Care pathways were used for all patients undergoingsurgical procedures. The hospital used evidence-basedcare pathways as commissioned and developed by theprovider. Care pathways were based on clinical guidelinesfrom recognised bodies and covered a range of procedures.Care pathways were accessed through the providerintranet. Pathways were updated in line with changes tonational guidelines.

A clinical audit programme was in place which supportedthe hospital’s management of its policies. The hospitalcompleted national and local audits. Outcomes of auditwere discussed at governance meetings. The hospitalparticipated in the national PLACE audit.

The hospital informed us ahead of the inspection it used arange of guidance and supporting tools to monitor andbenchmark performance against standards and otherhospitals and providers. This included the national clinicalscorecard and national audit programmes for effectivemanagement of cancer patients. The hospital coulddemonstrate effective patient outcomes for a number ofmeasures including surgical site infections, venousthromboembolism, pressure ulcers and returns to theatre.

The hospital undertook daily audits linked with clinicalscorecards which also informed its departmental audit

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action plan. We reviewed the completion of checklistswhich supported each aspect of care including assessmentof the patient’s preoperative mental health, alcohol history,and social needs.

We observed surgical procedures were performed as perthe respective specialities’ professional body guidelines.Surgical venous thromboembolism pathways and venousthromboembolism assessments were competed in eachset of patient case notes we reviewed and were welldocumented. Audits were undertaken for morbidity andmortality, surgical site infection, and venousthromboembolism. We observed audit results weredisplayed as posters in the hospital seminar room.

Patient reported outcome measures data was collated. Thehospital held a number of national accreditations whichdemonstrated the hospital met national quality markers.

Nutrition and hydration

Staff gave patients enough food and drink to meettheir needs and improve their health. They usedspecial feeding and hydration techniques whennecessary. Staff followed national guidelines to makesure patients fasting before surgery were not withoutfood for long periods.

Pre-admission information for patients provided them withclear instructions on fasting times for food and fluid prior tosurgery. We observed the guidelines of starvation forpatients prior to an operation were followed.

We observed adequate nutrition and hydration standardswere maintained in the theatres and ward areas. As part ofroutine practice, patients were given medicationsappropriate to their condition and treatment both duringand after a surgical procedure.

Patients were asked for feedback on the quality of food,with latest results (June 2019) showing 84% positivefeedback from patients; 12% above the provider’s average.

The service tailored its menus for patients to meet theirneeds for example for dietary requirements, toaccommodate any allergies or to ensure patients hadsomething they liked when they were not feeling well withbespoke meals cooked to order to reflect the patient’spreferences.

We spoke with four patients about how the hospital wasmeeting their nutrition and hydration needs and they

confirmed they had enjoyed the food provided and theirnutrition, hydration and fasting needs had beenadequately met by the hospital. Staff had communicatedclearly about the fasting requirements related to theirsurgery. The service made adjustments for patients’religious, cultural and other needs.

Prior to the inspection the hospital identified compliancewith patient fasting times and ensuring patient hydrationas an area for further improvement in its practice.Hydration champions were nominated for wards andtheatres to help ensure patients were hydrated. Thehospital informed us it was working to achieve King’s FundVTE exemplar status and had reviewed its documentationto help ensure patients were encouraged to remainhydrated. The hydration needs of two or three patients ineach of the morning and evening sessions was reviewed inmore detail to support this. A hydration committee hadbeen established to monitor and support practice.

Hydration scores were audited quarterly and hydration wasincluded on the hospital’s risk register. We observedcatering, patient allergies and other patient requirementswere included in the agenda for the daily ‘dash’ meeting.

Pain relief

Staff assessed and monitored patients regularly to seeif they were in pain and gave pain relief in a timelyway. They supported those unable to communicateusing suitable assessment tools and gave additionalpain relief to ease pain.

The patient’s pain score was assessed following guidelines.A pain assessment was performed at pre-assessment.During the patient’s admission pain scores were regularlychecked following their surgery and appropriate pain reliefprovided. Pain was assessed and recorded withobservations on the patient’s early warning score (NEWS2)chart.

Prior to the inspection the hospital identified managingpatient's pain with more consistency as an area for furtherimprovement in its practice. Pain management for clinicalstaff was included in annual mandatory training and thehospital pharmacist was involved in staff education. Amedicines management committee was in place chairedby a representative of the pharmacy department to helpensure consistency of practice.

Surgery

Surgery

Good –––


The patient satisfaction survey asked the patient how welltheir pain was managed throughout their stay in hospital.The latest 2019 data showed 88% of patients responded 'agreat deal' to pain being managed (where the patient hadpain to manage).

We spoke with six patients about how the hospital wasmanaging their needs for pain relief and they spokepositively as to how the hospital had undertaken thisaspect of their care and treatment. One of these patientshad not required pain relief although they confirmed it wasoffered. Our review of the patient’s records confirmed allpatients were given effective pain relief.

Pain audits were undertaken quarterly, including painscores and the most recent 2019 results showed 97%compliance.

Patient outcomes

Staff monitored the effectiveness of care andtreatment. They used the findings to makeimprovements and achieved good outcomes forpatients.

A range of national scorecards and dashboards were usedto monitor patient outcomes including specific servicedashboards. The hospital consistently achieved positivepatient outcomes including low rates of surgical siteinfection and positive patient reported outcome measureresults.

The hospital participated in national audits includingpatient reported outcome measures for hip and kneereplacement; the national joint registry data quality;national blood transfusion audits; surveillance for surgicalsite infections; national spinal registry; nationalconfidential enquiry into patient outcome and deathaudits; patient led assessment of the care environmentaudits; friends and family patient satisfaction surveys andthe provider’s national audit programme, dashboards andclinical scorecards.

Patient outcomes were measured and reported using theprovider’s clinical scorecard and were compared with otherhospitals to identify outliers and trends. Data had beencollected over an extended period so longer-term resultscould be compared. Patient outcomes were analysed forreturns to theatre, readmissions, transfers, surgical siteinfections, venous thromboembolism, falls and pressureulcers. The hospital prepared an action plan to address any

concerns and could demonstrate improvement over timewith several scorecard measures. The provider’s nationalclinical scorecard was used to compare the hospital withthe provider’s other hospitals for key performanceindicators.

The hospital contributed data to the Private HealthcareInformation Network to collate outcome data across theindependent sector that was comparable with the NHS.Data was submitted in accordance with legal requirementsregulated by the Competition Markets Authority. Thetheatre team undertook a ‘project of the week’ to inform ascorecard for the hospital. The hospital’s performance wasreviewed at the clinical audit and effectiveness committee,the clinical governance committee and the medicaladvisory committee. Red and amber results were added tothe hospital’s local risk register and an action plan forimprovement was prepared and monitored. For example,temperature control achieved 83% compared with a 95%standard.

The hospital reported 20 cases of unplanned readmissionswithin 28 days of discharge and nine unplanned returns tooperating theatre in the reporting period which was similarto expected compared with other independent hospitals.

Competent staff

The service made sure staff were competent for theirroles. Managers appraised staff’s work performanceand held supervision meetings with them to providesupport and development.

Staff were experienced, qualified and had the right skillsand knowledge to meet the needs of patients. New staffreceived a full induction tailored to their role before theystarted work and were paired with another member of staffas a buddy after they commenced in their role.

Managers supported staff, including consultant staff, withtheir development through six monthly or annualappraisals of their work performance. We saw evidence100% of staff had received their appraisal in the January toDecember 2019 period. Staff described the appraisalprocess as a valuable experience and felt their learningneeds were addressed.

The hospital used the provider’s nationally adoptedprogramme of clinical competencies to support stafftraining. Managers identified training needs of staff andsupported them with the opportunity to develop their skills

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and knowledge. Managers ensured staff received specialisttraining for their role. Staff we spoke with told us they weresupported to attend courses to further their development.Preceptorships were available to support staff learning anddevelopment.

Managers identified poor staff performance and supportedstaff to improve. There were systems in place to review andwithdraw the practising privileges of consultants. Anyconcerns about a consultant’s practice were discussed withthe hospital director and the chair of the medical advisorycommittee. Practising privileges were withdrawn in linewith the hospital’s policy in circumstances where standardsof practice or professional behaviour were in breach ofcontract.

A resident medical officer was employed through anational agency. The agency was responsible for theirongoing training and provided continuing professionaleducation sessions throughout the year. The chair of themedical advisory committee was available to supportmedical staff with appropriate clinical supervision.

Multidisciplinary working

Doctors, nurses and other healthcare professionalsworked together as a team to benefit patients. Theysupported each other to provide good care.

The hospital held effective multidisciplinary meetings todiscuss patients and improve their care. Staff workedacross health care disciplines and with other agencieswhen required to care for patients.

The hospital held several daily multidisciplinary team‘huddles’ to support effective communication. Weobserved the multidisciplinary briefing held in the hospitaldaily. The briefing was attended by all departments and theresident medical officer to ensure teams were updated withkey information. Any non-compliance was escalated fromthe previous day and a set template was used and sharedwith staff by email. Staff raised any safety concerns at thismeeting and daily safety checks were updated to reflectinformation shared. Patients did not proceed to theatrewho were not multidisciplinary team compliant unlessthere was a strong clinical reason, then a ‘mini-MDT’ washeld.

Other multidisciplinary meetings held daily includedclinical departmental meetings and clinical resuscitation‘huddles’ with consultants, specialist nursing staff and

radiologists to support patients with specific pathways orwith complex needs. We observed effectivemultidisciplinary communication in the theatre area whencement was in use which supported safe practice. Keyinformation was fed into the main daily multidisciplinarymeeting. When the patient was discharged, the dischargeletter and enclosures was shared with the patient’s GP.

The hospital had established effective working relationswith local NHS hospitals to provide services throughinter-provider transfer, and with the ambulance service foremergency transfers. A multidisciplinary team meeting washeld prior to the treatment of patients receiving treatmentfor cancer.

A biennial multidisciplinary team meeting for consultantstaff was held which was chaired by the lead for clinicalgovernance.

Pathways for all patients having cancer treatment werediscussed and agreed by a multidisciplinary team.Compliance with this requirement was supported by amonthly audit.

Seven-day services

Key services were available seven days a week tosupport timely patient care.

The hospital theatres operated Monday to Friday from 8amto 9pm and 8am to 1pm Saturday. Hospital wards wereopen seven days and consultants led daily ward rounds onall wards, including weekends. Patients were reviewed byconsultants depending on the care pathway. A residentmedical officer based in the hospital was available 24 hoursa day with immediate telephone access to on-callconsultants.

The hospital radiology and physiotherapy servicesoperated Monday to Friday from 8am until 9pm and from8am and 8am until 6pm on Saturdays. Outside of thesehours on-call arrangements were in place.

The hospital pharmacy was open Monday to Friday from8:30am until 4:30pm and Saturdays from 8:30am to 12midday. Pharmacy staff were available in the hospital andfor out of hours, on-call arrangements were in place.

Health promotion

Staff gave patients practical support and advice tolead healthier lives.

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The hospital had available information for patients whichpromoted healthy lifestyles and support. Staff assessedeach patient’s health when admitted and provided supportfor individual needs to promote healthy living.

Commissioning for Quality and Innovation (CQUIN) is aframework within the NHS that supports improvements inthe quality of services and the creation of new, improvedpatterns of care. A health promotion CQUIN was in place tomonitor smoking and alcohol consumption with trainingprovided to staff receiving patients as they arrived at thehospital to provide relevant advice. Advice was given topatients at the pre-op stage of their pathway of care.

Consent, Mental Capacity Act and Deprivation ofLiberty Safeguards

Staff supported patients to make informed decisionsabout their care and treatment. They followednational guidance to gain patients’ consent. Theyknew how to support patients who lacked capacity tomake their own decisions or were experiencingmental ill health.

The hospital had in place policies for consent, the MentalCapacity Act and Deprivation of Liberty safeguards. Thehospital gained consent from patients for their care andtreatment in line with legislation and guidance. Patientsconsented to treatment at their outpatient consultationand this was recorded.

Staff recorded consent in the patients’ records. Our reviewof patient records for 10 patients who were undergoingsurgery confirmed each patient was seen by ananaesthetist preoperatively as part of pre-op assessment. Aseparate consent form was completed with theanaesthetist which was separate to the surgical consentform. Our review of records confirmed consent forms forsurgery and anaesthetic were accurate and legiblealthough in one instance the consent form although signedwas undated.

Staff understood how and when to assess whether apatient had the capacity to make decisions about theircare. When patients could not give consent, staff madedecisions in their best interest, taking into accountpatients’ wishes, culture and traditions. Staff ensuredpatients consented to treatment based on all theinformation available.

The Mental Capacity Act (MCA) 2005, is designed to protectand empower individuals who may lack the mentalcapacity to make their own decisions about their care andtreatment. It is a law that applies to individuals aged 16and over. Following a capacity assessment, wheresomeone is judged not to have the capacity to make aspecific decision, that decision can be taken for them, but itmust be in their best interests.

Staff completed training in consent, the Mental CapacityAct and Deprivation of Liberty Safeguards as part of theirmandatory training. The hospital monitored the use ofDeprivation of Liberty Safeguards and ensured staff knewhow to complete them. Staff could describe and knew howto access policy and to obtain appropriate advice on theMental Capacity Act and Deprivation of Liberty Safeguards.

Are surgery services caring?

Good –––

Our rating of caring stayed the same. We rated it as good.

Compassionate care

Staff treated patients with compassion and kindness,respected their privacy and dignity, and took accountof their individual needs.

The hospital promoted privacy and dignity for patients andthe provider’s value statement was ‘Caring is our passion’.The hospital had in place a privacy and dignity policy. Stafffollowed policy to keep patient care and treatmentconfidential. Staff understood and respected the personal,cultural, social and religious needs of patients and howthey may relate to care needs.

We observed staff interactions with patients in the theatreand ward areas. Staff were compassionate, discreet andresponsive when caring for patients. Staff took time tointeract with patients and those close to them in arespectful and considerate way. We observed staff caringfor patients and found that they were compassionate andreassuring.

In the theatre area we observed as the team brief tookplace ahead of surgery. All checks supportingcompassionate care were discussed and in place, including

Surgery

Surgery

Good –––


the patient’s dignity. Excellent patient care wasdemonstrated throughout the anaesthetic process. Weobserved excellent patient care was provided during andfollowing surgery.

We spoke with 10 patients and several relatives and carerson the surgical wards. Each patient we spoke with was verypositive about their experience of the hospital and theircare and treatment. Patients told us staff treated them welland with kindness. Patients felt the entire pathway ofadmission to discharge process was very well informed andthey had been looked after well by the theatre team andward staff. Staff were very compassionate and in providingcare they were considerate and interacted well. Patientsalso felt their privacy and dignity was well respected in thetheatres and in the wards.

The hospital’s patient satisfaction survey results wereconsistently positive. Patients were asked for feedback andthe most recent 2019 patient satisfaction scores indicated93% of patients were satisfied with the privacy given, 73%stated their worries and fears were dealt with appropriately,92% informed the hospital their respect and dignity wasmaintained and 76% stated they were provided excellentcare from nurses.

Emotional support

Staff provided emotional support to patients, familiesand carers to minimise their distress. Theyunderstood patients’ personal, cultural and religiousneeds.

Staff gave patients and those close to them help, emotionalsupport and advice when they needed it.

Most patients we spoke with told us they had not neededemotional support but they were confident in would beavailable if they required. One patient spoke positivelyabout how staff had supported them in controlling theiranxiety and how well they were looked after. For anotherpatient, family members expressed the view they wereemotionally supported when it was needed. However, onepatient had been disturbed by the noise of staff in thetheatre area.

The hospital had a designated quiet room in the receptionarea and patients were provided access to facilities forpeople of different faiths if they wished. A space for prayerwas also accommodated if this was required.

Understanding and involvement of patients and thoseclose to them

Staff supported and involved patients, families andcarers to understand their condition and makedecisions about their care and treatment.

The hospital ensured patients and those close to themunderstood their care and treatment. Staff talked withpatients, families and carers in a way they couldunderstand, using communication aids where needed.

We observed during staff interaction with patients intheatre that staff gave informative explanations to thepatient and continued to keep them informed. We heardstaff introducing themselves by name and explaining thecare and treatment they were delivering.

Patients we spoke with said that they were aware of who toapproach if they had any issues regarding their care, andthey felt able to ask questions. Patients said medicalnursing and other staff took time to explain their care andthe risks and benefits of treatment.

Patients we spoke with said that they were aware of theirplans of care and they had been given the time forquestions and felt listened to. Patients we spoke with wereaware of their discharge arrangements and actionsrequired prior to discharge and were being supported withthese arrangements, for example, patients had alreadybeen supplied with equipment for their discharge.

Are surgery services responsive?

Good –––

Our rating of responsive stayed the same. We rated it asgood.

Service delivery to meet the needs of local people

The service planned and provided care in a way thatmet the needs of local people and the communitiesserved. It also worked with others in the wider systemand local organisations to plan care.

The hospital met quarterly with local healthcarecommissioners as well as commissioners from the widerarea to review quality and plan delivery arrangementswhich met the needs of the local community. Meetingswere recorded and an action log prepared and monitored.

Surgery

Surgery

Good –––


The hospital provided information for local GPs by holdingtraining courses and education lunch and learning andevening sessions for GPs. The service engaged with localcounsellors and the local residents association as to localcommunity events and regularly held events to engagewith the local community.

No high dependency or intensive care unit facility wasprovided at the hospital. The hospital had closed its highdependency unit after arranging for suitable facilities to beavailable with local NHS hospitals. Patients weretransported to an NHS hospital following surgery if theirclinical condition indicated. Patients with the long-termcomorbidities were referred to NHS hospitals.

To support effective planning of admissions pre-operativeassessment appointments were provided during days andevenings where clinically appropriate. The hospital offereda choice of consultants in most specialties and flexibility ofappointment times. Patients were offered a choice ofconsultant and appointment times to suit them. Eveningappointments and weekend clinics were available. Openvisiting times were encouraged and relatives could stayovernight in the hospital where appropriate.

Meeting people’s individual needs

The service was inclusive and took account ofpatients’ individual needs and preferences. Staffmade reasonable adjustments to help patients accessservices. They coordinated care with other servicesand providers.

The hospital supported patients living with dementia andthe lead for clinical governance acted as dementiachampion. A dementia strategy statement was in place.Alzheimer’s Society passports were used to support thepatient’s needs.

Rooms in the hospital could be adapted to meet the needsof patients with dementia; for example, furniture wasrearranged to reflect the arrangement in the patient’shome. One to one nursing was put in place where required.Single room facilities were provided for relatives to stayovernight. Dementia friends’ sessions were held as part ofmandatory training and staff received training in dementiaawareness twice yearly. A dementia awareness facilitieswere provided in the ward area.

The hospital supported patients with learning disabilitiesalthough few patients needing this support visited the

hospital. The patient was accommodated using their ownsoft furnishing in the hospital room to provide familiaritywith their surroundings. Hospital passports were used tosupport patients.

Hospital policy supported meeting the information andcommunication needs of patients with a disability orsensory loss. A hearing loop system was in place in thehospital. Partially sighted patients were escorted tofamiliarise with their room and provided with an‘obstructions menu.’ The patient’s bedroom was arrangedas near as possible to their home environment and familymembers were allowed unlimited visiting.

The hospital had a contract in place for information to beavailable in different formats to ensure patients of differentabilities could access clinical information. The hospitalprovided access to translation services for patients whereEnglish was not a first language. One-stop clinics were usedto reduce the need for patients to attend on severaloccasions.

Specialised equipment for bariatric patients was available.We checked and equipment was in place to carry outbariatric procedures. A specialist bariatric dietician wasavailable to provide support following the British Obesityand Metabolic Surgery Society national guidelines. Foreach bariatric patient, a bariatric multidisciplinary meetingwas held prior to surgery. Wards and departments wereaccessible for patients with limited mobility and peoplewho used a wheelchair.

Patients were not discharged on the day of their surgery ifthey lived alone and their circumstances were checked atthe pre-operative stage so that overnight accommodationwas pre-arranged. Patients were discharged with anaccompanying district nurse letter.

Access and flow

People could access the service when they needed itand received the right care promptly. Waiting timesfrom referral to treatment and arrangements toadmit, treat and discharge patients were in line withnational standards.

The hospital monitored waiting times to ensure patientsaccessed services when needed and received treatmentwithin agreed timeframes and national standards.Managers and staff worked to ensure patients did not stayin hospital longer than necessary.

Surgery

Surgery

Good –––


Managers worked to keep the number of cancelledoperations to a minimum. The hospital had eight cancelledprocedures for a non-clinical reason in the previous 12months. Of these cancelled procedures, each patient wasoffered another appointment within 28 days of thecancelled appointment where clinically possible.

Managers and staff worked to make sure that they starteddischarge planning as early as possible. Discharge planningwas discussed at the patient’s pre-assessment meeting.Patients requiring assistance from other services atdischarge were identified at pre-assessment.

In the previous 12 months there were six unplannedtransfers of inpatients to other hospitals, 20 unplannedreadmissions within 28 days of discharge and nineunplanned returns to theatre.

The hospital planned staggered admission times to ensurethere was minimal waiting to go to theatre on arrival and tooptimise patients being appropriately hydrated for surgery.Discharges were planned for before 11am whereverpossible. If a patient’s planned admission to theatre wasdelayed, the patient would be informed by reception oroutpatient nursing staff. The patient was only sent for fromtheir room when theatre was ready to receive them.Performance information reflected this and was confirmedby our observation of patient flow in the hospital.

Learning from complaints and concerns

It was easy for people to give feedback and raiseconcerns about care received. The service treatedconcerns and complaints seriously, investigated themand shared lessons learned with all staff.

Staff understood the hospital’s complaint policy and couldassist patients in applying it. Patients, relatives and carersknew how to complain or raise concerns. Patients we spokewith told us they were satisfied with the service in thehospital although they had received information abouthow to complain if they required to use it.

Information about how to raise a complaint was availablein patient areas. Complaints could be raised with thehospital informally through the hospital's website, throughpatient feedback forms, patient forums, social media, andin person to a member of staff as well as in writing and byemail. 'Please talk to us leaflets' explaining the complaintsprocess were available in the hospital.

The hospital investigated complaints and identifiedthemes. The hospital acknowledged complaints andpatients received feedback from managers after theinvestigation into their complaint. Managers sharedfeedback from complaints with staff and learning was usedto improve the service. Complainants were offered theopportunity to have a face to face meeting with theregistered manager.

Complaints and concerns were discussed daily at themultidisciplinary team huddle and the weekly clinicalgovernance brief. They were also discussed monthly at thehospital leadership team meeting and quarterly at theclinical governance committee and medical advisorycommittee. The registered manager and clinicalgovernance lead held a monthly complaints meeting todiscuss learning outcomes and trends which were sharedwith staff through a lessons learned bulletin, patientexperience meetings, clinical governance briefs, a monthlysafety bulletin and departmental monthly meetings.

The hospital complaint policy required complaints to beacknowledged within two days of receipt. The hospitalaimed to close all complaints within 20 working days andcompliance was monitored by the provider against astandard of 75%. The latest data for 2019 showed thehospital exceeded this standard with 82% of complaintsresponded to within the policy guidelines.

Learning from the investigation of complaints was sharedthrough management forums and meetings. A ‘you said,we did’ format displayed learning for patients and staff inthe hospital. A lessons learnt bulletin was emailed to staff.

In the year to July 2019, the hospital received 63complaints. Two of these were related directly to surgery.

As part of our inspection we reviewed four complaints files.Each file showed good risk assessment and investigations.The files showed that the investigator kept the complainantup to date on progress and that outcomes were shared.

Are surgery services well-led?

Good –––

Our rating of well-led went down. We rated it as good.

Leadership

Surgery

Surgery

Good –––


Leaders had the skills and abilities to run the service.They understood and managed the priorities andissues the service faced. They were visible andapproachable in the service for patients and staff.They supported staff to develop their skills and takeon more senior roles.

The hospital had a stable leadership structure with anexperienced hospital director and registered manager anda leadership team of 12 heads of department.

Staff spoke positively about the support they received fromthe leadership team. Staff were well supported at all levels,including more junior members of staff. Consultant staff wespoke with told us their engagement with the hospitalleadership team was positive. Staff told us thatmanagement were accessible and looked after them well.Staff felt they could approach managers with any concernsand managers listened.

Some of the management team told us that they were wellsupported by the hospital director and that they had beengiven opportunities to develop above and beyond whatthey had expected.

Vision and strategy

The service had a vision for what it wanted to achieveand a strategy to turn it into action, developed withall relevant stakeholders. The vision and strategywere focused on sustainability of services and alignedto local plans within the wider health economy.Leaders and staff understood and knew how to applythem and monitor progress.

The service had in place a hospital strategy and an annualbusiness plan. The hospital strategy was developedfollowing a series of meetings in which the hospital directorconsulted with staff about the proposed strategy and visionfor the hospital for 2019.

The overall strategy for the hospital was underpinned byclinical strategies and a hospital wide “Strategy on a page.”The ‘Strategy on a page’ was prepared to show how eachdepartment interlinked to deliver the hospital strategy.

The hospital followed the provider’s corporate vision,mission and values. The provider’s strategic vision was ofgrowth through investment in clinical quality implementedin each hospital. The vision was to be recognised as a worldclass healthcare business; its mission was to bring together

the best people who were dedicated to developingexcellent clinical environments and delivering the highestquality patient care; and its values included driving clinicalexcellence, doing the right thing, caring is our passion,keeping it simple, delivering on our promises andsucceeding and celebrating together.

We observed the provider’s vision mission and valuesdisplayed in the hospital. Staff appraisal objectives linkedpersonal objectives to the hospital strategy and corporatevalues.

Culture

Staff felt respected, supported and valued. They werefocused on the needs of patients receiving care. Theservice promoted equality and diversity in daily workand provided opportunities for career development.The service had an open culture where patients, theirfamilies and staff could raise concerns without fear.

Staff we spoke with were consistently positive about theculture they experienced in the hospital. Staff felt wellsupported and morale was high. Some staff described thehospital as a family with everyone working well as a team.Other staff described the culture as professional, open,friendly, welcoming and with a keenness to improve andsucceed.

A freedom to speak up guardian and ambassadors were inrole and endorsed the whistleblowing process. Staff wereencouraged to, and confident to raise issues.

The hospital had a track record of identifying anddeveloping talented staff from within the hospital and staffwere proud to work for the organisation. The hospital hadan established system to recognise and reward staff foreffort, achievement and innovation which included theprovider’s staff awards programme.

A robust procedure was in place for challenging consultantbehaviours and performance. Any staff issues were dealtwith supportively.

Governance

Leaders operated effective governance processes,throughout the service and with partnerorganisations. Staff at all levels were clear about theirroles and accountabilities and had regularopportunities to meet, discuss and learn from theperformance of the service.

Surgery

Surgery

Good –––


The hospital had in place clear and well-establishedgovernance structures. An annual governance plan was inplace. The governance framework was supported by anetwork of meetings and working parties that providedoversight of the clinical and non-clinical services in thehospital. An established board to ward system ofgovernance provided for correctional action to be takenpromptly. The hospital informed us a deputy head ofgovernance was being appointed during 2020.

A governance meeting was held weekly at which thetheatre department was represented. The seniormanagement team met weekly and escalated issues to theleadership team. Minutes from governance meetings wereshared with frontline clinical and non-clinical teams.

The senior leadership team met weekly and this included aweekly clinical governance briefing. The hospital leadershipteam met monthly and departmental and staff meetingswere held monthly. The theatre department met monthlyand was also represented at monthly governance meetingsattended by the registered manager and a consultantrepresentative as governance lead. A health and safetymeeting and team leaders meeting were held monthly.

Robust arrangements for clinical governance and anestablished clinical governance team were in place. Thedaily multidisciplinary team ‘huddle’ (duration observedwas 15 minutes) was attended by a representative ofclinical governance. The director of clinical services heldgovernance briefs weekly attended by the hospital directorand clinical heads of department. Specific hospitalcommittees fed into the overarching clinical governanceforums.

A revised medical governance policy was introduced during2019 and included a consultant handbook, whichcontained information on practicing privileges. Themedical advisory committee met quarterly. The clinicalgovernance meeting also met quarterly and included arepresentative of the medical advisory committee. Thechair of the medical advisory committee also chaired anymeeting about consultant concerns. The hospital metquarterly with commissioners to discuss governance andclinical quality.

Governance committee meetings were held quarterly andwere informed by a quarterly governance and qualityreport. An established audit programme supported thegovernance arrangements.

Arrangements were in place to recruit new consultants withpracticing privileges and to monitor their performance.When a new consultant approached the hospital to workunder practicing privileges, this was discussed with thetheatre manager, director of clinical services and businessdevelopment lead. The service were proactive in obtaininginformation about the consultant’s performance prior tointerview stage. Any consultant would then have to providetheir responsible officer’s reference and application whichcould be reviewed by the team prior to interview. Thiswould ensure that the consultants had the appropriatespecialty qualifications and experience, disclosure andbarring (DBS) clearance and cover some occupationalhealth information. This would be reviewed also at themedical advisory committee.

We were told by the leadership team that they workedproactively with the consultant’s responsible officers tokeep up to date information on the performance ofconsultants. Each consultant had a biennial review. Wewere also given an example of where a consultant hadretired from the NHS so had more frequent annual reviewssupported by an annual whole practice appraisal and fiveyearly GMC revalidation.

We reviewed the personnel files of three consultants withpracticing privileges. All the files showed that adequatechecks for employment were in place and there wasevidence of ongoing supervision and annual appraisalinformation from the responsible officer.

Managing risks, issues and performance

Leaders and teams used systems to manageperformance effectively. They identified andescalated relevant risks and issues and identifiedactions to reduce their impact. They had plans to copewith unexpected events. Staff contributed todecision-making to help avoid financial pressurescompromising the quality of care.

A risk management policy and significant risk register forthe hospital were in place which highlighted current risksand documented mitigating actions to reduce the risks. Arisk champion was appointed to role to support themonitoring of the hospital wide risk register.

Surgery

Surgery

Good –––


The risk register and escalation position was reviewed andupdated weekly. The risk register was regularly reviewed bythe senior management team with departmental leads andreviewed at monthly health and safety meetings. Risk wasalso a monthly agenda item at departmental meetings.

Red and amber rated risks were added to the hospital riskregister and an action plan for improvement prepared. Atinspection the risk register included 101 risks whichchanged weekly. The top six risks for the hospital and thetop three risks for each department were reviewedmonthly. Staff were familiar with the hospital’s risks. Anexample was the shortage of providers for advanced lifesupport training which was included in the risk register asthere were insufficient providers in theatre. The risk wasmitigated through a training course held in October 2019.

The hospital audited a range of performance indicators onits published clinical scorecard which reflectedprovider-wide scorecards and dashboards forbenchmarking results. Key performance indicators werereported each quarter. Results were benchmarkednationally and performance against standards rated.Performance reports were prepared and used to supportimprovements.

Staff were encouraged to record incidents involving theconduct and behaviour of the team including consultantsand other staff with practicing privileges.

We reviewed two serious incident reports and found thatall the relevant information for recording and investigatingwere present. Investigations were credible and there wasevidence of sharing of learning from the outcomes. In bothcases patients and families were involved in theinvestigation and informed of the outcomes. The provideralso exercised the duty of candour appropriately in bothcases.

Managing information

The service collected reliable data and analysed it.Staff could find the data they needed, in easilyaccessible formats, to understand performance, makedecisions and improvements. The informationsystems were integrated and secure. Data ornotifications were consistently submitted to externalorganisations as required.

Staff had access to up-to-date, accurate andcomprehensive information on patients’ care andtreatment. We observed staff accessed the clinical intranetto review clinical policies.

The hospital used a range of digital health facilities tofacilitate the patient pathway. Staff completed informationgovernance training annually to support keepinginformation secure and protecting confidentiality. ITpolicies governed practice and processes within theprovider.

Engagement

Leaders and staff actively and openly engaged withpatients, staff, equality groups, the public and localorganisations to plan and manage services. Theycollaborated with partner organisations to helpimprove services for patients.

The hospital could demonstrate high levels of patientsatisfaction. The hospital encouraged patient feedbackthrough various means including satisfaction surveys,“please talk to us “cards, patient forums and patients wereinvolved through the complaints process in improvinghospital services. NHS choices provided an independentmeans for patients to leave feedback. Feedback was usedto improve hospital services. You said, we did displays inthe hospital reflected learning from feedback andcomplaints and changes made in response.

All patients admitted to hospital were requested tocomplete an online survey. Results were collated andreported by an external provider. New questionnaires havebeen introduced to the hospital to help ensure service levelfeedback was specific and to supplement low responserates to external online surveys including the friends andfamily test.

Patient satisfaction surveys were emailed to each patientafter their stay and results were collated and reviewedmonthly. The results of the most recent patient satisfactionsurvey (November 2019) indicated 96% of patients werealways provided with enough privacy, 70% stated theyalways found someone on the hospital staff to talk to abouttheir worries and fears, 96% said their respect and dignitywas always maintained and 99% stated they were providedwith excellent care from nurses.

Patients were represented on NHS England’s annualpatient led assessments of the care environment (PLACE).

Surgery

Surgery

Good –––


The hospital recently established a patient experiencemeeting which was used to discuss learnings fromcomplaints, adverse events and to provide a furtheropportunity for patient feedback.

The hospital communicated with staff through a staffnewsletter, consultant newsletter, and staff communicationboards. The hospital held engagement meetings for staffincluding forums and working groups. Hospital and clinicalstrategies were developed with staff involvement.

The hospital recognised its staff by highlighting things thatit did well. Plaudits and compliments were shared widelythrough the daily huddles, staff recognition boards and‘Thank you Thursdays.’ Director-led staff forums were heldmonthly. The provider’s 'Inspiring People' award schemerecognised staff achievement.

Learning, continuous improvement and innovation

The hospital was committed to continually learningand improving services. It’s staff had anunderstanding of quality improvement methods andthe skills to use them. Leaders encouraged innovationand participation in research.

The hospital provided information for local GPs by holdingtraining courses and education lunch and learning andevening sessions for GPs. The hospital offered a varied GPeducation programme responsive to current ‘hot topics.’

The King's Thrombosis Centre was identified as the firstNHS VTE Exemplar Centre by the Department of Health andaimed to provide leadership in sharing best practice. Thehospital informed us it was working to achieve KingsCollege VTE exemplar status.

The hospital had an established system to recognise andreward staff for effort, achievement and innovation whichincluded the provider’s staff awards programme.

Some of the management team told us that they were wellsupported by the hospital director and that they had beengiven opportunities to develop above and beyond whatthey had expected.

Surgery

Surgery

Good –––


Safe Good –––

Effective




Are outpatients services safe?

Good –––

We previously inspected outpatients with diagnosticimaging, so we cannot compare our new ratings directlywith previous ratings. We rated it as good.

Mandatory training

The service provided mandatory training in keyskills to all staff and made sure everyone completedit.

The hospital set a target of 95% for mandatory training forstaff.

Staff received and kept up to date with their mandatorytraining. Mandatory training was provided as a mixture ofe-learning and face to face training depending on thetraining course. Where staff were not up to date withtraining, leaders told us they were booked on to completethe training.

The department management maintained oversight ofmandatory training compliance and leaders had accessto electronic systems which enabled them to monitortraining compliance levels across the services. During theinspection, we were told mandatory training compliancewas at 93% against the 95% target and this was not 100%because a staff member had recently started at thehospital and was working through the training modules.

The mandatory training included training modules suchas safeguarding, information governance and infectioncontrol amongst other modules. The informationprovided by the service showed the compliance foroutpatient’s administrative staff with mandatory training

was 100% across the various modules. Compliance foroutpatient’s staff ranged between 86% and 100% formandatory training, however this was from September2019 and during the inspection mandatory trainingcompliance had improved.

Safeguarding

Staff understood how to protect patients from abuseand the service worked well with other agencies todo so. Staff had training on how to recognise andreport abuse and they knew how to apply it.

The hospital had up to date safeguarding policies inplace which staff could access. The department did notsee many children as they were part of a hub and spokemodel for children’s outpatients with another Spirehospital. Where children did attend for outpatientappointments, it was mainly for ear, nose and throat,dermatology, orthopaedic and general surgeryconsultations or there was child psychology clinicsaround once a month.

Staff described the ‘was not brought’ policy regardingchildren not being brought to their appointment. Thesafeguarding policy for children and young people had asection for ‘was not brought’ for further guidance.

Staff had awareness of safeguarding including femalegenital mutilation (FGM) and there was an informationfolder in the outpatient managers office for FGM whichincluded a flow chart with what to do if there wereconcerns.

The hospital had safeguarding leads in place and thesewere the clinical governance lead and there was a leadphysiotherapist for children and young persons inoutpatients. These staff were available for support andadvice and we were told these staff, along with the

Outpatients

Outpatients

Good –––


hospital director, director of clinical services andoutpatients sister, were trained to level four safeguarding.The level four safeguarding training was provided atanother Spire site.

Staff we spoke with could describe the action they wouldtake if they had safeguarding concerns for adults orchildren across outpatients. Safeguarding posters wereon display in the department.

The hospital provided information on safeguarding levelsand training across the hospital. This showed the hospitalhad a requirement for consultants who provided care andtreatment to children to be level three safeguardingtrained along with registered nursing staff and alliedhealth professionals involved in the care of children.Some reception staff and ward administrators were alsorequired to be trained to level three childrensafeguarding. All other staff were trained to level twosafeguarding children and adults.

We requested compliance levels for safeguarding adultsand children split by the safeguarding level. The hospitalprovided information on safeguarding trainingcompliance as at 17 December 2019 which showed foroutpatients, compliance with safeguarding adults leveltwo was 91%.

Compliance with safeguarding children level two was91% and safeguarding children level three was 100%. Thedate for remaining staff to complete the training wasMarch 2020. The information showed compliance inphysiotherapy for safeguarding adults’ level two was100%, compliance with safeguarding children level twowas 100% and safeguarding children level three was100%. This showed that one staff member was trained tolevel four training and compliance was 100%.


The service controlled infection risk well. Staff usedequipment and control measures to protectpatients, themselves and others from infection.They kept equipment and the premises visibly clean.

Areas visited were visibly clean and tidy. During theinspection we saw staff adhering to ‘bare arms below theelbow’ and also saw posters on display regarding this insome clinic rooms. Hand sanitiser was available and

there were washing sinks available in the areas visited.Personal protective equipment was available in thedepartment, for example gloves and aprons. Hand washwas available in the areas visited.

Consulting and treatment rooms had paper on each ofthe trolley beds and we were told this was replaced aftereach patient. There were fabric curtains in some of thetreatment rooms and the changing dates on these weregenerally completed as required and in date, except forone. We highlighted the point about dates on equipmentand consumables during the inspection and the leaderstold us they would address it.

The clinical governance lead for the services was also theinfection prevention lead and staff could contact theinfection prevention lead for advice and support asrequired.

Information provided by the hospital highlighted therehad been no infections in outpatients and staff told us ifthere was an infection, a root cause analysis would becompleted along with an incident form. Staff told uspatients with a communicable disease would beallocated to the end of a clinic list and there would be adeep clean afterwards as required.

There was daily cleaning in the outpatient departmentand waste disposal available for various types of wasteacross the outpatient services. At the previous inspection,there were concerns regarding cleaning logs. At thisinspection we found these to be present outside theconsulting and treatment room doors and the December2019 cleaning logs were completed as required. We sawsome of the previous three months cleaning logs andfound these to be generally completed as required withone day not documented in one of the previous threemonths. The department managers had recently revisedthe cleaning logs, and these included the daily, weeklyand monthly cleaning schedule.

The ear, nose and throat outpatient clinics usedendoscopes for procedures. Staff told us there was asystem for cleaning these which used specific cleaningwipes and the endoscopes were then sent to the internalsterile services department for cleaning. Leaders told usthere was a green bag and red bag system used toindicate which endoscope was clean.

The hospital completed environment audits to enableleaders to monitor the environment as required. This

Outpatients

Outpatients

Good –––


audit also considered the oncology area. In July 2019, thescore for oncology was 100%. The cleaning checklist inthe children’s outpatient waiting area was completed asrequired.

Staff had access to an infection prevention and controlpolicy which had a review date of February 2022. Therewas also a management of MRSA document which had areview date of April 2020. The meeting minutes from July2019 for the infection prevention committee includedagenda items such as antimicrobial stewardship andmanagement of risks.

The departments completed hand hygiene audits on theenvironment, observation and technique. The quarterthree 2019 hand hygiene environment audits showedpositive answers to all, but one question and theSeptember 2019 hand hygiene technique audit had allquestions answered positively. The service provided anobservational hand hygiene audit compliance reportwhich showed 100% compliance across four sessions.


The design, maintenance and use of facilities,premises and equipment kept people safe. Staffwere trained to use them. Staff managed clinicalwaste well.

The outpatient department was located along a corridorwhich had consulting and treatment rooms along with areception area where reception staff could book andorganise appointments for patients as they were leavingthe department. Patients checked in at the main hospitalreception and would then be called for their appointmentas required. Toilets were available in the outpatientdepartment.

The corridor next to the outpatient department waswhere the physiotherapy team were based and there wasa phlebotomy room on the corridor for outpatient use.The physiotherapy department had a waiting room whichhighlighted the patient outcome information, had anumber of patient information leaflets and a folder withchildren’s packs for when children attended thedepartment.

There was seating available in the waiting rooms forpatients waiting for appointments. There was also a quietroom available for patient and visitor use in theoutpatient waiting area. The main outpatient corridor

also had a pharmacy available and the pathology unitwas at the end of the corridor. The oncology outpatientteam were located in a separate part of the hospital. Thechildren’s and young persons activity area had smalltables and chairs alongside books.

The outpatient area displayed various information topatients and visitors such as the vision and purpose.There was a children’s waiting area within the outpatientwaiting area.

There was waste disposal available in the department forclinical and non-clinical waste.

Consulting and treatment rooms had doors with keypadlocks attached which enhanced the security of the rooms.

The outpatient department had a resuscitation trolleyavailable for use. We checked recent dates for these andthese were checked as required. The resuscitationtrolleys were checked daily and the trolleys were secured.We found one of the security tags was not completelysecure, however, we raised this with staff and this wasdealt with.

We saw one asset where the portable appliance testingsticker date was 25 June 2016. We raised this with leaderswho advised servicing was up to date, but the sticker hadnot been replaced and they were going to address it.

There was signage directing staff to the various parts ofthe department. Wheelchairs were available for patientuse across the department.

Staff had access to personal protective equipment suchas gloves and aprons. These were available in each of theconsulting or treatment rooms. There was enoughequipment for staff to use and computers were availablein the department. The hospital had a maintenance teamwhich staff could contact if required. There was access toan information technology team for advice and supportas required.

The physiotherapy experience survey from November2019 showed 82% of respondents said the environmentwas excellent and 18% of respondents said thephysiotherapy environment was good.

Outpatients

Outpatients

Good –––


The services took part in the patient led assessments ofthe care environment (PLACE) audits and the report from2019 included outpatients. The report showed all relevantquestions for the cleanliness part of the audit hadpassed.

The hospital provided examples of equipmentreplacement from 2018 which showed various equipmentsuch as gym equipment replacement.

The hospital provided and had a maintenance schedulefor 2019 and 2020 in place for the hospital including theoutpatient department. The was also a service schedulefor the outpatient department.


Staff completed and updated risk assessments andremoved or minimised risks. Staff identified andquickly acted upon patients at risk of deterioration.

Safety checklists were in use in the outpatientdepartment in the orthopaedic clinics for injections.During the inspection we saw four of these checklists andthree were completed as required, however one was notfully complete. These safety checklists includedinformation such as the step one sign in, step two timeout and step three signature. We were told these wereused each time for injections.

Where patients were clinically unwell or deterioratedduring their visit to outpatients, staff would contact theresuscitation team. There was medical and nursing staffavailable in the outpatient department during the daywhen outpatients was open. The hospital providedinformation stating outpatient staff were trained in basiclife support with compliance at 93%.

The service could access a children’s nurse at anotherSpire hospital site for advice if required and there was aresident medical officer at the hospital. The departmentalso had access to a paediatric resuscitation trolley.

The safeguarding policy for children and young peoplehad a section for ‘was not brought’ for staff to access forguidance.

Leaders told us staff would receive a debrief whererequired if there had been an incident in the outpatientdepartment.

Nurse staffing

The service had enough nursing and support staffwith the right qualifications, skills, training andexperience to keep patients safe from avoidableharm and to provide the right care and treatment.Managers regularly reviewed and adjusted staffinglevels and skill mix, and gave bank and agency staffa full induction.

Leaders told us there were no concerns with staffinglevels in the outpatient department and they had recentlyrecruited to the department and currently had novacancies. Staffing rotas were planned in advance andtook into account the type and number of clinics theservice had, and the department leaders used a saferstaffing tool which assisted in planning for staffing levels.The service provided information stating safety assurancewas provided by the safe staffing tool and daily assurancewas provided by the daily huddle which was held inoutpatients each morning and took into account staffingin outpatients. The department manager or senior nursealso attended the hospital multidisciplinary team huddleeach morning where safe staffing was discussed.

The service provided an audit for the safe staffing toolwhich they completed and this showed there had beenno incidents reported relating to safe staffing inoutpatients.

Oversight of staffing was maintained by the leadershipteam and where required and there were vacancies, theservice would recruit. Where needed to ensure staffinglevels were as required, bank staff would be utilised.

The service provided information showing there were sixregistered nurses, nine healthcare assistants and therewere three bank staff available as required. There was anoutpatient manager and a senior nurse in outpatients.

Medical staffing

For our detailed findings on medical staffing please seethe Safe section in the surgery report.

Medical staff were not managed directly by the outpatientdepartment.

Medical staff worked at the hospital under practisingprivileges and held outpatient appointment clinics asrequired in the department. The granting of practisingprivileges is a well-established process within

Outpatients

Outpatients

Good –––


independent healthcare whereby a medical practitioneris granted permission to work in an independent hospitalor clinic, in independent private practice or within theprovision of community services.

The service provided information stating an Ad-hocresident medical officer clinic was available Monday toFridays for patients requiring urgent or planned medicalreviews. The information provided by the service alsostated resident medical officers worked on a seven-dayrota.

The hospital had access to a safe staffing policy with areview date of April 2022.

Records

Staff did not always keep detailed records ofpatients’ care and treatment. Records were storedsecurely and easily available to all staff providingcare.

Records were mainly paper records across theoutpatients department. Records were stored securelyduring the inspection and there was a locked cupboard inthe department for patient records and the clinic roomdoors had key pad locks to enhance the security ofrecords. In the consulting and treatment rooms therewere also cupboards which could be locked. Patientrecords were brought to the clinic rooms as required.

We reviewed ten records during the inspection and foundthese were not always completed as required. Forexample, there were three records which did not have asignature. There was evidence of multidisciplinary teamworking in the records.

Staff told us it was rare for patient notes to not be readyand available for outpatient clinics and where they werenot available, staff would contact the patient recordsdepartment or would create a temporary set of records ifrequired. The hospital provided information stating lessthan 5% of patients were seen without a record beingavailable.

The hospital provided further information on theprocesses which assisted in managing the risk if a patientwas to attend and the records were not available. Thehospital stated the administration manager reported to

the daily huddle if there were any records unavailable forpatients attending that day and that actions would betaken by staff to locate the records in time for the patientattending the hospital.

There was a patient records policy which had a reviewdate of September 2022.

The medical records audit from the 27 November 2019showed that out of twenty records audited, all of thesewere completed as required with only one record nothaving the last clinic letter in notes and the consultantdocumentation not legible. There was an action planfollowing the clinical audit in November 2019 whichdetailed the issues raised, action required, outcomemeasure, action lead and the date due.

Medicines


For our detailed findings on medicines please see theSafe section in the surgery report.

Medicines seen during the inspection were storedsecurely and the medicine cupboard keys were kept by aregistered nurse or locked away in a cupboard. Medicinesseen during the inspection were found to be in date. Theoutpatient department did not keep any controlled drugsand did not have any patient group directives in place.Prescription pads were stored securely.

There was a pharmacy department with dedicatedpharmacy staff available within the outpatientdepartment where support and advice could be sought.There was a management of medicines policy availableto staff which had a review date of October 2019, howeverthe document stated it had been extended for six monthswhilst it was under review. This policy had a section onantibiotic prescribing and the principles of stewardship.There were antibiotic prescribing guidelines with a reviewdate of February 2020.

Medicines refrigerator checks were completed asrequired in the temperature logs we saw.

Incidents

Outpatients

Outpatients

Good –––


The service managed patient safety incidents well.Staff recognised and reported incidents and nearmisses. Managers investigated incidents and sharedlessons learned with the whole team and the widerservice.

The service had an incident reporting policy which had areview date of January 2022.

There had been no never events or serious incidentsacross outpatients in the previous 12 months.

The department staff had access to an electronic incidentreporting system in outpatients and staff we spoke withwere aware of this system and could describe how theywould report an incident.

Leaders in the department would investigate theincidents or would ask the relevant person to investigatethe incident and we were told the clinical governancelead also had oversight of incidents across the service.Root cause analysis were completed for serious incidentsif they occurred and the hospital provided informationhighlighting they were supported by a national patientsafety team.

Leaders told us there had not been many incidents in theprevious 12 months across outpatients but where therehad been an incident this would be shared at themonthly team meetings with the team. Team meetingminutes showed incidents were part of the monthlyagenda.

The hospital provided information highlighting incidentswhere there had been learning from the incidentsidentified and how this learning from incidents had beencompleted.

They had added the outpatient department to theincident reporting system in April 2019. The hospitalprovided a document with the incidents which hadoccurred in the previous eight months and each incidentreported stated ‘no harm caused’.

Staff we spoke with could describe the duty of candour.Duty of candour means the service must be open andhonest with patients and other relevant persons whenthings go wrong with care and treatment, giving themreasonable support, truthful information and a writtenapology.

Are outpatients services effective?


Mandatory training


The hospital set a target of 95% for mandatory training forstaff.

Staff received and kept up to date with their mandatorytraining. Mandatory training was provided as a mixture ofe-learning and face to face training depending on thetraining course. Where staff were not up to date withtraining, leaders told us they were booked on to completethe training.

The department management maintained oversight ofmandatory training compliance and leaders had accessto electronic systems which enabled them to monitortraining compliance levels across the services. During theinspection, we were told mandatory training compliancewas at 93% against the 95% target and this was not 100%because a staff member had recently started at thehospital and was working through the training modules.

The mandatory training included training modules suchas safeguarding, information governance and infectioncontrol amongst other modules. The informationprovided by the service showed the compliance foroutpatient’s administrative staff with mandatory trainingwas 100% across the various modules. Compliance foroutpatient’s staff ranged between 86% and 100% formandatory training, however this was from September2019 and during the inspection mandatory trainingcompliance had improved.

Safeguarding


The hospital had up to date safeguarding policies inplace which staff could access. The department did not

Outpatients

Outpatients

Good –––


see many children as they were part of a hub and spokemodel for children’s outpatients with another Spirehospital. Where children did attend for outpatientappointments, it was mainly for ear, nose and throat,dermatology, orthopaedic and general surgeryconsultations or there was child psychology clinicsaround once a month.

Staff described the ‘was not brought’ policy regardingchildren not being brought to their appointment. Thesafeguarding policy for children and young people had asection for ‘was not brought’ for further guidance.

Staff had awareness of safeguarding including femalegenital mutilation (FGM) and there was an informationfolder in the outpatient managers office for FGM whichincluded a flow chart with what to do if there wereconcerns.

The hospital had safeguarding leads in place and thesewere the clinical governance lead and there was a leadphysiotherapist for children and young persons inoutpatients. These staff were available for support andadvice and we were told these staff, along with thehospital director, director of clinical services andoutpatients sister, were trained to level four safeguarding.The level four safeguarding training was provided atanother Spire site.

Staff we spoke with could describe the action they wouldtake if they had safeguarding concerns for adults orchildren across outpatients. Safeguarding posters wereon display in the department.

The hospital provided information on safeguarding levelsand training across the hospital. This showed the hospitalhad a requirement for consultants who provided care andtreatment to children to be level three safeguardingtrained along with registered nursing staff and alliedhealth professionals involved in the care of children.Some reception staff and ward administrators were alsorequired to be trained to level three childrensafeguarding. All other staff were trained to level twosafeguarding children and adults.

We requested compliance levels for safeguarding adultsand children split by the safeguarding level. The hospitalprovided information on safeguarding trainingcompliance as at 17 December 2019 which showed foroutpatients, compliance with safeguarding adults leveltwo was 91%.

Compliance with safeguarding children level two was91% and safeguarding children level three was 100%. Thedate for remaining staff to complete the training wasMarch 2020. The information showed compliance inphysiotherapy for safeguarding adults’ level two was100%, compliance with safeguarding children level twowas 100% and safeguarding children level three was100%. This showed that one staff member was trained tolevel four training and compliance was 100%.



Areas visited were visibly clean and tidy. During theinspection we saw staff adhering to ‘bare arms below theelbow’ and also saw posters on display regarding this insome clinic rooms. Hand sanitiser was available andthere were washing sinks available in the areas visited.Personal protective equipment was available in thedepartment, for example gloves and aprons. Hand washwas available in the areas visited.

Consulting and treatment rooms had paper on each ofthe trolley beds and we were told this was replaced aftereach patient. There were fabric curtains in some of thetreatment rooms and the changing dates on these weregenerally completed as required and in date, except forone. We highlighted the point about dates on equipmentand consumables during the inspection and the leaderstold us they would address it.


Information provided by the hospital highlighted therehad been no infections in outpatients and staff told us ifthere was an infection, a root cause analysis would becompleted along with an incident form. Staff told uspatients with a communicable disease would beallocated to the end of a clinic list and there would be adeep clean afterwards as required.

There was daily cleaning in the outpatient departmentand waste disposal available for various types of wasteacross the outpatient services. At the previous inspection,

Outpatients

Outpatients

Good –––


there were concerns regarding cleaning logs. At thisinspection we found these to be present outside theconsulting and treatment room doors and the December2019 cleaning logs were completed as required. We sawsome of the previous three months cleaning logs andfound these to be generally completed as required withone day not documented in one of the previous threemonths. The department managers had recently revisedthe cleaning logs, and these included the daily, weeklyand monthly cleaning schedule.

The ear, nose and throat outpatient clinics usedendoscopes for procedures. Staff told us there was asystem for cleaning these which used specific cleaningwipes and the endoscopes were then sent to the internalsterile services department for cleaning. Leaders told usthere was a green bag and red bag system used toindicate which endoscope was clean.

The hospital completed environment audits to enableleaders to monitor the environment as required. Thisaudit also considered the oncology area. In July 2019, thescore for oncology was 100%. The cleaning checklist inthe children’s outpatient waiting area was completed asrequired.

Staff had access to an infection prevention and controlpolicy which had a review date of February 2022. Therewas also a management of MRSA document which had areview date of April 2020. The meeting minutes from July2019 for the infection prevention committee includedagenda items such as antimicrobial stewardship andmanagement of risks.

The departments completed hand hygiene audits on theenvironment, observation and technique. The quarterthree 2019 hand hygiene environment audits showedpositive answers to all, but one question and theSeptember 2019 hand hygiene technique audit had allquestions answered positively. The service provided anobservational hand hygiene audit compliance reportwhich showed 100% compliance across four sessions.



The outpatient department was located along a corridorwhich had consulting and treatment rooms along with areception area where reception staff could book andorganise appointments for patients as they were leavingthe department. Patients checked in at the main hospitalreception and would then be called for their appointmentas required. Toilets were available in the outpatientdepartment.

The corridor next to the outpatient department waswhere the physiotherapy team were based and there wasa phlebotomy room on the corridor for outpatient use.The physiotherapy department had a waiting room whichhighlighted the patient outcome information, had anumber of patient information leaflets and a folder withchildren’s packs for when children attended thedepartment.

There was seating available in the waiting rooms forpatients waiting for appointments. There was also a quietroom available for patient and visitor use in theoutpatient waiting area. The main outpatient corridoralso had a pharmacy available and the pathology unitwas at the end of the corridor. The oncology outpatientteam were located in a separate part of the hospital. Thechildren’s and young persons activity area had smalltables and chairs alongside books.

The outpatient area displayed various information topatients and visitors such as the vision and purpose.There was a children’s waiting area within the outpatientwaiting area.


Consulting and treatment rooms had doors with keypadlocks attached which enhanced the security of the rooms.

The outpatient department had a resuscitation trolleyavailable for use. We checked recent dates for these andthese were checked as required. The resuscitationtrolleys were checked daily and the trolleys were secured.We found one of the security tags was not completelysecure, however, we raised this with staff and this wasdealt with.

We saw one asset where the portable appliance testingsticker date was 25 June 2016. We raised this with leaderswho advised servicing was up to date, but the sticker hadnot been replaced and they were going to address it.

Outpatients

Outpatients

Good –––


There was signage directing staff to the various parts ofthe department. Wheelchairs were available for patientuse across the department.

Staff had access to personal protective equipment suchas gloves and aprons. These were available in each of theconsulting or treatment rooms. There was enoughequipment for staff to use and computers were availablein the department. The hospital had a maintenance teamwhich staff could contact if required. There was access toan information technology team for advice and supportas required.

The physiotherapy experience survey from November2019 showed 82% of respondents said the environmentwas excellent and 18% of respondents said thephysiotherapy environment was good.

The services took part in the patient led assessments ofthe care environment (PLACE) audits and the report from2019 included outpatients. The report showed all relevantquestions for the cleanliness part of the audit hadpassed.

The hospital provided examples of equipmentreplacement from 2018 which showed various equipmentsuch as gym equipment replacement.

The hospital provided and had a maintenance schedulefor 2019 and 2020 in place for the hospital including theoutpatient department. The was also a service schedulefor the outpatient department.



Safety checklists were in use in the outpatientdepartment in the orthopaedic clinics for injections.During the inspection we saw four of these checklists andthree were completed as required, however one was notfully complete. These safety checklists includedinformation such as the step one sign in, step two timeout and step three signature. We were told these wereused each time for injections.

Where patients were clinically unwell or deterioratedduring their visit to outpatients, staff would contact theresuscitation team. There was medical and nursing staff

available in the outpatient department during the daywhen outpatients was open. The hospital providedinformation stating outpatient staff were trained in basiclife support with compliance at 93%.

The service could access a children’s nurse at anotherSpire hospital site for advice if required and there was aresident medical officer at the hospital. The departmentalso had access to a paediatric resuscitation trolley.

The safeguarding policy for children and young peoplehad a section for ‘was not brought’ for staff to access forguidance.

Leaders told us staff would receive a debrief whererequired if there had been an incident in the outpatientdepartment.

Nurse staffing

The service had enough nursing and support staffwith the right qualifications, skills, training andexperience to keep patients safe from avoidableharm and to provide the right care and treatment.Managers regularly reviewed and adjusted staffinglevels and skill mix, and gave bank and agency staffa full induction.

Leaders told us there were no concerns with staffinglevels in the outpatient department and they had recentlyrecruited to the department and currently had novacancies. Staffing rotas were planned in advance andtook into account the type and number of clinics theservice had, and the department leaders used a saferstaffing tool which assisted in planning for staffing levels.The service provided information stating safety assurancewas provided by the safe staffing tool and daily assurancewas provided by the daily huddle which was held inoutpatients each morning and took into account staffingin outpatients. The department manager or senior nursealso attended the hospital multidisciplinary team huddleeach morning where safe staffing was discussed.

The service provided an audit for the safe staffing toolwhich they completed and this showed there had beenno incidents reported relating to safe staffing inoutpatients.

Outpatients

Outpatients

Good –––



The service provided information showing there were sixregistered nurses, nine healthcare assistants and therewere three bank staff available as required. There was anoutpatient manager and a senior nurse in outpatients.

Medical staffing


Medical staff were not managed directly by the outpatientdepartment.

Medical staff worked at the hospital under practisingprivileges and held outpatient appointment clinics asrequired in the department. The granting of practisingprivileges is a well-established process withinindependent healthcare whereby a medical practitioneris granted permission to work in an independent hospitalor clinic, in independent private practice or within theprovision of community services.

The service provided information stating an Ad-hocresident medical officer clinic was available Monday toFridays for patients requiring urgent or planned medicalreviews. The information provided by the service alsostated resident medical officers worked on a seven-dayrota.


Records


Records were mainly paper records across theoutpatients department. Records were stored securelyduring the inspection and there was a locked cupboard inthe department for patient records and the clinic roomdoors had key pad locks to enhance the security ofrecords. In the consulting and treatment rooms therewere also cupboards which could be locked. Patientrecords were brought to the clinic rooms as required.

We reviewed ten records during the inspection and foundthese were not always completed as required. Forexample, there were three records which did not have asignature. There was evidence of multidisciplinary teamworking in the records.

Staff told us it was rare for patient notes to not be readyand available for outpatient clinics and where they werenot available, staff would contact the patient recordsdepartment or would create a temporary set of records ifrequired. The hospital provided information stating lessthan 5% of patients were seen without a record beingavailable.

The hospital provided further information on theprocesses which assisted in managing the risk if a patientwas to attend and the records were not available. Thehospital stated the administration manager reported tothe daily huddle if there were any records unavailable forpatients attending that day and that actions would betaken by staff to locate the records in time for the patientattending the hospital.


The medical records audit from the 27 November 2019showed that out of twenty records audited, all of thesewere completed as required with only one record nothaving the last clinic letter in notes and the consultantdocumentation not legible. There was an action planfollowing the clinical audit in November 2019 whichdetailed the issues raised, action required, outcomemeasure, action lead and the date due.

Medicines


For our detailed findings on medicines please see theSafe section in the surgery report.

Medicines seen during the inspection were storedsecurely and the medicine cupboard keys were kept by aregistered nurse or locked away in a cupboard. Medicinesseen during the inspection were found to be in date. Theoutpatient department did not keep any controlled drugsand did not have any patient group directives in place.Prescription pads were stored securely.

Outpatients

Outpatients

Good –––


There was a pharmacy department with dedicatedpharmacy staff available within the outpatientdepartment where support and advice could be sought.There was a management of medicines policy availableto staff which had a review date of October 2019, howeverthe document stated it had been extended for six monthswhilst it was under review. This policy had a section onantibiotic prescribing and the principles of stewardship.There were antibiotic prescribing guidelines with a reviewdate of February 2020.

Medicines refrigerator checks were completed asrequired in the temperature logs we saw.

Incidents



There had been no never events or serious incidentsacross outpatients in the previous 12 months.

The department staff had access to an electronic incidentreporting system in outpatients and staff we spoke withwere aware of this system and could describe how theywould report an incident.


Leaders told us there had not been many incidents in theprevious 12 months across outpatients but where therehad been an incident this would be shared at themonthly team meetings with the team. Team meetingminutes showed incidents were part of the monthlyagenda.

The hospital provided information highlighting incidentswhere there had been learning from the incidentsidentified and how this learning from incidents had beencompleted.

They had added the outpatient department to theincident reporting system in April 2019. The hospitalprovided a document with the incidents which hadoccurred in the previous eight months and each incidentreported stated ‘no harm caused’.


Are outpatients services caring?

Good –––


Compassionate care

Staff treated patients with compassion andkindness, respected their privacy and dignity, andtook account of their individual needs.

Overall, patient feedback regarding the care they receivedwas positive. Patients felt involved in the care andtreatment they received. The hospital provided thefriends and family test results from November 2019 whichshowed 81% of respondents were extremely likely torecommend the hospital and 15% of respondents werelikely to recommend the hospital.

Where required the service had implemented patientsatisfaction survey action plans, for example for quarterthree in 2019. This included information, for example ofthe actions required and the date it was due to becompleted.

Outpatients

Outpatients

Good –––


Privacy and dignity was maintained in the outpatientreception area as patients did not wait for appointmentsin this area and therefore this reduced the risk of beingoverheard whilst speaking with reception staff in theoutpatient corridor.

Staff maintained patient privacy and dignity by ensuringconsulting and treatment room doors were closed andwhere required there were curtains available in therooms. Patients told us their privacy and dignity wasmaintained during their visit.

Staff told us chaperones were available and provided asnecessary across the outpatient department. There was achaperone policy available for reference which could beused by staff. There were also chaperone posters advisingpatients about chaperones displayed in various areas ofthe outpatient department. Staff had access to achaperone guidelines document which had a review dateof August 2022.

The mandatory training document for the outpatientservice showed 100% of staff in outpatients hadcompleted compassion in practice training.

Emotional support

Staff provided emotional support to patients,families and carers to minimise their distress. Theyunderstood patients’ personal, cultural and religiousneeds.

The outpatient department had access to a quiet roomnear the reception area which patients could use. Thisroom had seating available and the department managertold us the room could also be used for patients who maybe anxious or for vulnerable patients. The quiet room hadfacilities for patients with dementia and also facilities forpeople of different faiths.

There were nursing staff with additional knowledge andskills who could provide further support and advice. Forexample, there was a lead nurse for oncology workingacross the outpatient department. The oncology servicelinked with some external groups to provide additionalsupport and advice to patients.

The oncology team had set up support groups forpatients, for example the service provided informationstating they had set up a breast support group forpatients.

Staff we spoke with understood how to support patientsattending who may need additional support, forexample, patients living with dementia or vulnerablepatients.

Understanding and involvement of patients andthose close to them


During the inspection, patients told us they were involvedin decisions about their care and treatment. Staff wereapproachable, and we saw some staff introducingthemselves to patients and visitors.

Patients we spoke with told us staff involved patients andthose close to them and there was opportunity to askquestions. Patients were provided with patientinformation leaflets as required.

There was a patient satisfaction poster in the hospitaland outpatient waiting area which stated 96% ofrespondents highlighted that staff understood theirneeds.

Letters were provided and communicated to the generalpractitioners as required.

To assist in communication with patients there werepicture cards which could be used.

Are outpatients services responsive?

Good –––



The service planned and provided care in a way thatmet the needs of local people and the communitiesserved. It also worked with others in the widersystem and local organisations to plan care.

For our main findings please refer to the surgery report.

Outpatients offered a variety of services and clinics. Theoutpatient’s leadership team worked together to deliver

Outpatients

Outpatients

Good –––


the services to patients. Leaders across the servicesworked with other internal and external teams to manageservices, for example some teams met with directoratemanagers within local NHS trusts to plan and deliverservices. Leaders utilised business cases as required todevelop the services provided. Leaders told us qualityand safety was considered as part of business cases.

Leaders worked with local healthcare providers whererequired to deliver services to patients.

The services received referrals from local NHS healthcareproviders and we were told there were agreements inplace for these services.

Services were provided to adults and children inoutpatients, however we were told there were not manychildren seen across outpatients. Of the total numberappointments in outpatients, 0.5% of appointments werefor patients under the age of 18. There were 12 clinicrooms which were mainly consulting rooms, althoughthere were treatment rooms available. There was aphlebotomy department available. There was also aphysiotherapy department with a gym.

The hospital had introduced one stop breast clinics.These clinics enabled patients to attend to visit a doctorand a mammogram or ultrasound could be performedalong with results. Where needed a biopsy could be done.

The oncology clinic had a counselling area available forpatients.

There were evening and weekend appointmentsavailable in outpatients to provide flexibility to patientsattending for appointments. Choice of appointmenttimes were available when patients were bookingappointments. The service provided information statingwhere a patient required an urgent appointmentfollowing a consultation they would try to do this at thesame time, for example scans.

The ‘did not attend’ rate in September 2019 was 1.93%,was 1.72% in October 2019 and 2.08% in November 2019.The hospital provided information stating that in theprevious six months to the inspection there had been28,294 outpatient bookings and 453 ‘did not attends’which was 1.6%. To assist in addressing the ‘did notattend’ rate, the service had introduced text messagereminders for appointments. The hospital providedfurther information stating ‘did not attends’ were logged

as an incident on the electronic systems and that theprocess regarding management of DNA’s includedattempting to contact patients and offering theopportunity to rebook the appointment.

The hospital provided the clinic utilisation rates foroutpatients. This showed that between June 2019 andNovember 2019 the clinic utilisation rate varied between46% and 59%.

Parking was available on site, however some patientfeedback indicated finding a parking space could bechallenging.


The service was inclusive and took account ofpatients’ individual needs and preferences. Staffmade reasonable adjustments to help patientsaccess services. They coordinated care with otherservices and providers.


The service had access to translation services.

There was a quiet room available in the departmentwhich could be used for patients who may be anxious orwhere patients preferred a quieter environment.Appointment times varied depending on the clinic andthe treatment or consultation, although in general a firstappoint was around 20 minutes and a follow upappointment around 10 minutes. Where appointmentswere delayed, staff informed patients of the delay.

There were staff who had completed training for patientsliving with dementia and the service would makereasonable arrangements as required for patients. Staffhad access to a dementia champion who was availablefor advice and support.

There were a range of patient information leafletsavailable throughout the department.

Access and flow


Outpatients

Outpatients

Good –––


There were various specialties which operated fromoutpatients, for example, orthopaedic surgery, generalsurgery and ear, nose and throat. 33.7% of all outpatientswere from the general surgery speciality.

Waiting lists and appointments were managed by threeteams across the hospital, the National Health Service(NHS) appointments team, the self-pay team and theteam which dealt with insured customers.

Waiting lists for National Health Service patients weremanaged by a team in the hospital. We were told patientswere not lost to follow up because all patients werebooked onto the system with appointments unless theyrequired an appointment at a date later in the future inwhich the referrals were kept in a folder which wasreviewed daily by an administrative member of the team.

During the inspection, we were told there were only 15patients waiting to be booked into an appointment andthese were only waiting because the appointments werenot due for a long period but were monitored daily by theNHS appointments team. Where there was anappointment slot issue on the e-referral system the teamwould contact the general practitioner and ask them torebook the patient onto the appropriate appointmentslot to resolve the issue.

The hospital provided the referral to treatment times forNational Health Service (NHS) patients, self-fundedpatients and insured patients. This information showedwaiting times for NHS patients for first and follow uppatients across all specialities were between 14 and 21days. Waiting times for first and follow up appointmentsfor insured patients and self-funded patients was twodays. The report showed that waiting times for urgentappointments for NHS patients, self-funded patients andinsured patients were within targets.

The service was not commissioned to provide cancerservices for NHS patients, this service was only availableto private patients. For insured and self-funded patients,the report stated waiting times for cancer appointmentswould be one to two days. The hospital providedinformation stating when a appointment for urgentcancer appointments was requested, the call handlerprioritised the booking and informed the medical staff.

Referral to treatment waiting lists for NHS patients wasten weeks for the specialties and 7 to 14 days for insuredand self-funded patients.

The NHS appointments team in the hospital managedreferrals from five specialities and e-referrals could beused by patients to book their appointments. We weretold there were no backlogs with waiting lists and theaverage time from referral to treatment across all fivespecialties was around 10 weeks. Where a patient hadreceived an appointment but had received diagnostictests elsewhere the hospital would try and request thetests through the electronic system to ensure the patientwas seen promptly. Referrals were received and dealtwith daily by the team. The longest follow upappointment times were for rheumatology which werearound four weeks. We were told there would not usuallybe a wait for a follow up appointment of more than fourweeks.

The 18-week breach rate was around 3% every quarterand we were told the only reason a patient would breachthe 18 weeks wait if it was patient choice. We were toldthat where a patient required an appointment, the doctorwould request the follow up appointment date and thisdate could be requested without delay in appointments.

During the inspection we were told there were notwaiting lists for other appointments, for example fromself-pay patients and were told that when anappointment was requested the service could providethat appointment for the date when it was required aslong as the doctor and speciality had a clinic running.This was the case for new and follow up appointments.

When a follow up appointment was required, the patientswould book this on their way out of the clinic with thereception team to ensure they received an appointmentas required. A choice of appointments was available topatients.

The department had completed an audit for patientwaiting times in the clinics. This was completed between31 August 2019 and 6 September 2019. The auditconsidered 371 appointments in outpatients and found68% of these were called to their appointment on timewith 32% being called to their appointment later thantheir scheduled appointment time. The average delay totheir appointment time was 16 minutes and on oneoccasion the delayed appointment was around 60minutes. The service had produced an action planfollowing this audit which included four actions. Three ofthe actions were documented as completed and oneaction was ongoing. The July 2019 patient survey for

Outpatients

Outpatients

Good –––


outpatients showed that between February 2019 and July2019 the percentage of appointments being on time inthe hospital was between 60% and 77%. During ourinspection, appointment and clinics were generally ontime, however there were limited instances where theclinics were running later. Staff informed patients of thedelay when this occurred.

There had been cancelled appointments in the previousmonths, however we did not see any action being takento address cancelled appointments during theinspection. We requested the number of cancelled clinicsand this showed there had been 87 cancelled clinicsbetween June 2019 and November 2019 within six weekswhich was low at only 0.40% of appointments. Thehospital stated a proportion of these clinics had nopatients booked into them and were therefore cancelled.Where possible staff called patients to notify them of thecancelled appointment and the leaders of thedepartment monitored cancelled appointments andclinics.

The hospital provided a document for onward referralswhich detailed information on referrals from the services,for example this document highlighted clinic letters weretyped and sent to the general practitioner with a copyprovided to patients.


It was easy for people to give feedback and raiseconcerns about care received. The service treatedconcerns and complaints seriously, investigatedthem and shared lessons learned with all staff.

There were posters on display in the department advisingpatients and visitors on how to complain to the service.Leaders told us they attempted to address complaintsinformally if appropriate, however encouraged patientsand visitors to complain formally if they were unsatisfiedwith the service and it could not be dealt with informally.The outpatient department kept a log of informalcomplaints to enable the leaders to identify trends andstill deal with complaints when they were not formallyprovided to the hospital. The hospital provided examplesof learning, which included for example where an ad hocclinic had been established to improve patients beingseen in a timely manner.

Complaints could be raised with the hospital throughemail and there was a section on the website regardingcomplaints.

Staff and leaders had access to a complaints policy. Thishad a review date of September 2021.

Where complaints were received they were investigatedby the leaders of the department and we were told wherethere was learning from complaints available, this wouldbe shared at the team meetings or the daily huddles.Team meeting information was also provided to staff whocould not attend. The clinical governance quarter two2019 report highlighted that learning from complaintswould be cascaded to relevant departments throughdepartmental leads at team meetings and minutes. Thisreport also highlighted learning from complaints throughthe incident and complaints learning outcomesnewsletter, clinical governance quarterly newsletters andsafety brief and team lead events.

The hospital provided a complaints log for complaintsbetween January 2019 and June 2019. This showed onecomplaint for outpatients and included the actions taken.

Are outpatients services well-led?

Good –––


Leadership

Leaders understood and managed the priorities andissues the service faced. They were visible andapproachable in the service for patients and staff.They supported staff to develop their skills and takeon more senior roles.

The hospital had a management structure whichincluded a hospital director and director of clinicalservices. Managers in the outpatient departmentreported to the director of clinical services, however wewere told they could also contact the hospital director ifrequired. There was a clear management structure in theoutpatient department. There was an overall departmentmanager which two senior registered nurses reported toand the registered nurses and healthcare assistants

Outpatients

Outpatients

Good –––


reported to the senior nurses. We were told there was aregistered nurse on duty each day in outpatients. Theservice had access to a maintenance team at the hospitalwho we were told were accessible and available.

The hospital had a meetings organisational chart for 2019which showed there were meetings across the hospital,for example a complaints meeting, risk committee,infection prevention meeting, clinical governancecommittee and the hospital leadership meeting. Theoutpatient department had a morning huddle where theydiscussed staffing and the service tried to have a monthlyteam meeting where they discussed any outpatientissues and information from the hospital wascommunicated to the team.

The hospital leadership team meeting from July 2019included pathology and outpatients as an agenda item.

Leaders understood the challenges faced by thedepartment and could describe these along with the risksassociated with the risk register.

Feedback regarding leadership in the hospital waspositive and we were told leaders were visible andapproachable. We were told leaders had an open-doorpolicy and could be contacted as required by staff.

During the day in outpatients, there was a registerednurse in charge supported by the outpatients anddiagnostic imaging manager.

Vision and strategy

The service had a vision for what it wanted toachieve and a strategy to turn it into action,developed with all relevant stakeholders. The visionand strategy were focused on sustainability ofservices and aligned to local plans within the widerhealth economy. Leaders and staff understood andknew how to apply them and monitor progress.

The hospital had a vision which was to be recognised as aworld class healthcare business and the hospital had aset of values which included driving clinical excellence,doing the right thing, caring is our passion, keeping itsimple, delivering on our promises and succeeding andcelebrating together. There was a hospital managementstructure in place.

There was a documented hospital strategy for 2019 whichincluded points such as ‘develop and involve our staff in

decision making with clear communication processes’.This also included information from the variousdepartments such as outpatients and inpatient bookings.The section for outpatients and oncology highlighted apoint regarding ‘work closely with the administrationteam in order to ensure room utilisation is efficient’. Thegovernance section of the strategy 2019 highlighted theyservice wanted to ‘ensure all investigations and RCA’s arecompleted within the agreed timescale of 45 days. Thestrategy also included pathology and physiotherapy.

We asked senior managers across the service about thevision and strategy and were told this was aligned withthe overall hospital and Spire strategy.

Staff had been involved in the development of thestrategy of the hospital and service which involved staffattending an event which assisted in the development ofthe strategy.

The hospital provided information stating they hadrecently introduced a new Spire purpose which wascompleted using workshops with staff.

Culture

Staff felt respected, supported and valued. Theywere focused on the needs of patients receivingcare. The service promoted equality and diversity indaily work, and provided opportunities for careerdevelopment. The service had an open culturewhere patients, their families and staff could raiseconcerns without fear.

Overall, morale across the department was good. Stafffelt supported, respected and valued by the hospital anddescribed good teamwork across the services. We weretold there was openness and honesty. There were regularstaff meetings to share information and discuss issues orchallenges.

Staff and leaders, we spoke with could describe the dutyof candour.

There was a poster called ‘Have your voice heard’ whichhighlighted ways to have your voice heard and referencedthe freedom to speak up guardian and thewhistleblowing policy. There was a hospital freedom tospeak up guardian.

The hospital provided information stating staff hadaccess to an assistance line for staff wellbeing.

Outpatients

Outpatients

Good –––


Governance


Leaders we spoke with could describe the governancearrangements for the department which included dailymeetings and a hospital wide weekly governancemeeting. Leaders could describe the ward to boardgovernance arrangements and were told incidents werereported via the incident reporting form and staff wouldspeak with managers. Where there was a serious incident,this would be discussed with the senior leadership team.Risks and governance issues were also discussed at thedaily meetings which included any issues from theprevious day. Each week incidents were discussed at theweekly clinical governance meeting. There was also aweekly meeting which senior managers such as thehospital director and director of clinical services attendedand included representatives from the medical advisorycommittee.

The clinical governance meeting from December 2019showed for example, agenda items such as clinicaleffectiveness, clinical audit and matters to escalate to theclinical governance committee or senior managementteam.

Incidents across the service were sent to the departmentmanager for initial investigation. The clinical governancelead also had oversight of incidents.

Leaders told us their assurance around patient safetycame from the daily huddles which for example includeditems such as safe staffing and how many patients wereattending. We were told leaders asked staff if they hadany concerns on the day. The clinical scorecard was alsoused to assist in providing assurance to departmentleaders and the leadership team.

There was an annual plan for governance andimprovement for 2019. This included information such asimproving the audit structure, continuing to build andpromote a prominent safety culture and utilising nationaldocuments on patient safety to improve the quality ofcare.

The clinical governance and audit committee meetingminutes from July 2019 included information such asNational institute for Health and Care Excellenceguidance to review, the clinical scorecard, mandatorytraining and audits.

The service had produced a quarterly clinical governancereport, we saw the quarter two 2019 report. Thisdocumented the priorities and challenges across theservices, adverse events, safeguarding, safe staffing,clinical scorecard information, patient satisfaction surveyand complaints.

There was a medical advisory committee which leaderstold us they had good links with and the hospitalprovided information stating they provided medicaladvice and support to the hospital.

We were told the oncology service had service levelagreements with local healthcare providers.


Leaders and teams used systems to manageperformance effectively. They identified andescalated relevant risks and issues and identifiedactions to reduce their impact.

There was a risk management policy available to staffwhich had a review date of July 2021. The policy includedvarious sections, for example on the process formanaging risk and the risk register.

The service utilised risk registers to assist in managingand monitoring risks across the service. The hospital hada hospital wide risk register which included risks forexample from pathology and oncology. This risk registerhad a key controls and actions section.

Leaders used performance reports and information tomonitor and manage the risks, issues and performanceacross outpatients’ services.

Leaders attended a daily meeting which was in place toensure the departments could plan for the days work andensure staff were aware of any safety information.

The hospital provided information showing there wereservice level agreements in place with other providers asrequired and this document showed what the servicelevel agreements were for and whether they were in dateand valid.

Outpatients

Outpatients

Good –––


The outpatient staff meeting minutes from October 2019showed for example, agenda items such as the riskregister update, mandatory training update, complaintsand lessons learned. The outpatient managers meetingfrom November 2019 showed for example, agenda itemssuch as incidents, competencies, issues and the monthlysafety brief.

There was a business continuity document with a reviewdate of July 2022.


The service collected reliable data and analysed it.Staff could find the data they needed, in easilyaccessible formats, to understand performance,make decisions and improvements. The informationsystems were integrated and secure.

Staff had access to the required information systems.Staff could access the intranet for information and newsabout the hospital. Policies and procedures wereavailable on the hospital intranet and there were foldersavailable in the department with relevant policies andprocedures available for staff to access. Staff had accessto an information technology team for support asrequired.

Leaders had access to performance reports and there wasperformance and risk information on display in staffareas. These enabled staff to understand the risk acrossthe services along with being able to access relevantinformation and news about the various departments.

Information systems were used across the department toprovide care and treatment to patients. There was alsoaccess to information systems to enable risk to bemanaged such as the incident reporting system.

There was information on display regarding theaccessible information standard in the hospital.

Leaders in outpatients told us there had been no recentinformation governance breaches.

Engagement

Leaders and staff actively and openly engaged withpatients, staff, and local organisations to plan andmanage services. They collaborated with partnerorganisations to help improve services for patients.

The service utilised friends and family tests to gatherfeedback and enable improvements to be made ifrequired.

There was an annual staff survey to enable staff toprovide feedback to the leadership team. Leaders told usthis had improved on the previous year and there wereno areas of significant concern. The hospital producedstaff and consultant newsletters, held monthly staffforums and staff told us there were monthly teammeetings across the outpatient department.

The service provided further information stating theyproduced three clinical newsletters which included amonthly safety update, monthly lessons learnt and aninfection prevention newsletter. The hospital had awardsfor staff which contributed to staff engagement.

The service provided information stating they hadengaged with external groups and planned to provide atalk to promote the services offered at the hospital.

The main waiting area had a board which highlighted thesenior management team at the hospital.


All staff were committed to continually learning andimproving services.

The department had implemented a safe staffing tool toensure the appropriate number of staff were on duty asrequired throughout the day in outpatients.

The oncology team in outpatients had a long establishedbreast cancer support group in the service which metmonthly. This included for example, holistic therapysessions.

The services shared risk and governance information onnotice boards in the various departments for staff to view.

There were plans to introduce a patient experience leadin 2020 to contribute to the hospital patient experiencework.

Outpatients

Outpatients

Good –––


Safe Good –––

Effective




Are diagnostic imaging services safe?

Good –––

We previously inspected diagnostic imaging jointly withoutpatients, so we cannot compare our new ratingsdirectly with previous ratings.

We rated it as good.

Mandatory training


The hospital set a target of 95% for mandatory training forstaff. The information provided by the service showed thecompliance for diagnostic imaging across all mandatorytraining modules was 95% or above for all modulesexcept one where compliance was 90%. The date forremaining staff to complete the training was March 2020.

Staff received and kept up to date with their mandatorytraining. Mandatory training was provided as a mixture ofe-learning and face to face training depending on thetraining course. Where staff were not up to date withtraining, leaders told us they were booked on to completethe training. Training compliance records, for example theresuscitation training log highlighted staff were bookedon to complete training.

The department management maintained oversight ofmandatory training compliance and leaders had accessto electronic systems which enabled them to monitortraining compliance levels across the services.

The mandatory training included training modules suchas safeguarding, information governance and infectioncontrol amongst other modules.

Safeguarding


The hospital had safeguarding policies in place whichstaff could access.

The hospital had safeguarding leads in place and thesewere the clinical governance lead and a leadphysiotherapist for children and young persons. Thesestaff were available for support and advice and we weretold these staff were trained to level four safeguarding.We saw safeguarding training compliance levels whichshowed the different levels of safeguarding staff weretrained to. The level four safeguarding training wasprovided at another Spire site.

Staff we spoke with could describe the action they wouldtake if they had safeguarding concerns for adults orchildren. Safeguarding posters were on display in thedepartment.

Staff could describe using the ‘pause and check’ checklistwhich we were told had been adapted to include thethree-point identification checks. The three-pointidentification check included name, date of birth andaddress. We saw evidence of the three-point checks inrecords seen. The ‘paused and check’ checklist was ondisplay in departments during the inspection. The‘paused and check’ poster is a clinical imaging operator

Diagnosticimaging

Diagnostic imaging

Good –––


checklist used in radiology departments for procedures.The pause part of the checklist indicates patient,anatomy, user checks, systems and settings checks,exposure and draw to a close.

We requested compliance levels for safeguarding adultsand children split by the safeguarding level. The hospitalprovided information on safeguarding trainingcompliance as at 17 December 2019.

Compliance with safeguarding adults and children leveltwo was 97% and safeguarding children level three was70% and adults 100%. This showed that fourteen staffhad completed level three safeguarding children trainingand one staff member was trained to level threesafeguarding adults.



Areas visited were visibly clean and tidy. During theinspection we saw staff adhering to ‘bare arms below theelbow’ and also saw posters on display regarding this invarious areas. Hand sanitiser was available and therewere hand washing sinks available in the areas visited.Personal protective equipment was available in thedepartment, for example gloves and aprons.

Staff told us ultrasound probes were cleaned after eachpatient with specialist cleaning wipes. Scanning bedswere wiped down after each patient as needed and a newpaper cover was put on the scanner bed.


Information provided by the provider highlighted therehad been no infections in diagnostic imaging and stafftold us if there was an infection, a root cause analysiswould be completed along with an incident form. Stafftold us patients with a communicable disease would beallocated to the end of a clinic list and there would be adeep clean afterwards as required.

There was daily cleaning in the radiology department andwaste disposal available for various types of waste acrossthe radiology services. We found cleaning logs had beencompleted as required across diagnostic imaging. Wesaw ‘I am clean’ stickers in use across the department.

Staff had access to an infection prevention and controlpolicy which had a review date of February 2022. Therewas also a management of MRSA policy which had areview date of April 2020. The meeting document fromJuly 2019 for the infection prevention committeeincluded agenda items for example, such asantimicrobial stewardship and management of risks.

The departments completed hand hygiene audits on theenvironment, observation and technique. The handhygiene audit showed 100% compliance across radiologyservices.



The diagnostic imaging department was located along acorridor next to the outpatient corridor. There was areception area where patients could check in and speakwith reception staff and there was a waiting area withseating available. This waiting area had a television,water dispenser and information for patients on display.There was changing facilities available in the departmentfor patients to use when they were having scans.

Patients checked in at the main hospital reception andwould be directed to the diagnostic imaging department.Toilets were available in the department.

The various departments within the diagnostic imagingunit had relevant warning signage on display to highlightrestricted areas to staff, patients and visitors. The x-rayareas had lights warning of x-rays. There was also warningsignage such as ‘authorised persons only’ on display.

There were three reporting rooms available in thedepartment for staff to report scans.

There was also a quiet room available for patient andvisitor use in the waiting area. There was a children’s andyoung person’s activity area in the main waiting areawhich had small tables and chairs alongside books.

Diagnosticimaging

Diagnostic imaging

Good –––



The department had a resuscitation trolley available foruse. We checked recent dates for these and these werechecked as required. The resuscitation trolleys werechecked daily and the trolleys were secured.

There was signage directing staff and visitors to thevarious parts of the department. Wheelchairs wereavailable for patient use across the department.

Staff had access to personal protective equipment suchas lead aprons. These were available in each of theimaging rooms. There was enough equipment for staff touse and computers were available in the department.The hospital had a maintenance team which staff couldcontact if required. There was access to an informationtechnology team for advice and support as required.

We visited the magnetic resonance imaging unit (MRI)and found equipment was MR compatible and staff toldus they did not remove the equipment or bring otherequipment into the MRI room. For example, there was anMR safe wheelchair and MR safe trolley in the room andthere was equipment with MR safe stickers attached.

The MRI unit had warning signage on display to highlightthe risks to staff and patients. Patients had to complete asafety questionnaire before they could enter the MRI unitwith staff.

Equipment such as lead aprons had annual audits tocheck for the lead apron integrity. Staff wore dosimeterswhere applicable to monitor exposure to radiation. Therewas a daily huddle board on display in the departmentand the dosimeter information was put on this board toinform the staff whether there were any issues or not.

The services took part in the patient led assessments ofthe care environment (PLACE) audits and the report from2019 included radiology. The report showed all relevantquestions for the cleanliness part of the audit hadpassed. The patient led assessment of the careenvironment (PLACE) report for radiology showed 99.09%compliance for cleanliness and 97.62% for condition,appearance and maintenance.

There was a document on display in the staff office forequipment which showed the equipment available andthe servicing dates.

There were consumable expiry date check logs on displayin the department and the logs seen were completed asrequired.

There was a maintenance and planned preventativemaintenance schedule for equipment in the diagnosticimaging department. This showed the equipment whichhad been serviced, the number of services and the dates.This ensured the management team in the diagnosticimaging department had oversight of plannedpreventative maintenance for equipment.



The department had access to an external medicalphysics expert, radiation protection expert and thedepartment had two radiation protection supervisors foradvice. The radiation protection supervisors workedacross magnetic resonance imaging (MRI) and computedtomography (CT). Staff told us they had access to aradiologist for advice as needed.

Where patients were clinically unwell or deteriorated inthe department, staff would call the hospitalresuscitation team and had access to a resuscitationtrolley. The resuscitation equipment was checkedregularly and records confirmed it had been checkeddaily as required. Where a patient was clinically unwell ordeteriorated in the MR imaging room, staff would transferthe patients to a trolley and remove the patient from theroom. There was an emergency protocol in place toremove the patient from the scanner if required.

The service had local rules in place for staff to follow fortheir speciality area. These were on display in the variousareas of the department. Patients attending the MRdepartment had to complete a safety form prior toentering the scanning area. Staff could describe thecritical care pathways for patients and there was aresident medical officer available on site for advice asneeded.

The World Health Organisation (WHO) checklist was usedfor invasive procedures, for example injections. Duringthe inspection, we saw one of these safety checklistscompleted as required in the department.

Diagnosticimaging

Diagnostic imaging

Good –––


Staff in the department wore dosimeters and these werechanged every two months. These were worn to monitorthe staff exposure to radiation in the department.

Staff told us patients receiving contrast in the CTdepartment stayed in the department for around 30minutes after the procedure for safety precautions. Staffcompleted basic life support training as part ofmandatory training.

There were diagnostic reference levels on display in thevarious areas of the department. There was a procedurein the reporting room for significant findings on scans.

The safety forms used in the MRI department includedquestions, for example regarding pregnancy. This formwas completed prior to patients going in for a scan andthese were then scanned onto the electronic system forrecord keeping.

Staff used the ‘paused and check’ checklist in thedepartment to check the correct patient was receivingthe correct scan. We were told this was audited and wesaw audits completed by the service and the recentresults had been positive. A previous month had notshown 100% compliance and the department leadershad put actions in place to address this and checked thedocuments for a week to ensure staff were completingthe checks.

Risk assessments had been completed for various risksacross the department. For example, there was an IRR17radiation hazard and risk assessment for the generalradiology room fluoroscopy. Fluoroscopy is a type ofimaging which uses x-rays. This detailed who assessedthe hazard, detailed a brief description of the workundertaken, list of existing documented control measuresand the recording of any identified actions. The lastreview date was August 2018 with a three-yearly reviewscheduled.

Lead apron audits were completed annually to check forthe lead apron integrity and there was a list available forstaff detailing the ongoing lead apron audits. Leaders toldus they would replace the aprons where issues wereidentified during the audits.

Leaders told us staff would receive a debrief whererequired if there had been an incident in the department.There were patient emergency buttons in the scanning

rooms. There were anaphylactic packs in the department.These packs were sealed and in date. For example, thepack contained adrenaline. These packs were providedby the pharmacy department.

Where appropriate, we were told the service would tryand access previous images and if possible andappropriate, the service would try and use these.

There was a local MRI safety policy with a review date ofJanuary 2023. There was also a radiation safety policywhich had a review date of June 2021.

There were posters on display in the departmentregarding ‘How safe are x-rays’.

There was a resident medical officer on site at thehospital.

Diagnostic Imaging staffing

The service had enough staff with the rightqualifications, skills, training and experience tokeep patients safe from avoidable harm and toprovide the right care and treatment. Managersregularly reviewed and adjusted staffing levels andskill mix, and gave bank and agency staff a fullinduction.

Leaders told us there were no concerns with staffinglevels in the diagnostic imaging department and thedepartment had only one vacancy which they wererecruiting to. This was for a whole-time equivalentradiographer. There were five radiographers in thedepartment. There was one assistant practitioner andhealthcare assistant in the department.

Staffing rotas were planned seven days in advance andtook into account the type and number of imagingservices the department had. Rotas were on display inthe staff offices. Staff worked on shifts between 08:30 and20:00 Monday to Friday and there was on-call for out ofhours. Staff in the MRI and CT department were trained inboth areas so there was additional flexibility in the servicewhere required.

Staffing was displayed on the notice board in thedepartment. On the day of the inspection, the plannedstaffing level was for four staff in diagnostic imaging andthe actual documented on the notice board was fourstaff.

Diagnosticimaging

Diagnostic imaging

Good –––


The department manager or a representative attendedthe hospital multidisciplinary team huddle each morningwhere safe staffing was discussed.



Medical staffing


Medical staff worked at the hospital under practisingprivileges and worked in the diagnostic imagingdepartment as required or as planned with the managersin the department. The granting of practising privileges isa well-established process within independenthealthcare whereby a medical practitioner is grantedpermission to work in an independent hospital or clinic,in independent private practice or within the provision ofcommunity services.

Leaders told us there were no concerns with availabilityof Radiologists and where required they would recruitand that as a contingency and if required, thedepartment could contact other Spire hospitalselsewhere for assistance in remote reporting. Theradiologists were not always on site but were accessibleand available for advice and support. The radiologistshad set sessions and times for attending the department.

Records


Records were kept electronically, and scans wereavailable electronically after the scan was complete.There was electronic access to scans and results acrossthe hospital. Where paper safety checklists were used,these were scanned onto the system. Records werestored securely at the time of the inspection.

We reviewed fifteen records during the inspection andfound these to be mostly completed as required. For

example, we saw evidence of identification checks andpatient information included. Although we did see fourrecords which did not have all the checks documented.We raised this with managers at the inspection and theywere going to address it.

Managers also showed us recent referral proforma reviewaudit results which showed between January and March2019 there were two records without documentedpregnancy checks out of twenty sets of records audited.The audit between April and June 2019 showed 100%compliance of the same checks. Between October andDecember 2019/2020, the audit results showed 100%compliance for checking whether a person may bepregnant or not.

There was evidence of multidisciplinary team working inthe records. MRI safety forms we saw were completed asrequired.

The hospital provided further information on theprocesses which assisted in managing the risk if a patientwas to attend and the records were not available. Thehospital stated the administration manager reported tothe daily huddle if there were any records unavailable forpatients attending that day and that actions would betaken by staff to locate the records in time for the patientattending the hospital.


Medicines


For our detailed findings on medicines please see theSafe section in the surgery report

Medicines seen during the inspection were storedsecurely and the medicine cupboard keys were kept by aregistered professional or locked away in a cupboard.Medicines seen during the inspection were found to be indate. The department did not keep any controlled drugsor prescription pads.

We looked at patient group directions (legal frameworkwhich allows registered health professionals to supply

Diagnosticimaging

Diagnostic imaging

Good –––


and/or administer specified medicines to a pre-definedgroup of patients without them having to see aprescriber) used in the department and found all to be indate and signed by the appropriate individuals.

Refrigerator checks were found to have been completeddaily as required. The rooms had consumable andmedicine expiry checklists on display and the ones wesaw were completed as required.

There was a pharmacy department with dedicatedpharmacy staff available where support and advice couldbe sought. There was a management of medicines policyavailable to staff which had a review date of October2019, however the document stated it had been extendedfor six months whilst it was under review.

Incidents



There had been no never events or serious incidentsacross diagnostic imaging in the previous 12 months.There had been two IRMER incidents in the department,although staff had contacted the radiation protectionadvisor, and these had not been reportable incidents tothe Care Quality Commission. Staff had completedreflective practice from these incidents and leaders hadshared the lessons learnt from these incidents at theNovember 2019 team meeting. These were documentedin the team meeting minutes so staff who were not inattendance could read them.

We saw an example of the actions and learningdocument from an incident which showed the actionrequired, outcome measure, who was leading on theaction and the date due to be completed. This confirmedthe actions had been completed in November 2019.

The department had not reported any IRMERnotifications to the Care Quality Commission in theprevious 12 months. There was an IRMER incident log ondisplay in the manager’s office.

The department staff had access to an electronic incidentreporting system in diagnostic imaging and staff wespoke with were aware of this system and could describehow they would report an incident. There had been 33incidents in the previous 12 months, of which 25 werereported as no harm, seven reported as low harm andone as moderate harm.



Are diagnostic imaging serviceseffective?

We do not rate effective in diagnostic imaging.


The service provided care and treatment based onnational guidance and evidence-based practice.

Staff followed up to date policies to plan and deliver highquality care according to best practice and nationalguidance. Policies and procedures were available andaccessible through the hospital systems. Policies viewedas part of our inspection were found to be in date. Staff inthe service had access to policies such as incidentreporting, mental capacity act and deprivation of libertysafeguards and the chaperone policy amongst others.

There was a folder which included examples of the royalcollege of radiologists guidance, for example thestandards for intravascular contrast administration toadult patients.

Diagnosticimaging

Diagnostic imaging

Good –––


Diagnostic reference levels (DRL) were used in thedepartment and these were on display in areas visited.These were not audited annually, although thedepartment did have a book in which any issues withdiagnostic reference levels would be logged for reference.

Information provided by the hospital highlighted it usedvarious tools to monitor and benchmark the servicesagainst other providers, for example the national clinicalscorecard.

The services across the hospital had access to an annualaudit programme 2019 which highlighted the variousaudits that were completed by the services, for examplethe records audits. The quality audit schedule which wasdisplayed in the manager’s office and showed audits suchas hand hygiene and infection prevention werecompleted.

Information provided by the hospital highlighted theservices followed the Spire care pathways which hadbeen developed for the specialties and aligned to bestpractice and guidelines.


There was drinks available for patients attending thedepartment. Staff told us they could provide patients withfood and drink if required and for example, if a patientwas a diabetic patient. Leaders told us the hospital hadrecently started to provide hot food until 8pm.

The service provided information stating they could tailormenus to meet the needs of patients dietaryrequirements.

Pain relief

Pain relief was not generally provided in diagnosticimaging, although there were medical staff available onsite for advice if required and where needed the servicecould provide some pain relief.

Patient outcomes

The services at the hospital participated in a number ofaudits.

Leaders told us the medical staff were part of discrepancymeetings at their respective trusts.

Safety checklists were use in the department for invasiveprocedures to contribute to patient safety.

Competent staff


Staff received appraisals which were three times a year.These were overseen and managed by the leaders of thedepartment. Appraisals were an opportunity to discussobjectives for the year. Staff told us there was opportunityfor development and continued professionaldevelopment. Compliance with appraisals was 100%.

Staff had received radiation safety training which hadbeen delivered through a presentation and the serviceprovided three types of course to staff depending on theirrole. For example, there was a presentation for staff whodirectly worked in the department and a presentation forstaff who may work in the department but not all of thetime, for example engineering staff. The training slides forthis routine radiation worker training showed it includedtraining on IRMER 2017 and lessons learnt from theregulators.

Three staff had attended the radiation protectionsupervisors’ course.

There was a video available for staff who do not alwayswork in the MR department for staff to watch regardingMR safety.

Some of the radiographers had attended study days inNovember 2019 for continued professional developmentand some staff had visited MRI departments in otherhospitals to keep up to date with evidence basedpractice.

There was a document for clinical supervision whichreferenced the policy and this document highlighted thatit was available to staff and to contact the peoplehighlighted on the document to arrange clinicalsupervision. The clinical supervision policy had a reviewdate of March 2021.

Staff received an induction programme to the hospitalwhen they started working at the service.

There were competencies which staff were required tocomplete and there were two types of competency, the

Diagnosticimaging

Diagnostic imaging

Good –––


level two competency for new staff and a level threecompetency for staff who had previous experience. Thecompetency packs included mandatory training and theinduction training.

The department had an education lead.


Doctors, nurses and other healthcare professionalsworked together as a team to benefit patients. Theysupported each other to provide good care.


There were radiographers, assistant practitioners,healthcare assistants, radiologists, reception staff andmanagers working collaboratively to meet the needs ofpatients using the diagnostic imaging services.

The department was part of the one-stop breast clinicwhere staff worked together across departments toprovide one-stop services to patients and to reduce thenumber of repeat visits they needed to make to thehospital.

Seven-day services

The department was open Monday to Friday between08:30 and 20:00. The department was also open on aSaturday between 08:30 and 12:30. The department wasclosed on Sundays. Staff were on call when thedepartment was closed for any emergency scans.

A computed tomography (CT) scan service was scheduledevery Thursday but was available for more urgent scansseven days a week.

Health promotion

There were patient information leaflets and posters ondisplay regarding the various specialties across thehospital and diagnostic imaging department.

Consent and Mental Capacity Act

Staff supported patients to make informed decisionsabout their care and treatment. They followednational guidance to gain patients’ consent.

There was a deprivation of liberty safeguards policy witha review date of October 2019, however the policy stated

it was currently under review and the review date hadbeen extended by six months. Staff had access to aconsent to investigation or treatment policy with a reviewdate of September 2021.

Patients told us consent was taken as required in theclinics. Staff could describe gaining verbal consent in thediagnostic imaging department and described takingwritten consent for invasive procedures such as injection.Records seen showed consent forms being signed.

Staff we spoke with understood consent. We sawevidence of consent in the patient notes reviewed.

Are diagnostic imaging services caring?

Good –––



Compassionate care

Staff treated patients with compassion andkindness, respected their privacy and dignity, andtook account of their individual needs.

The reception was in a separate room to the waiting areaso patients could speak with reception staff withoutbeing overhead to contribute to privacy and dignity in thedepartment. The patient led assessment of the careenvironment (PLACE) report for radiology showed 100%compliance for privacy in the assessment.

Chaperones were available in the department and therewere posters on display regarding this in the departmentand the waiting areas.

Privacy and dignity was maintained in the department byensuring doors were closed where required and therewere changing rooms in the department. Staff werediscreet and responsive when caring for patients. Stafftook time to interact with patients and those close tothem in a respectful and considerate way.

We spoke with four patients during our inspection andpatient feedback was positive.

Diagnosticimaging

Diagnostic imaging

Good –––


Results from a patient experience survey from October toDecember in 2019 showed 97% of respondents werelikely to recommend the service. Of the respondents, 95%said the service met or exceeded their expectations.

Emotional support

Staff provided emotional support to patients,families and carers to minimise their distress. Theyunderstood patients’ personal, cultural and religiousneeds.

Staff responded to patients where they may be anxious orclaustrophobic and could offer visits to the departmentbefore appointments to address patient concerns.

Patients told us staff were friendly and caring andpatients received relevant information before theirexamination.

Additional appointment and scanning time could beprovided to patients if additional support and care wasrequired. There was equipment such as items to coverthe eyes of patients if they required this to reduce patientanxiety during their MRI scan.

Understanding and involvement of patients andthose close to them


Staff provided information to patients and explained theprocedures to the patients. Patients told us they knewwho to contact if they had any concerns after theprocedure or scan.

Staff supported patients to make informed decisionsabout their care. Staff communicated with patientsthroughout their treatment and procedures in thedepartment. Where required, patients’ families wereinvolved and could stay with patients during their scans ifrequested and appropriate.

There was information regarding x-ray’s available and ondisplay in the waiting room to provide further informationon x-ray safety to patients.

Patients and their families could give feedback on theservice and their treatment and staff supported them todo this.

The patient experience survey results from November2019 which were completed across the hospital showed75% of appointments were on time, 14% were up to 15minutes late and other appointments were delayed over15 minutes.

Are diagnostic imaging servicesresponsive?

Good –––




The service planned and provided care in a way thatmet the needs of local people and the communitiesserved. It also worked with others in the widersystem and local organisations to plan care.


The diagnostic imaging department provided a variety ofscans to meet the needs of patients. The diagnosticimaging leadership team worked together to deliver theservices to patients. Leaders across the services workedwith other internal and external teams to manageservices, for example some teams met with clinicalcommissioning groups (CCG) to plan and deliver servicesaccording to the needs of the population.

The services received referrals from local NHS healthcareproviders and we were told there were service levelagreements in place for these services. Waiting listinformation showed waiting times were less than sixweeks across all services.

The hospital had introduced one stop breast clinics.These clinics enabled patients to attend to visit a doctorand a mammogram or ultrasound could be performedalong with results. The one stop clinic included thediagnostic imaging department and scans would bereported during the one stop clinics.

Leaders received a monthly report regarding ‘did notattend’ appointments and we were told the service

Diagnosticimaging

Diagnostic imaging

Good –––


monitored these and would contact the patient if they‘did not attend’ appointments. The hospital hadundertaken work for the local NHS which had a ‘did notattend’ rate between August 2019 and January 2020 at8.2%. We saw a ‘did not attend’ action plan whichhighlighted the action taken when a patient ‘did notattend’ their appointment. The administrative teamwould try and contact the patient twice and then send aletter if required. If the patient had been referred fromanother hospital, the team would refer this back to thehospital.

Parking was available on site.


The service was inclusive and took account ofpatients’ individual needs and preferences. Staffmade reasonable adjustments to help patientsaccess services. They coordinated care with otherservices and providers.


The service had access to translation services.Information was on display in various areas of thedepartment in different languages regarding access tointerpreters. There were a range of patient informationleaflets available throughout the department. There wereposters on display asking whether a patient may bepregnant and these were in different languages.

There was a quiet room available in the departmentwhich could be used for patients who may be anxious orwhere patients preferred a quieter environment.Appointment scanning times varied depending on thetype of scan and needs of the patient.

There were staff who had completed online training onhow to care for patients living with dementia. Staff hadaccess to a dementia champion who was available foradvice and support. The service would make reasonablearrangements as required for patients and adjustmentscould be made for patients when referral forms werereceived and reviewed and additional needs wereidentified.

Patients were offered a choice of appointments andprovided with information prior to the examination.

The provider highlighted some imaging equipment had aweight limit, therefore some patients were not suitable

for imaging at the hospital. For patients accessingbariatric services, specialist equipment could be broughtfrom the ward to support the appointment as needed e.g.bariatric chairs.

Access and flow


Request for scans were put in the administration teamprotocol tray. The radiography staff would then processand vet these requests and state the scan and timerequired on the document. During the inspection wewere told, procedures which were ready to be appointedwould be done so and the wait time would generally beless than five days. Appointment times were allocateddepending on what the patient was having done.

We were told all patients had an appointment booked inand no patients were waiting on a list for anappointment. There were procedures where patientswould be required to complete a questionnaire prior tothe appointment being booked and where this wasrequired, the administration team would send the patienta letter asking them to contact the hospital. Once thisquestionnaire was complete the team could book anappointment.

The average number of days from receipt of the requestto the date of the test across all specialties in diagnosticimaging was 8.8 days.

We were told that as long as there was a referral from thepatient’s general practitioner, patients could access thex-ray service the same day or the next day. Informationfrom December 2019 on waiting times showed theaverage number of days from receipt of the request to thedate of the test for an x-ray was 1.5 days.

Waiting times showed the average number of days fromreceipt of the request to the date of the test for an MRIscan was 20 days.

Waiting times showed the average number of days fromreceipt of the request to the date of the test for anultrasound was 20.4 days.

Diagnosticimaging

Diagnostic imaging

Good –––


Waiting times showed the average number of days fromreceipt of the request to the date of the test forfluoroscopy was 2.1 days.

Waiting times showed the average number of days fromreceipt of the request to the date of the test for an CTscan was 7.6 days. This was a scheduled weekly service,not available every day.

Waiting times showed the average number of days fromreceipt of the request to the date of the test for Bariumprocedures was 18.5 days.

The service was meeting the six-week waiting timeindicator and we were told during the inspection allspecialties were within four weeks for waiting times. Theonly time where there would be a wait of over six weekswould be if it was patient choice. Information showedonly 1.6% of patients waited more than 42 days for anappointment.

The service had previously completed an audit of waitingtimes for patients whilst in the department. Leaders toldus this had not highlighted any issues with waiting timeswhen in the department. The audit in ultrasound on the23 July 2019 showed the longest wait when in thedepartment was ten minutes. In fluoroscopy, MRI and CT,the longest wait was 20 minutes.

We asked about waiting times for patients for reportingand were told the radiologists had specific times theycame in to report on scans and we were told it would notbe longer than five working days for any reporting acrossall specialties in diagnostic imaging. Information we sawfor October 2019 to December 2019 for all proceduresregarding reporting times showed CT scans had anaverage of 1.52 working days for reporting turnaroundtimes, MRI had an average of 1.97 working days forreporting turnaround times and x-ray had an average ofone working day for reporting turnaround times.

The reporting turnaround times audits for October toDecember in 2019 across all areas of the departmentshowed 97% of reporting was done within 5 days of thescan.

Two scanning slots were kept open each day to ensureurgent and priority scans could be accommodated. Wewere told the medical staff would inform the

administration team if the appointment required wasurgent and the team would liaise with the relevant team,for example the MRI team. The urgent slots could be usedfor these urgent and priority referrals.

We were told reporting of scans was based on the priorityand urgency of the report. For example, the systemhighlighted scans that must be reported and categorisedas urgent in orange. There was a document on display inthe reporting room which highlighted the requirement toreport on scans which were categorised as orange.

We were told cancelled scans by the service were rareand did not happen often. Where they did happen, thehospital would contact the patient and reappoint asrequired. Between August 2019 and January 2020, CT hadcancelled 0.5% of their appointments, MRI had cancelled0.7% of their appointments, Ultrasound had cancelled0.3% of their appointments, fluoroscopy had cancelled1.5% of their appointments and x-ray had cancelled 3.8%of their appointments.


It was easy for people to give feedback and raiseconcerns about care received. The service treatedconcerns and complaints seriously, investigatedthem and shared lessons learned with all staff.

There had been three complaints in the previous 12months relating to the diagnostic imaging service.

There were posters on display in the department advisingpatients and visitors on how to complain to the service.Leaders told us they attempted to address complaintsinformally if appropriate, however encouraged patientsand visitors to complain if they were unsatisfied with theservice and it could not be dealt with informally.

Complaints could be raised with the hospital throughemail and there was a section on the website regardingcomplaints. Patients told us they knew how to make acomplaint if required.

Staff and leaders had access to a complaints policy. Thishad a review date of September 2021.

Where complaints were received they were investigatedby the leaders of the department and we were told wherethere was learning from complaints available, this wouldbe shared at the team meetings or the daily huddles.Team meeting information was also provided to staff who

Diagnosticimaging

Diagnostic imaging

Good –––


could not attend. The clinical governance April to June2019 report highlighted that learning from complaintswould be cascaded to relevant departments throughdepartmental leads at team meetings and minutes. Thisreport also highlighted learning from complaints throughthe incident and complaints learning outcomesnewsletter, clinical governance quarterly newsletters andsafety brief and team lead events.

The complaints log detailed the learning outcomes andthe actions taken from the complaints.

Are diagnostic imaging services well-led?

Good –––



Leadership

Leaders had the skills and abilities to run theservice. They understood and managed thepriorities and issues the service faced. They werevisible and approachable in the service for patientsand staff. They supported staff to develop their skillsand take on more senior roles.

The hospital had a management structure whichincluded a hospital director and director of clinicalservices. Managers in the department reported to thedirector of clinical services, however we were told theycould also contact the hospital director if required. Therewas a clear management structure in the diagnosticimaging department. There was a department managerand there were senior radiographers working in thedepartment. The service had access to a maintenanceteam at the hospital who we were told we accessible andavailable.

The hospital had a meetings organisational chart for 2019which showed there were meetings across the hospital,for example a complaints meeting, risk committee,infection prevention meeting, clinical governancecommittee and the hospital leadership meeting. Thediagnostic imaging department had a morning huddle

where they discussed staffing and the service tried tohave a monthly team meeting where they discussed anydiagnostic imaging issues and information from thehospital was communicated to the team.

Diagnostic Imaging was discussed as part of the regularhospital leadership team meetings. For example, thehospital leadership team meeting from July 2019included diagnostic imaging as an agenda item.

Leaders understood the challenges faced by thedepartment and could describe these along with the risksassociated with the risk register.

Leaders utilised business cases as required to developthe services provided. Leaders told us quality and safetywas considered as part of business cases.

Feedback regarding leadership in the hospital waspositive and we were told leaders were visible andapproachable. We were told leaders had an open-doorpolicy and could be contacted as required by staff.

Vision and strategy

The service had a vision for what it wanted toachieve and a strategy to turn it into action,developed with all relevant stakeholders. The visionand strategy were focused on sustainability ofservices and aligned to local plans within the widerhealth economy. Leaders and staff understood andknew how to apply them and monitor progress.

The hospital had a vision which was to be recognised as aworld class healthcare business and the hospital had aset of values which included driving clinical excellence,doing the right thing, caring is our passion, keeping itsimple, delivering on our promises and succeeding andcelebrating together.

There was a documented strategy for the diagnosticimaging department. For example, the radiology strategyincluded increase customer satisfactions for insured andself payors by providing an appointment within 48 hoursor at the convenience of the client, support the breastservice by providing 2 additional imaging specialists thatare able to perform mammography, ensure that self-paycustomers are issued with a formal quote for theirimaging costs and ensure green key performanceindicators whilst providing safe and efficient staffinglevels.

Diagnosticimaging

Diagnostic imaging

Good –––


We asked senior managers across the service about thevision and strategy and were told this was aligned withthe overall hospital and Spire strategy.

Staff had been involved in the development of thestrategy of the hospital and service which involved staffattending an event which assisted in the development ofthe strategy.

The hospital provided information stating they hadrecently introduced a new Spire purpose which wascompleted using workshops with staff.

Culture

Staff felt respected, supported and valued. Theywere focused on the needs of patients receivingcare. The service promoted equality and diversity indaily work, and provided opportunities for careerdevelopment. The service had an open culturewhere patients, their families and staff could raiseconcerns without fear.

Overall, morale across the department was good. Stafffelt supported, respected and valued by the hospital anddescribed good teamwork across the services. We weretold there was openness and honesty. There were regularstaff meetings to share information and discuss issues orchallenges.

The November 2019 team meeting included agendaitems such as mandatory training, the risk register,complaints, business and financial updates and thesafety brief.

There was a poster called ‘Have your voice heard’ whichhighlighted ways to have your voice heard and referencedthe freedom to speak up guardian and thewhistleblowing policy. There was a hospital freedom tospeak up guardian.

The hospital provided information stating staff hadaccess to an assistance line for staff wellbeing.

Governance


Leaders we spoke with could describe the governancearrangements for the department which included dailymeetings and a hospital wide weekly governancemeeting. Leaders could describe the ward to boardgovernance arrangements and were told incidents werereported via the incident reporting form and staff wouldspeak with managers. Where there was a serious incident,this would be discussed with the senior leadership team.Risks and governance issues were also discussed at thedaily meetings which included any issues from theprevious day. Each week incidents were discussed at theweekly clinical governance meeting. There was also aweekly meeting which senior managers such as thehospital director and director of clinical services attendedand included the medical advisory committee chair.

There were annual radiation protection committeemeetings with the external radiation protection advisorand the leaders in the department.

The clinical governance meeting from December 2019showed for example, agenda items such as clinicaleffectiveness, clinical audit and matters to escalate to theclinical governance committee or senior managementteam.

Incidents across the service were sent to the departmentmanager for initial investigation. The clinical governancelead also had oversight of incidents.

Leaders told us their assurance around patient safetycame from the daily huddles which for example includeditems such as safe staffing and how many patients wereattending. We were told leaders asked staff if they hadany concerns on the day. The clinical scorecard was alsoused to assist in providing assurance to departmentleaders and the leadership team.

There was an annual plan for governance andimprovement for 2019. This included information such asimproving the audit structure, continuing to build andpromote a prominent safety culture and utilising nationaldocuments on patient safety to improve the quality ofcare.

The clinical governance and audit committee meetingminutes from July 2019 included information such asNational institute of Care and Clinical Excellenceguidance to review, the clinical scorecard, mandatorytraining and audits.

Diagnosticimaging

Diagnostic imaging

Good –––


The service had produced a quarterly clinical governanceApril to June 2019 report. This documented the prioritiesand challenges across the services, adverse events,safeguarding, safe staffing, clinical scorecard information,patient satisfaction survey and complaints.

There was a medical advisory committee which leaderstold us they had good links with and the hospitalprovided information stating they provided medicaladvice and support to the hospital.


Leaders and teams used systems to manageperformance effectively. They identified andescalated relevant risks and issues and identifiedactions to reduce their impact.

There was a risk management policy available to staffwhich had a review date of July 2021. The policy includedvarious sections, for example on the process formanaging risk and the risk register.

Staff had access to radiation protection supervisors andexternal radiation protection advisors for advice andsupport. Staff told us they worked well with the externalteams.

Leaders could describe the quality assurance programmeto ensure equipment was serviced and maintained asrequired. There were folders for each of the scanners androoms which included servicing reports and dates ofprevious servicing of the equipment. The different areaswithin the department led on their own quality assuranceon a monthly basis and leaders described the daily orweekly testing which would be done on the equipment.The department had an external team come in andcomplete some of the quality assurance.

The service had an annual radiation protection meetingand from this received a report and recommendations oractions if required. The service had an ongoing actionplan. There was one outstanding action and the mostrecent audit was in late 2019. The radiation protectionadvisor and staff from the hospital attended this meetingand there was terms of reference for the radiationprotection committee meeting. The last meeting wasSeptember 2019. The agenda included discussion of theRPA audit report, MPE report feedback and radiologyincidents.

The service utilised risk registers to assist in managingand monitoring risks across the service. The diagnosticimaging risk register included three risks. These wereradiology equipment breakdown causing patientcancellations and delayed diagnosis. This risk registerdocumented the key controls which for exampleincluded, annual physicist inspection, local qualityassurance performed by RPS, equipment replacementplan in place, regular maintenance on equipment andthe service contract in place. The second risk was acompliance risk regarding discrepancy audits whichleaders told us medical staff participated in their trustdiscrepancy audits. Medical staff completed a form at thehospital to confirm this. The third risk was staff absence,recruitment and retention reducing the departmentscapacity and efficiency. Leaders told us action to thisincluded ongoing recruitment and using bank staff.

Leaders told us they did consider reject analysis acrossthe department and the team were required to documentwhat they had rejected. The target was less than 2%. InJanuary 2020 this was 0.5%. Reject analysis is the analysisof images which were rejected.

Leaders used performance reports and information tomonitor and manage the risks, issues and performanceacross outpatients’ services. Leaders had access to aradiology quality dashboard. Leaders attended a dailymeeting which was in place to ensure the departmentscould plan for the day’s work and ensure staff were awareof any safety information.

There was a communication diary which includedinformation that staff could read when they were not inthe department at the time the information was sharedwith staff. The staff meeting agenda was emailed to staff.

The service level agreement for services provided to thediagnostic imaging department was in date with a reviewdate of March 2020.

The mammography room had an uninterrupted powersupply and the hospital and department had access to abackup generator.

There was a business continuity document with a reviewdate of July 2022.


The service collected reliable data and analysed it.Staff could find the data they needed, in easily

Diagnosticimaging

Diagnostic imaging

Good –––


accessible formats, to understand performance,make decisions and improvements. The informationsystems were integrated and secure. Data ornotifications were submitted to externalorganisations as required.

Staff had access to the required information systems.Staff could access the intranet for information and newsabout the hospital. Policies and procedures wereavailable on the hospital intranet and there were foldersavailable in the department with relevant policies andprocedures available for staff to access. Staff had accessto an information technology team for support asrequired.

There was access to the electronic scans through thesystems in the hospital and staff told us results would beemailed back to the referrer, for example the generalpractitioner.

Leaders had access to performance reports and there wasperformance and risk information on display in staffareas. These enabled staff to understand the risk acrossthe services along with being able to access relevantinformation and news about the various departments.

Information systems were used across the department toprovide care and treatment to patients. There was alsoaccess to information systems to enable risk to bemanaged such as the incident reporting system.

There was information on display regarding theaccessible information standard in the hospital.

Leaders in diagnostic imaging told us there had been norecent information governance breaches.

Engagement

Leaders and staff actively and openly engaged withpatients, staff, and local organisations to plan andmanage services. They collaborated with partnerorganisations to help improve services for patients.

The service utilised friends and family tests to gatherfeedback and enable improvements to be made ifrequired. There was a ‘have your voice heard’ poster andwe saw ‘you said, we did’ information on display in thedepartment.

There was an annual staff survey to enable staff toprovide feedback to the leadership team. Leaders told usthis had improved on the previous year and there wereno areas of significant concern. The hospital producedstaff and consultant newsletters, held monthly staffforums and staff told us there were monthly teammeetings across the department.

The service provided further information stating theyproduced three clinical newsletters which included amonthly safety update, monthly lessons learnt and aninfection prevention newsletter. The hospital had awardsfor staff which contributed to staff engagement.

The service provided information stating they hadengaged with external groups and planned to provide atalk to promote the services offered at the hospital.

The main waiting area had a board which highlighted thesenior management team at the hospital.


All staff were committed to continually learning andimproving services. They had a good understandingof quality improvement methods and the skills touse them.

The services shared risk and governance information onnotice boards in the various departments for staff to view.

There were plans to introduce a patient experience leadin 2020 to contribute to the hospital patient experiencework.

Where required, the diagnostic imaging service was partof the one stop services the hospital offered to patients.

The department management was part of the dailyhospital meeting and information provided by thehospital highlighted these meetings ensured thedepartments could plan for the day’s activity and beaware of key safety information.

Diagnosticimaging

Diagnostic imaging

Good –––


Safe Good –––

Effective Good –––

Caring Not sufficient evidence to rate –––



Are termination of pregnancy servicessafe?

Good –––

Our rating of safe stayed the same. We rated it as good.

Mandatory training

The service provided mandatory training in key skillsto all staff and made sure everyone completed it.

The consultants who led this service were employed by alocal NHS trust, and, as part of the process of acquisitionand maintenance of their practising privileges with SpireWashington Hospital, they provided evidence of ongoingmandatory training and professional development in theirNHS trust roles.

Specific training in termination of pregnancy was not partof the induction training or mandatory training packagesfor all Spire Washington Hospital staff, as staff werepermitted to opt out of treating and/or caring for patientswho used this service. For those staff who did treat andcare for these patients, the lead consultant providedregular training sessions, at least annually, covering areasspecific to the service.

Staff we spoke with confirmed that they were up-to-datewith mandatory training.

Staff we spoke with also told us that they were allowedsufficient time to complete mandatory training and wereencouraged to develop professionally.

See also information under this sub-heading in the surgerysection.

Safeguarding

Staff understood how to protect women from abuse.They had training on how to recognise and reportabuse, and they knew how to apply it.

The hospital had up-to-date safeguarding policies foradults and children, and staff we spoke with were aware ofthese policies and related procedures. They could describewhat they would do if they were to have concerns aboutthe safety of a vulnerable adult or child. The service did nottreat children under 18 years old and any patientpresenting at this age would be referred to NHS services.

The lead nurses for the service were trained tosafeguarding level 3 for both vulnerable adults andchildren. They worked closely with the hospital lead forsafeguarding, who was trained to level 4.

All other staff, including those in non-clinical roles, weretrained to at least level 2.

Staff underwent annual refresher training in safeguarding.

Safeguarding information was clearly visible oninformation points on the ward.

Staff were aware of child sexual exploitation (CSE) andfemale genital mutilation (FGM), and they could explainwhat they would do if they were to become concernedabout signs of one or both of these in any woman using theservice.

Local commissioners had carried out a safeguardingassurance visit to the hospital a few weeks prior to ourinspection, and they had concluded that there were robustprocesses in place for safeguarding adults.

Terminationofpregnancy

Termination of pregnancy

Good –––


Staff told us that any lessons learned from safeguardingconcerns would be disseminated through regular staffmeetings and via safety briefings, which were issued to allstaff.



The service controlled infection-risk well. Staff usedequipment and control measures to protect patients,themselves, and others from infection. They keptequipment and the premises visibly clean.

The hospital had an up-to-date infection prevention andcontrol policy, and staff we spoke with were aware of thepolicy and related procedures.

All wards, clinical areas, and non-clinical areas were visiblyclean. Theatre equipment bore ‘I am clean’ stickers, whichwere updated between each usage following cleaning.

Clear information about infection control was displayedthroughout the hospital.

The clinical governance lead for the hospital was also theinfection prevention lead, and they were available to stafffor advice and support as required.

Separate hand-washing basins, hand wash, and handsanitizer were available on the wards, in theatres, and inwaiting areas. There was also a supply of personalprotective equipment, including gloves and aprons.

We observed staff following good hand-hygiene practice,including washing their hands and using hand gel betweeninstances of patient contact. Staff adhered to thebare-below-the-elbow rule.

All patients undergoing elective surgery who met thehospital’s screening criteria were screened forMethicillin-resistant Staphylococcus Aureus (MRSA), andthere were procedures in place to isolate patients whenappropriate, in accordance with infection control policies.

There were no reported cases of Clostridium Difficile, MRSAor Meticillin-sensitive Staphylococcus aureus (MSSA) withinthe service during the 12 months prior to our inspection.

Staff told us that any woman using the service for who hada communicable disease would be allocated to the end ofa clinic or theatre list and there would be a deep clean ofthe theatre after use.

Standards of cleanliness were monitored, and infectioncontrol audits were completed every month to monitorcompliance with key organisational policies such as handhygiene. An annual plan showed all infection control auditresults.

There had been no instances of surgical-site infection inpatients who had undergone surgical termination ofpregnancy during the 12 months prior to our inspection.For further information on infection control please seesurgery report.

The 2018 Patient-led Assessment of the Care Environment(PLACE) audit rated the hospital at 99.41% for cleanliness,which was better than the national average (98.5%).



The design, maintenance, and use of facilities,premises, and equipment kept people safe. Staff weretrained to use them. Staff managed clinical wastewell.

The hospital reception had a private room nearby, whichwas available on request to anyone attending who wishedto speak to a receptionist without being overheard.

The reception and waiting areas were comfortable andspacious, with adjacent toilets, drinks machines, andplenty of seating.

There were four general-purpose consulting roomsavailable to the service. These were spacious andcomfortable.

The ward comprised a corridor of single rooms, each withen-suite bathroom facilities. The rooms were fitted withsuction equipment, piped oxygen, and emergency callfacilities. There was a nurses’ station at the centre point ofthe ward corridor.

There were four theatres including a JAG accreditedendoscopy theatre, and five adjacent recovery areasavailable to the service, with the smallest of the fourtheatres being that mainly used by the service. Weinspected this theatre and found that it was spacious andfitted with laminar airflow equipment.



Good –––


Resuscitation equipment was available in case ofemergency and was checked daily to ensure that it wasoperational. Records showed that checks were completeand up-to-date. The equipment was also serviced regularly,in line with the hospital’s policy.

We checked a sample of single-use items and found thatthey were each in good condition, sealed, and within-date.

Safety testing of electrical equipment had been carried out,and labels were clear and within-date.



Staff completed and updated risk assessments foreach patient and removed or minimised risks. Staffidentified and quickly acted upon patients at risk ofdeterioration.

All patients were risk-assessed at the point of admission,and national early warning scores (NEWS) were recordedduring all nursing observations. All surgical terminations ofpregnancy were carried out under general anaesthetic. Forfurther information regarding anaesthetic cover please seethe surgery report.

Pregnancy testing was carried out at the initial consultationwith the service, to confirm the pregnancy, and womenusing the service then underwent an ultra-sound scan todetermine gestation of the pregnancy, unless formal resultsof a dating scan carried out elsewhere were available.

Screening for sexually-transmitted infections (STIs) wasoffered at the initial consultation to all women using theservice.

Before each surgical termination, a risk-based pre-opassessment was carried out, in line with guidance from theRoyal College of Obstetricians and Gynaecologists (RCOG).This included a pre-op assessment by the anaesthetist anda venous thromboembolism assessment.

Prior to termination procedures all women should have ablood test to identify their blood group, so that any patientwho has a rhesus-negative blood group can be given aninjection of anti-D to protect against complications in anyfuture pregnancy. The records that we reviewed

demonstrated that each woman using the serviceunderwent a blood test prior to the termination procedure,and each of those who had a rhesus-negative blood groupreceived an anti-D injection.

Women undergoing medical termination of pregnancy(MToP) were required to be readmitted to the hospital forthe second stage of the medical treatment; there was nooption to take the second treatment home, and the leadconsultant told us that, given the small size of the service,he had no plans to offer this as an option

There were clear patient pathways for the service, includingescalation policy for the deteriorating patient.

Nursing staff had good access to medical support in theevent a patient’s condition were to deteriorate. If thepatient’s consultant gynaecologist was not available onsite, they could be contacted at any time by telephone andwould return to the hospital as quickly as possible. Thelead consultant told us that they did not operate at anytime when they would not be available to the patient overthe following 24 hours.

Should a patient require urgent medical attention, staffcould call upon the resident medical officer (RMO), whowas available on site 24 hours per day every day.

There were emergency transfer arrangements in place tolocal NHS hospitals should they be required.

Women with special conditions such as fetal anomaly andectopic pregnancy were not treated at the hospital; theywere referred to local NHS providers.


Nurse staffing

The service had enough nursing and support staffwith the right qualifications, skills, training, andexperience to keep patients safe from avoidable harmand to provide the right care and treatment.

Either the lead nurse for the service or the ward managerwho was trained in this service was on site whenever awoman attended for a termination and during any post-oprecovery. Because the number of procedures carried outwas so small, this could be planned in advance by liaisonbetween the consultant carrying out the procedure and theappropriate nursing staff.



Good –––


There was also always at least one sister or senior nursealso on duty.

Medical staffing

The service had enough medical staff with the rightqualifications, skills, training and experience to keeppatients safe from avoidable harm and to provide theright care and treatment.

Both consultants who carried out the termination ofpregnancy service held weekly gynaecology clinics at thehospital. They did not use locum cover; they would providecover for each other when required.

A consultant who accepted a woman for a termination ofpregnancy procedure was responsible for the full episodeof her care. Admissions were therefore booked in a waythat ensured the consultant would be available for thewhole time required to provide safe care. Staff told us thatconsultants were always available should they needsupport.

The hospital held information outlining consultant-coverarrangements electronically. All staff could access thisinformation. Information regarding anaesthetic cover canbe found in the surgery report.

Records

Staff kept detailed records of patients’ care andtreatment. Records were clear, up-to-date, storedsecurely, and easily available to all staff providingcare.

Patient records were paper-based. We reviewed five sets ofpatient records for the service; we found these to be clear,compliant with hospital policies, and well-organised.Records bore clear dates, times, and designations of thepersons completing the documents.

All sets of notes recorded informed consent, currentmedicines, allergies, medical history, and family history.Notes relating to surgical terminations also contained ananaesthetics record. Care pathways were completedclearly.

There was some use of green ink within the notes. This wasless easy-to-read than notes completed in standard blackink.

Patient information and records were stored safety andsecurely in lockable cabinets, in line with the DataProtection Act 2018.

Staff followed local protocols to ensure that patient recordswere made available to consultants and other relevant staffin a timely and accessible way when women attended forclinic appointments and for termination procedures.

Record-keeping and documentation audits were carriedout monthly within the service. We reviewed these auditsfor each of the six months prior to our inspection and foundthat compliance was 100% every month.

Medicines


Only registered medical practitioners are legally permittedto prescribe medicine that is intended to procure amiscarriage. All medicines were prescribed by one of theHSA1 signatories who was a consultant.

For our detailed findings on medicines please see the Safesection in the surgery report.

Incidents

The service managed patient-safety incidents well.Staff recognised and reported incidents and nearmisses. Managers investigated incidents and sharedlessons learned with the whole team and the widerservice. When things went wrong, staff apologisedand gave patients honest information and suitablesupport. Managers ensured that actions from patientsafety alerts were implemented and monitored.

The hospital had an up-to-date incident-reporting policyand used an electronic system to report incidents. All staffwe spoke with told us that they were encouraged to reportincidents and near misses. Staff were familiar with how touse the system and understood the importance ofreporting.

In the 12 months prior to our inspection there had been noincidents relating to termination of pregnancy patients orprocedures.

Staff we spoke with told us that they received feedback onincidents they had reported.



Good –––


Hospital governance meetings were held weekly, and therewas opportunity for learning from incidents within theservice at these meetings. Information about reportedincidents was shared and discussed, and relevant riskassessments were updated. Learning and actions werecascaded to clinical staff at local team meetings.

Duty of candour applies when things go wrong with careand treatment; a service must be open and honest withpatients and other relevant persons, giving themreasonable support, truthful information, and, in somecases, a written apology. Staff we spoke with understoodthe principles of their Duty of Candour towards patientsand could explain what they should and would do in suchcircumstances.

Are termination of pregnancy serviceseffective?

Good –––

Our rating of effective stayed the same. We rated it asgood.


The service provided care and treatment based onnational guidance and evidence-based practice.Managers checked to make sure staff followedguidance. Staff protected the rights of patients whowere subject to the Mental Health Act 1983.

Consultants providing this service adhered to Royal Collegeof Obstetricians and Gynaecologists (RCOG) guidelines, TheAbortion Act 1967, and other legislation relevant totermination of pregnancy.

Policies relating to the service had been developed in linewith Department of Health Required Standard OperatingProcedures (RSOP) relating to termination of pregnancy.Staff followed a local work instruction for termination ofpregnancy based on RSOP that also included standardoperating procedures specific to Spire Washington Hospitaland best practice following RCOG clinical guidelines formedical and surgical terminations.


Staff gave patients enough food and drink to meettheir needs. The service made adjustments forpatients’ religious, cultural and other needs.

Women who were to undergo surgical termination ofpregnancy were given clear advice about how long theywould need to fast prior to the procedure.

Women experiencing nausea and/or vomiting wereformally assessed using a scoring system, and thisassessment was recorded and monitored

Water was available at all times, and other beverages wereoffered regularly to women who were not required to fast.

A variety of food was available, including vegetarian,gluten-free, and lighter options.

The hospital catered for a variety of cultural and religiouspreferences.

The hospital took care to ensure that food allergies wererecorded and brought to the attention of kitchen staff.

Pain relief

Staff assessed and monitored patients regularly to seeif they were in pain and gave pain relief in a timelyway.

Pre and post-procedural pain relief was prescribed for allwomen using the service, where required.

The National Early Warning Score (NEWS) charts used bythe hospital included a pain assessment scale. Patientsrecords we reviewed showed that pain had been assessedin each case and pain relief offered where appropriate.

Nursing staff told us that, following medical termination ofpregnancy, they would ask the patient about pain duringnursing observations. If further pain relief was required, theconsultant gynaecologist would be asked to reassess thepatient. Should the consultant be unavailable, the residentmedical officer (RMO) would be asked to assess the patientfor pain relief.

Following surgical abortion, the anaesthetist would visitpatients on the ward to check pain levels and prescribefurther pain relief as necessary.

No patient was discharged without a full assessment bytheir consultant.

Patient outcomes



Good –––


Staff monitored the effectiveness of care andtreatment. They used the findings to makeimprovements and achieved good outcomes forpatients.

The service carried out 15 medical terminations ofpregnancy and seven surgical terminations of pregnancy inthe 12-month period between August 2018 and July 2019.All women who underwent medical termination ofpregnancy were required to attend the hospital on twoseparate occasions, two days apart, to take the medicinesrequired. There was no option to take the second medicineat home. This meant that women were on site for thesecond part of the procedure, and staff could monitor theprocess closely.

All women who underwent surgical termination ofpregnancy had the procedure within five working days oftheir initial outpatient appointment. This was compliantwith RCOG and RSOP guidance.

No patient who had undergone surgical termination ofpregnancy in the 12 months prior to our inspection hadrequired a return to theatre. There had been no unplannedtransfers to NHS trust hospitals, no failed terminations, andno instances of retained products following surgery.

The lead staff nurse for the service carried out a monthlyaudit of terminations of pregnancies, examining patientrecords for compliance with legal reporting requirements,consent for procedure and disposal of pregnancy remains,drug prescription and dispensing, and care pathwaysfollowed. Compliance was consistently 100% in the 12months prior to our inspection.

A full audit of all terminations of pregnancies was alsocarried out annually by the deputy director of clinicalservices. We reviewed the most recent of these, fromJanuary 2019.

Only 50% of patient records for women who hadundergone termination of pregnancy at the hospital duringthe period covered by the audit (September 2017 toOctober 2018) showed that the consultant had offeredscreening for sexually-transmitted infections (STIs). This fellshort of the hospital’s target of 100%. Actions to addressthis shortfall were noted in the audit documentation. Theseincluded reminding the consultants of the need to bothoffer screening and record that it had been offered.

Compliance with all other measures covered by the auditwas at least 96% and was 100% in most cases. Actions toaddress the small shortfalls were noted in the auditdocumentation. These included reminding the consultantsof the omitted factors, amending the consultation historysheet to show where the missing information should berecorded, and introducing the use of labels in patientrecords.

Records that we reviewed during the inspection indicatedthat, for the measures audited, compliance with hospitaltargets had improved.

Competent staff


To acquire and maintain practising privileges with SpireWashington Hospital, the consultants providing itstermination of pregnancy services had provided evidenceof annual whole-practice appraisal, indemnity cover, anup-to-date disclosure and barring service (DBS) report, andup-to-date HEP B, HEP C, and HIV status.

All new staff were supported through an induction process,which included competence-based training relevant totheir general nursing roles. However, staff at the hospitalwere not subject to any specific formal training orcompetency assessments in respect of termination ofpregnancy. Instead, informal training was provided to thosecaring for women using the service by its lead consultant.

Staff we spoke with told us that they had annual appraisalsand that these were up-to-date. There were alsosix-monthly reviews for each member of staff, and anadditional review would be arranged should there be anychange to practice or concern about individualcompetency.



Doctors, nurses, and other healthcare professionalsworked together as a team to benefit patients. Theysupported each other to provide good care.



Good –––


Medical staff, nursing staff, allied health professionals andother, non-clinical, staff told us that they worked welltogether as a team and that the service had clear lines ofaccountability.

The hospital had service level agreements withneighbouring NHS trusts which allowed them to transfer apatient to the hospitals in case of medical or surgicalemergency.

Seven-day services

Services were not available seven days per week, butadvice to patients was accessible at all times, tosupport timely patient care.

The gynaecology-outpatient clinics, which women seekinga termination of pregnancy would attend, were held ononly one weekday, during the afternoon and evening.

Most terminations of pregnancies at the hospital werecarried out as day procedures. However, facilities wereavailable for overnight stays where required.

Terminations were arranged at times that were mutuallyconvenient to the patient and consultant.

The Department of Health and Social Care RequiredStandard Operating Procedures (RSOP) set out that womenshould have access to a 24-hour advice line whichspecialises in post-termination support and care. Staff toldus that, should any woman call the hospital with concernsor questions following a termination, a message would betaken and passed to her consultant, who would thencontact her with advice, either directly or via the hospitalstaff. The lead consultant confirmed that they were alwaysavailable for contact by patients for at least 24 hoursfollowing a termination procedure.

Health promotion

Staff gave patients practical support and advice tolead healthier lives.

Women who used the service were provided withinformation about contraception. Any woman who chosenot to start a contraception method immediately followinga termination was given information about localcontraception providers and/or encouraged to see her GP.

Information about national health-improvement prioritieswas also available; for example, the service providedinformation about sources of support to quit smoking andreduce alcohol intake.

Consent and Mental Capacity Act

Staff supported patients to make informed decisionsabout their care and treatment. They followednational guidance to gain patients’ consent. Theyknew how to support patients who lacked capacity tomake their own decisions or were experiencingmental ill health.

Staff were clear about their roles and responsibilities underthe Mental Capacity Act 2005. They were able to describewhat they should and would do if they were concernedabout a women’s capacity to make an informed decision toundergo a termination procedure. No children were seenby the service.

There had been no instances in which staff had hadconcerns about the capacity of a woman using the serviceto make an informed decision in the 12 months prior to ourinspection. Staff gained consent from women according tothe policy of the hospital and also ensured that womenwere certain of their decision.

Are termination of pregnancy servicescaring?

Not sufficient evidence to rate –––

We had insufficient evidence to rate ‘caring’ within thisservice.

Compassionate care

Staff treated patients with compassion and kindness,respected their privacy and dignity, and took accountof their individual needs.

There were no women attending clinics or the ward forconsultation, procedure, or advice during our inspection.We were therefore unable to observe the way patients weretreated by staff.

Staff described to us how they treated women withcompassion, kindness, dignity, and respect.

Emotional support



Good –––


Staff provided emotional support to patients,families, and carers to minimise their distress. Theyunderstood patients’ personal, cultural and religiousneeds.

All women who sought to use the service were offeredcounselling prior to a termination of pregnancy procedure.Details of professional pregnancy and terminationcounsellors were given to women at their initialconsultations.

Following a termination procedure, women were alsooffered counselling and were given information and namesand contact details for counsellors.

Nursing staff told us that they would answer any queriesand offer support in the 24 hours following a terminationprocedure.

Understanding and involvement of patients and thoseclose to them


Staff told us that women’s preferences for sharinginformation with their partners and/or family memberswere established, respected, and reviewed throughouttheir care.

Staff told us that a nurse would offer to be present duringconsultations and examinations, or the woman could bringher own chaperone.

Although we were unable to observe any initialassessments, staff told us that they explained the availablemethods for termination of pregnancy that wereappropriate and safe to each woman. The consultantwould consider gestational age and clinical needs whensuggesting the most suitable option.

The records we reviewed recorded post-discharge supportavailable for women and those close to them; women weregiven written information about accessing support in the24 hours following their procedure.

Staff told us that they made women aware of the statutoryrequirement to return anonymised data to the Department

of Health and Social Care on an HSA4 form. They explainedhow they reassured women that this was required forstatistical purposes only and would not contain anyinformation by which they could be identified.

Are termination of pregnancy servicesresponsive?

Good –––

Our rating of responsive stayed the same. We rated it asgood.


The service planned and provided care in a way thatmet the needs of local people and the communitiesserved.

The hospital’s consultant gynaecologists usually providedappointments on one weekday afternoon and evening,however should a patient require a more immediateappointment, ad hoc clinics could be arranged.

The hospital was able to offer contact information for otherSpire Healthcare Limited hospitals and/or local NHS trusthospitals if a woman expressed a preference for a differentday, time, or location, or if she did not want to pay for theprocedure or found the fee prohibitive.


The service was inclusive and took account ofpatients’ individual needs and preferences.

The service treated fit and healthy women without anyunstable medical condition. Women who did not meetthese criteria were referred to the most appropriate NHSprovider to ensure that they received the treatment theyrequired in a timely and safe way.

No women aged under 18 years underwent a terminationof pregnancy at the hospital. Should any woman under 18years old contact the hospital about this service, she wouldbe referred to local NHS providers.

At initial consultation, women attending the service weregiven information leaflets about different options availablefor termination of pregnancy, including what to expectwhen undergoing a surgical or medical termination. They



Good –––


were also given information about potential risks,counselling services, and sensitive disposal of thepregnancy remains. This information was available in otherlanguages and accessible formats if required.

A professional interpreting service was available face toface or via telephone to enable staff to communicate withwomen whose first language was not English. There werealso staff within the hospital who spoke other languagesfluently and had agreed to be called upon to translatebasic information or put patients at ease. Staff told us thatthey would always use the interpreting service to ensurethe patient understood, and could therefore make aninformed decision about, the termination procedure.

Staff told us that support was available for women withlearning disabilities or other complex needs.

Nurses and medical staff undertaking pre-surgicalassessments had a range of information available to themthat they could give to women as required. This includedadvice on contraception, sexually-transmitted infections,services to support women who were victims of domesticviolence, and how to access sexual-health clinics.

Following a termination procedure, women were givenleaflets which explained what to expect in the subsequent24 hours, to support the verbal information that they hadalready been given. These leaflets were available in otherlanguages and accessible formats if required.

The hospital had a policy for the disposal of pregnancyremains. Women using the service were provided with aninformation sheet which explained how the pregnancyremains would be managed. In all cases, pregnancyremains were stored securely, before being collected andtransported to the pathology department of aneighbouring NHS hospital for respectful cremation.

During the 12 months prior to our inspection, no womanusing the service had expressed an interest in disposing ofpregnancy remains herself, but staff told us that this couldbe accommodated by collection of remains from thehospital’s pathology department. Staff in the pathologydepartment confirmed that they were aware that this mightbe requested and that they knew how to respond to such arequest.

Access and flow

Women received care promptly. Waiting times fromreferral to treatment and arrangements to admit,treat, and discharge patients were in line withnational standards.

Most women using the service self -referred or werereferred by their GPs. Those who self-referred were askedwhether they wanted their GPs to be informed by letterabout their treatment and care. Their decisions wererecorded, and their wishes were respected.

The service monitored its performance againstwaiting-time guidance from RCOG and RSOP. No womanwaited longer than the recommended time of five workingdays from referral to consultation, and none waited longerthan five working days from decision to proceed totermination of pregnancy.

Women who had undergone a surgical terminationprocedure were offered a follow-up appointment, but stafftold us that women did not usually accept this offer.


It was easy for people to give feedback and raiseconcerns about care received. The service hadprocesses to treat concerns and complaints seriously,investigate them, and share lessons learned with allstaff. It had processes to include patients in theinvestigation of their complaint.

The hospital had a clear and up-to-date complaints policy.Staff we spoke with were aware of the policy and of how toguide any woman in their care who might wish to make acomplaint.

The complaints process appeared robust, with any themesor trends identified being marked for review by the clinicalgovernance lead, senior management team, and medicaladvisory committee. Actions to be taken, outcomes, andlessons learned were to be shared with clinical teams andall departments.

Staff we spoke with told us that patients would be givenopportunity to raise concerns with any staff member whilstat the hospital; all staff would know how to help a patientto access the complaints process. Staff said that they feltempowered to attempt to resolve situations themselveswhere appropriate.

Leaflets explaining the complaints policy were available inreception, on the ward, and in consultation rooms.



Good –––


The service had not received any complaints in the 12months prior to our inspection.

Are termination of pregnancy serviceswell-led?

Good –––

Our rating of well-led stayed the same. We rated it as good.

Leadership

Leaders had the skills, and abilities to run the service.They were visible and approachable in the service forpatients and staff.

The Department of Health and Social Care certificate ofapproval for carrying out termination of pregnancy wasdisplayed at the hospital entrance.

Staff we spoke with told us that they were supported by theconsultants who led the service and would feel able toraise concerns with them.


Vision and strategy

There was no separate vision or strategy for thetermination of pregnancy service within the hospital.

Culture

Staff felt respected, supported, and valued. They werefocused on the needs of women receiving care. Theservice had an open culture where patients, theirfamilies, and staff could raise concerns without fear.

Staff we spoke with told us that they felt respected,supported, and valued by leaders of the service. Leadersspoke about staff in a respectful and caring way.

Staff displayed a caring, compassionate, and supportiveattitude to the care they delivered to women seeking andundergoing terminations of pregnancy and were focusedon the needs of these women.

Staff described the service as having an open culture, inwhich patients, their families, and staff could raise concernswithout fear.


Governance

Leaders operated effective governance processesthroughout the service. Staff at all levels were clearabout their roles and accountabilities.

Staff had access to both online and hard copies ofelectronic and paper access to relevant guidelines, policies,and procedures in respect of termination of pregnancy, tosupport and guide them in their work. Staff we spoke withknew how to access these and whom they could consult foradditional support and information. They were clear abouttheir roles and accountabilities.

There was no delegation of duty in relation to medicaltermination of pregnancy; medicines were administered bythe woman’s consultant, in line with hospital policy.

The service ensured that conscientious objection wasmanaged appropriately by allowing staff to opt out ofcaring for patients who were undergoing procedures toterminate pregnancy.

The consultants who led the service measured outcomesand processes against other private services in the region,using these to form locally-agreed standards against whichperformance could be audited.

If a woman using the service was unwilling/unable toinvolve her GP in signing the form that, under Section 1 ofthe abortion act 1967, must be completed, signed, anddated by two registered medical practitioners before atermination procedure can be carried out (form HSA1), thetwo consultants who provided the service at this hospitalwould make arrangements to review and countersign theforms of one another’s patients within 24 hours. Theresident medical officer would never be asked tocountersign an HSA1 form.

In the five sets of records we reviewed, all gestations were10 weeks or below prior to termination. All HSA1 forms hadtwo appropriate signatures; one from the consultantcarrying out the procedure and the second from either thepatient’s GP or another consultant carrying outterminations at this hospital. Completed HSA1 Forms wereaudited monthly, these audits showed that the secondsignatory either saw the patient in person or reviewed theirrecords.



Good –––



Managing risks, issues, and performance

Leaders and staff used systems to manageperformance effectively. They identified andescalated relevant risks and issues and identifiedactions to reduce their impact. They had plans to copewith unexpected events.

See information under this sub-heading in the surgerysection.


The service collected reliable data and analysed it.Staff could find the data they needed, in easilyaccessible formats, to understand performance, andto make decisions and improvements. Theinformation systems were integrated and secure. Dataor notifications were consistently submitted toexternal organisations as required.

Paper records were stored securely on site for 12 monthsbefore being transferred to a national record-storagecentre, from where they could be retrieved if required.

The lead staff nurse for the service carried out a monthlyaudit of terminations of pregnancies, examining patientrecords for compliance with legal reporting requirements,consent for procedure and disposal of pregnancy remains,drug prescription and dispensing, and care pathwaysfollowed. Compliance was consistently 100% in the 12months prior to our inspection.

A full audit of all terminations of pregnancies was alsocarried out annually by the deputy director of clinicalservices. There were arrangements to ensure thatinformation was used to monitor, manage and report onquality and performance. These include a range of audits,monthly and annually. However, actions were not alwaystaken to address the gaps in audit performance forexample in the screening of STIs.

Patient information and records were stored safety andsecurely in lockable cabinets, in line with the DataProtection Act 2018.

The Department of Health and Social Care (DHSC) requireshospitals to maintain registers of women undergoingterminations of pregnancy. The service kept paperregisters, which were mostly completed clearly andaccurately. During our inspection we pointed out a smallnumber of inconsistencies of process, and these wererectified immediately. Additionally, some recentprocedures had not yet been entered in the appropriateregister(s), but the service had plans to rectify this and hadbegun to carry them out.

The DHSC requires every provider undertaking terminationof pregnancy to submit demographical data following eachprocedure, using an HSA4 form. We saw that this data hadbeen collected at initial consultations and passed to theDHSC within the 14 day deadline

Engagement

Leaders and staff engaged with patients and eachother to plan and manage services.

See information under this sub-heading in the surgerysection.


Staff were committed to continually learning andimproving services.

Consultant gynaecologists provided the service using skillsand experience gained in their NHS posts. Although therewas no formal training on site for staff caring for womenwho were undergoing termination of pregnancyprocedures, the lead consultant carried out regularinformal training sessions with these staff.



Good –––


Outstanding practice

The hospital provided information for local GPs byholding training courses and education lunch andlearning and evening sessions for GPs. The hospital

offered a varied GP education programme responsive tocurrent ‘hot topics’ demonstrating an example of asystematic approach being taken to work with otherorganisations to improve care outcomes for patients.

Areas for improvement

Action the provider SHOULD take to improve

• The provider should ensure patient records arealways signed by the consultant.

• The provider should consider ways to ensure allsafety checklists used in outpatients are completedas required.

• The provider should improve consistency of practicein completing the WHO checklist.

• The service should ensure that all Department ofHealth and Social Care (DHSC) register entriesrelating to termination of pregnancy are made in atimely way.

• The service should make sure patients have thechoice whether the second medication ofmisoprostol is taken at home or at the clinic.

Outstandingpracticeandareasforimprovement

Outstanding practice and areasfor improvement


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