We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

Transcription

1 Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Spire Gatwick Park Hospital Povey Cross Road, Horley, RH6 0BB Tel: Date of Inspection: 21 January 2013 Date of Publication: February 2013 We inspected the following standards as part of a routine inspection. This is what we found: Respecting and involving people who use services Care and welfare of people who use services Safety and suitability of premises Requirements relating to workers Complaints Inspection Report Spire Gatwick Park Hospital February

2 Details about this location Registered Provider Registered Managers Spire Healthcare Limited Mrs. Heather Dob Overview of the service Type of service Regulated activities The Spire Gatwick Park Hospital is a purpose built private hospital located at Horley. The hospital has three operating theatres, a high dependency unit, an endoscopy suite and a day care unit. There are 64 inpatient beds, outpatient services, imaging and physiotherapy departments. The hospital also performs its own sterile services and pathology service at this location. Acute services with overnight beds Diagnostic and screening procedures Family planning Management of supply of blood and blood derived products Services in slimming clinics Surgical procedures Treatment of disease, disorder or injury Inspection Report Spire Gatwick Park Hospital February

3 Contents When you read this report, you may find it useful to read the sections towards the back called 'About CQC inspections' and 'How we define our judgements'. Summary of this inspection: Page Why we carried out this inspection 4 How we carried out this inspection 4 What people told us and what we found 4 More information about the provider 4 Our judgements for each standard inspected: Respecting and involving people who use services 6 Care and welfare of people who use services 8 Safety and suitability of premises 10 Requirements relating to workers 12 Complaints 13 About CQC Inspections 15 How we define our judgements 16 Glossary of terms we use in this report 18 Contact us 20 Inspection Report Spire Gatwick Park Hospital February

4 Summary of this inspection Why we carried out this inspection This was a routine inspection to check that essential standards of quality and safety referred to on the front page were being met. We sometimes describe this as a scheduled inspection. This was an unannounced inspection. How we carried out this inspection We looked at the personal care or treatment records of people who use the service, carried out a visit on 21 January 2013, observed how people were being cared for and talked with people who use the service. We talked with staff. What people told us and what we found We met and talked with six people staying at the hospital. They were all positive about the care they were receiving and half told us they had stayed at the hospital before. One person told us "I can't fault the nurses.they are very professional but also friendly and will stop to chat." Another person told us "I have been looked after very well." This was supported by our own observations that the staff were polite, professional and respectful in their dealings with people. The care records we looked at were well completed and indicated a careful attention to the safety and welfare of patients. The provider had effective staff recruitment and vetting procedures in place. There was an open culture and the staff we spoke to enjoyed working for the provider. We found that overall the premises provided good standards of general cleanliness and comfort and were being appropriately maintained. The provider had an effective complaints system which was overseen by senior managers and which sought to resolve complaints speedily. You can see our judgements on the front page of this report. More information about the provider Please see our website for more information, including our most recent judgements against the essential standards. You can contact us using the telephone number on the back of the report if you have additional questions. There is a glossary at the back of this report which has definitions for words and phrases Inspection Report Spire Gatwick Park Hospital February

5 we use in the report. Inspection Report Spire Gatwick Park Hospital February

6 Our judgements for each standard inspected Respecting and involving people who use services People should be treated with respect, involved in discussions about their care and treatment and able to influence how the service is run Our judgement The provider was meeting this standard. People were involved in their own care and their views and experiences were taken in to account in the way the service was provided and delivered. Reasons for our judgement People who use the service were given appropriate information and support regarding their care or treatment. We found that the provider had developed a range of information leaflets relating to the specific outpatient and inpatient services and treatments offered. These were complemented by a clearly written admission booklet which was issued in advance to all patients coming to the hospital for surgery. This booklet dealt with a range of subjects such as what to bring to hospital, how to recognise the different healthcare staff from their uniforms and the discharge procedures. We were told that the booklet had been developed based on feedback from patients and changes were planned based on further feedback. We also saw that the provider had a comprehensive web site providing information for patients. We spoke to six patients following their surgery and before their departure from the hospital. They confirmed that they had received full information about their surgery and also a full explanation from their consultant about the risks and benefits. They also told us that they had valued the opportunity to ask the nurse any further questions at a preoperative assessment. One person told us "I feel like everything has been tailored to my needs, from the very first appointment right up to now." We saw that patient care records were stored in files in each patient's room and they were encouraged to read these. We saw that in addition to the patient care record these files contained 'handy hints' on subjects such as dealing with constipation or what to do if feeling sick. This meant that the provider encouraged patients to be informed and involved in their own care. One patient told us that they had found this reading material very useful. All the patients we spoke with during our visit confirmed that they had felt able to express their views and preferences, had been given the time they needed and treated with respect. Inspection Report Spire Gatwick Park Hospital February

7 We saw that the hospital ran various patient surveys to gather the views of patients on the services they offered. People were asked to complete a satisfaction form on leaving the hospital and one major survey was also run over three months each summer by the provider organisation. The results were analysed and compared across the wider organisation. We saw that the results of this survey were positive. During 2012 the hospital had taken additional steps to gather the feedback of patients. They had conducted a second survey which focussed less on systems and procedures and more on how people using the hospital felt about their care. The survey dealt with issues related to respect, diversity and equality. This had been followed by a meeting with a group of the survey respondents to obtain more detailed information about the issues highlighted. There was evidence that the provider had received valuable feedback and had acted on this. The feedback had also directly informed the hospital's strategy plans. Inspection Report Spire Gatwick Park Hospital February

8 Care and welfare of people who use services People should get safe and appropriate care that meets their needs and supports their rights Our judgement The provider was meeting this standard. People experienced care, treatment and support that met their needs and protected their rights. Reasons for our judgement Everything we saw and heard indicated that people's needs were assessed and care and treatment was planned and delivered in line with their individual care plans. We visited an inpatient ward and the day care unit, observed what was going on and spoke to staff members and patients. We saw that staff treated patients with care and respect and one person told us "The staff always knock, even when my door is already open." There was evidence that there was communication between the staff, for example the nurses had a shift handover procedure between the night and day staff at 7.00am each morning to ensure that patients received continuity of care. There was a resident medical officer (RMO) in the hospital 24 hours a day and the staff we spoke to told us they felt comfortable raising concerns and obtaining assistance from the RMO at any time. We reviewed a sample of patient care records and found that the records were well maintained and held a range of health assessments, risk assessments and monitoring forms. These were person centred and specific to the surgery undertaken. Risk assessments included those for thrombosis and moving and handling. Care records evidenced regular monitoring of each person's condition, which mean that staff responded to changing care and welfare needs. This was supported by what patients told us about the attentiveness of the nursing team and the monitoring that they performed. One person said " The nurses are never far away. I had one to one care when I was in the high dependency unit after my surgery. It was excellent." Patients were particularly positive about the way in which assessments had been completed and physiotherapy planned with a view to ensuring that they could return home, and cope at home, as soon as possible. One of the patients we spoke to explained that they had left hospital but had needed to return when they developed an infection. They told us that the consultant had warned of this risk and that the hospital had given them clear directions on what to look out for and who to contact if they had concerns. When they phoned the hospital the nursing staff contacted the consultant immediately and asked the patient to come to the hospital. The patient was readmitted to receive a course of intravenous antibiotics. They told us "The situation was managed very quickly and very well." Inspection Report Spire Gatwick Park Hospital February

9 During our visit to the ward we saw in the nursing office that adverse incidents and near misses which had been identified and investigated were then shared and discussed with the whole nursing team. This was so that the nurses could learn from mistakes and improve the safety of the care they provided in the future. We also visited the imaging department where magnetic resonance imaging (MRI) and computerised tomography (CT) scans were performed. We reviewed the records of twelve MRI scans and five CT scans. Each record contained a safety screening questionnaire which had been completed and signed by the patient before the procedure. This questionnaire was used to ensure that it was safe for a patient to undergo a scan. We found that in every case where a patient had given a response on a questionnaire which required clarification, the radiographer had clarified the position with the patient and documented the outcome before proceeding with the scan. This meant that the safety and welfare of the patients was assured. The manager explained to us that the hospital offered surgery for children although there were only a few procedures for children each month. The booking process for children was therefore carefully coordinated to ensure that a specialist paediatric nurse was at the location to care for a child 24 hours per day. We saw that the hospital had procedures and equipment in place for dealing with foreseeable emergencies. There were four identical emergency trolleys sited at appropriate points throughout the hospital. These contained emergency drugs and resuscitation equipment including defibrillators. There was evidence that these were regularly checked. The staff we spoke to knew how to use the equipment and had received training in life support. Inspection Report Spire Gatwick Park Hospital February

10 Safety and suitability of premises People should be cared for in safe and accessible surroundings that support their health and welfare Our judgement The provider was meeting this standard. People who use the service, staff and visitors were protected against the risks of unsafe or unsuitable premises Reasons for our judgement The provider had taken steps to provide care in an environment that was suitably designed and adequately maintained. The grounds and parking areas were well maintained and provided disabled parking and pick up and drop off facilities.the car parks were not cleared of ice and snow on the day of our visit, although the area outside the main entrance doors appeared to have been cleared. During our inspection we visited all clinical and non clinical areas of the hospital including the physiotherapy and imaging departments. We observed that corridors, staircases, lifts, toilets and public waiting and changing areas were clean, well maintained and uncluttered. We also looked in consulting rooms and visited the rooms and bathrooms of inpatients and saw that these were suitably designed and maintained. All bedrooms had en suite bathroom facilities which provided full privacy. We found that the manager responsible for the facilities had standard operating procedures for the maintenance of the building and service level agreements were in place with facilities and equipment suppliers and manufacturers. Some service contracts were managed on a corporate, organisation-wide basis and others were specific to this hospital location. We saw that there was computer software which was used to assist staff in identifying and scheduling regular building maintenance checks and tasks. We looked at a sample of records and discussed these with the manager. It was evident that the rolling schedule of work was very largely up to date. We also saw that there was a separate building management software which was continuously monitoring the performance of plant such as the hot water system. This meant that there were controls in place to minimise the risk of legionella (a germ found in the environment which can contaminate water systems in buildings). We reviewed the records of a number of important annual audits and risk assessments completed in the previous 12 month period. These included the hospital's disabled access audit and fire risk assessment as well as records demonstrating that portable appliance Inspection Report Spire Gatwick Park Hospital February

11 testing (PAT testing) had been completed. The manager told us that there was a back up generator in place to support services during a power cut. We saw that critical services such as theatre lighting and power were supported by dedicated uninterrupted power supply packs. The provider had written emergency plans which included action plans for the loss of key utilities and communications. The staff we spoke to knew who to speak to in the event of an emergency. The overall response to an emergency would be coordinated by the senior manager on site at the time. From everything we saw and heard we judged that the premises were well managed and maintained. Inspection Report Spire Gatwick Park Hospital February

12 Requirements relating to workers People should be cared for by staff who are properly qualified and able to do their job Our judgement The provider was meeting this standard. People were cared for, or supported by, suitably qualified, skilled and experienced staff. Reasons for our judgement Appropriate checks were undertaken before staff began working in the service. We reviewed the recruitment files of six members of staff who worked in different areas of the hospital. We found that checks had been performed to ensure staff were eligible to work in the UK and were of good character. Checks included those to verify identity and address, a check of the records held by the Criminal Records Bureau (CRB) and previous employer references. We saw that for qualified healthcare workers copies of qualifications were held on file and also notes indicating that checks had been performed to ensure that staff were, and continued to be, registered with their professional bodies. This was to ensure that staff had the continuing right to practice. We saw that there were effective procedures, including a recruitment checklist, to ensure that all the checks were completed before a person started work with the provider. The only exception to this was if a reply was still awaited from the CRB when a worker was ready to start. We saw that in this situation a risk assessment was performed. If the assessment was satisfactory then the new member of staff could start work pending receipt of the CRB check but subject to direct supervision. The manager confirmed that this approach was very rare and generally the hospital liked to receive the CRB check before the new member of staff was authorised to start. The provider may like to note that the risk assessment form used did not state that a CRB check must always be received before a person could start work where this involved working with children. We also noted that the provider took steps to refer staff to their professional body if they felt that the conduct of a worker met the criteria for referral. Inspection Report Spire Gatwick Park Hospital February

13 Complaints People should have their complaints listened to and acted on properly Our judgement The provider was meeting this standard. There was an effective complaints system available. Comments and complaints people made were responded to appropriately. Reasons for our judgement People's complaints were fully investigated and resolved, where possible, to their satisfaction. We reviewed the provider's written complaints policy, spoke with the member of staff responsible for logging and coordinating responses to complaints and reviewed a sample of complaints on file. We found that when a verbal or written complaint was received it was recorded and passed to a central coordinator to be logged, numbered and escalated for investigation. We found that the central records were complete and well maintained and there was an effective administrative procedure in place to track and ensure responses were received within appropriate timescales. It was evident that complaints were taken seriously by the provider and complaints investigators and staff required to contribute to investigations were keen to respond and resolve complaints in a timely fashion. We also saw that the provider had a 'Complaints Toolkit' available on their Intranet to support staff to undertake effective complaint investigations. There was evidence that the provider apologised and accepted fault where appropriate and that lessons learned from complaints were acted on. As an independent hospital which also provided care to NHS patients, the hospital was required to deal with complaints from NHS patients in line with NHS complaints regulations. This was stated in the provider's written policy; however, we found that this was not always done in practice. For example in one case we found that the final response letter to a complainant did not remind them of their right to refer to the Parliamentary and Health Service Ombudsman. Also it was not clear for staff how NHS complaints should be handled when received orally. The regulations require that a written record is made of a complaint and a copy of this be provided to the complainant. The provider may wish to review its written complaints policy to ensure that this correctly references all aspects of the NHS complaints regulations. We also found that the provider's policy stated that the summary leaflet sent to patients should make it clear where a copy of the full complaints policy could be found. We reviewed the two complaints leaflets entitled 'Please talk to us' and noted that they did not mention this. Inspection Report Spire Gatwick Park Hospital February

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15 About CQC inspections We are the regulator of health and social care in England. All providers of regulated health and social care services have a legal responsibility to make sure they are meeting essential standards of quality and safety. These are the standards everyone should be able to expect when they receive care. The essential standards are described in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations We regulate against these standards, which we sometimes describe as "government standards". We carry out unannounced inspections of all care homes, acute hospitals and domiciliary care services in England at least once a year to judge whether or not the essential standards are being met. We carry out inspections of dentists and other services at least once every two years. All of our inspections are unannounced unless there is a good reason to let the provider know we are coming. There are 16 essential standards that relate most directly to the quality and safety of care and these are grouped into five key areas. When we inspect we could check all or part of any of the 16 standards at any time depending on the individual circumstances of the service. Because of this we often check different standards at different times but we always inspect at least one standard from each of the five key areas every year. We may check fewer key areas in the case of dentists and some other services. When we inspect, we always visit and we do things like observe how people are cared for, and we talk to people who use the service, to their carers and to staff. We also review information we have gathered about the provider, check the service's records and check whether the right systems and processes are in place. We focus on whether or not the provider is meeting the standards and we are guided by whether people are experiencing the outcomes they should be able to expect when the standards are being met. By outcomes we mean the impact care has on the health, safety and welfare of people who use the service, and the experience they have whilst receiving it. Our inspectors judge if any action is required by the provider of the service to improve the standard of care being provided. Where providers are non-compliant with the regulations, we take enforcement action against them. If we require a service to take action, or if we take enforcement action, we re-inspect it before its next routine inspection was due. This could mean we re-inspect a service several times in one year. We also might decide to reinspect a service if new concerns emerge about it before the next routine inspection. In between inspections we continually monitor information we have about providers. The information comes from the public, the provider, other organisations, and from care workers. You can tell us about your experience of this provider on our website. Inspection Report Spire Gatwick Park Hospital February

16 How we define our judgements The following pages show our findings and regulatory judgement for each essential standard or part of the standard that we inspected. Our judgements are based on the ongoing review and analysis of the information gathered by CQC about this provider and the evidence collected during this inspection. We reach one of the following judgements for each essential standard inspected. This means that the standard was being met in that the provider was compliant with the regulation. If we find that standards were met, we take no regulatory action but we may make comments that may be useful to the provider and to the public about minor improvements that could be made. Action needed This means that the standard was not being met in that the provider was non-compliant with the regulation. We may have set a compliance action requiring the provider to produce a report setting out how and by when changes will be made to make sure they comply with the standard. We monitor the implementation of action plans in these reports and, if necessary, take further action. We may have identified a breach of a regulation which is more serious, and we will make sure action is taken. We will report on this when it is complete. Enforcement action taken If the breach of the regulation was more serious, or there have been several or continual breaches, we have a range of actions we take using the criminal and/or civil procedures in the Health and Social Care Act 2008 and relevant regulations. These enforcement powers include issuing a warning notice; restricting or suspending the services a provider can offer, or the number of people it can care for; issuing fines and formal cautions; in extreme cases, cancelling a provider or managers registration or prosecuting a manager or provider. These enforcement powers are set out in law and mean that we can take swift, targeted action where services are failing people. Inspection Report Spire Gatwick Park Hospital February

17 How we define our judgements (continued) Where we find non-compliance with a regulation (or part of a regulation), we state which part of the regulation has been breached. We make a judgement about the level of impact on people who use the service (and others, if appropriate to the regulation) from the breach. This could be a minor, moderate or major impact. Minor impact people who use the service experienced poor care that had an impact on their health, safety or welfare or there was a risk of this happening. The impact was not significant and the matter could be managed or resolved quickly. Moderate impact people who use the service experienced poor care that had a significant effect on their health, safety or welfare or there was a risk of this happening. The matter may need to be resolved quickly. Major impact people who use the service experienced poor care that had a serious current or long term impact on their health, safety and welfare, or there was a risk of this happening. The matter needs to be resolved quickly We decide the most appropriate action to take to ensure that the necessary changes are made. We always follow up to check whether action has been taken to meet the standards. Inspection Report Spire Gatwick Park Hospital February

18 Glossary of terms we use in this report Essential standard The essential standards of quality and safety are described in our Guidance about compliance: Essential standards of quality and safety. They consist of a significant number of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations These regulations describe the essential standards of quality and safety that people who use health and adult social care services have a right to expect. A full list of the standards can be found within the Guidance about compliance. The 16 essential standards are: Respecting and involving people who use services - Outcome 1 (Regulation 17) Consent to care and treatment - Outcome 2 (Regulation 18) Care and welfare of people who use services - Outcome 4 (Regulation 9) Meeting Nutritional Needs - Outcome 5 (Regulation 14) Cooperating with other providers - Outcome 6 (Regulation 24) Safeguarding people who use services from abuse - Outcome 7 (Regulation 11) Cleanliness and infection control - Outcome 8 (Regulation 12) Management of medicines - Outcome 9 (Regulation 13) Safety and suitability of premises - Outcome 10 (Regulation 15) Safety, availability and suitability of equipment - Outcome 11 (Regulation 16) Requirements relating to workers - Outcome 12 (Regulation 21) Staffing - Outcome 13 (Regulation 22) Supporting Staff - Outcome 14 (Regulation 23) Assessing and monitoring the quality of service provision - Outcome 16 (Regulation 10) Complaints - Outcome 17 (Regulation 19) Records - Outcome 21 (Regulation 20) Regulated activity These are prescribed activities related to care and treatment that require registration with CQC. These are set out in legislation, and reflect the services provided. Inspection Report Spire Gatwick Park Hospital February

19 Glossary of terms we use in this report (continued) (Registered) Provider There are several legal terms relating to the providers of services. These include registered person, service provider and registered manager. The term 'provider' means anyone with a legal responsibility for ensuring that the requirements of the law are carried out. On our website we often refer to providers as a 'service'. Regulations We regulate against the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations Responsive inspection This is carried out at any time in relation to identified concerns. Routine inspection This is planned and could occur at any time. We sometimes describe this as a scheduled inspection. Themed inspection This is targeted to look at specific standards, sectors or types of care. Inspection Report Spire Gatwick Park Hospital February

20 Contact us Phone: Write to us at: Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA Website: Copyright Copyright (2011) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Inspection Report Spire Gatwick Park Hospital February