Ashtead Hospital is operated by Ramsay Health Care UK Operations Ltd and provides a range of surgical services to private and NHS-funded patients from the local community.

We published our last report following our inspection in December 2016, as part of our national programme to inspect and rate all independent healthcare providers. We reviewed three core services at the hospital, which incorporated all the activity undertaken. These were surgery, children and young people (CYP) and outpatients, including diagnostic imaging.

At that inspection we rated the hospital as good overall, although we found improvements were required in some areas to minimise risks and promote safety. Concerns were identified about low training rates for some topics, and a lack of audits on children and young people attending for outpatient appointments or physiotherapy appointments. Other concerns included aspects of governance, such as CYP representation on the senior management team and safeguarding lead involvement with training and awareness. We told the hospital to develop and implement an action plan showing how it would bring services into line with the regulations.

We acknowledge the hospital has since permanently ceased the provision of services for children.

The hospital rapidly responded with a comprehensive 24-point action plan and updated us on progress as they resolved the issues identified. We scheduled a return visit within six months of our inspection to review the results of the plan and related initiatives the hospital had completed.

We found the hospital had significantly improved and during this inspection we were assured the hospital had met all of our concerns. We saw that staff mandatory training rates (including safeguarding) had been given a higher target and these had been met or exceeded. Governance processes including risk management and learning from incidents were firmly embedded and worked effectively. Patient documentation and records were clear and comprehensive.

Moreover, the relatively new senior management team had used the opportunity to review and enhance other aspects of the service. During our inspection we found examples of excellent practice and saw that innovations introduced as part of the overall process had resulted in the hospital being benchmarked as one of the better providers in the corporate group.

At the time the inspection was undertaken, we did not re-rate services. We will continue to monitor the performance of this service as part of our routine programme of provider engagement.

Amanda Stanford

Deputy Chief Inspector of Hospitals (South)

This planned inspection was undertaken by two compliance inspectors and a specialist advisor. During our visit we spoke with five people who used the service, nine members of staff, the matron and the registered manager.

Patients we spoke with told us they had signed consent forms prior to receiving their treatment. One patient told us “I completed a consent form when I was admitted. The pros and cons of the procedure were also fully explained.” Another patient told us, “I filled in and signed the consent form. The Consultant explained the possible side effects.”

Patients told us that their care and treatment met their individual needs. One patient told us, “I was provided with lots of information about my treatment including the risks.”

Patients told us that the environment at the service was very clean and tidy. They told us that their room was cleaned every day. They also said that staff looked after them well and they believed the staff received the training they required.

Patients told us they had received an information pack prior to being admitted to the hospital and this included information in relation to making a complaint. Patients we spoke with told us they had not needed to make a complaint.

We met and talked with five people using the hospital. They were all positive about the care they had received and two told us they had stayed at the hospital before. One person told us "I have received terrific nursing and care here" and another told us " I am very impressed. Everything is immaculate. I have been very well looked after." This was supported by our own observation that the staff were professional, calm and respectful in their dealings with patients.

The care records we saw were well completed and indicated a person centred approach to care. There were procedures in place to keep records secure and confidential.

We found that in general procedures relating to the management of medicines were satisfactory however there was one area where this was not the case and we asked the provider to take action to address this.

The provider had enough skilled and experienced staff to meet patient's needs and the nursing and theatre teams were supported by health care assistants and agency staff.

There were systems in place to audit and monitor the quality of the services being provided.

People were very pleased with the quality of care. They felt the staff were caring. Medical and surgical procedures were explained in layman’s terms. The level of information provided was excellent. The hospital was clean. There was little time waiting in outpatients to be seen.

Ashtead Hospital is operated by Ramsay Health Care UK Operations Ltd. The hospital has 29 ensuite patient rooms, a two bedded extended recovery area and 13 ambulatory care pods, of which four have ensuite WCs. Facilities include three laminar flow operating theatres (a system that circulates filtered air to reduce the risk of airborne contamination), an in-house Theatre Sterile Services Unit alongside the theatre suite, used to clean and sterilise all the hospital’s surgical instruments and their sister hospital’s instruments, and a five bedded recovery area. There is a dedicated Joint Advisory Group (JAG) accredited endoscopy unit with its own recovery area, 13 consulting rooms within the outpatient unit and seven designated treatment rooms within the physiotherapy department. The diagnostic imaging department includes X-ray, MRI and CT.

The hospital provides surgery, medical care, services for children and young people, and outpatients and diagnostic imaging. We inspected surgery, outpatients and services for children and young people. Medical care services are reported under the surgery section. Services for children and young people were limited to outpatients and represented 3% of the hospital’s total activity, with most aged 0 – 15 and a small proportion aged 16-17.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 12 – 14 December 2016.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

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

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

Services we rate

We rated this hospital as good overall. Although some elements of the children and young people’s service required improvement, the overall standard of service provided throughout the hospital was largely good. Since the children and young people’s service represented only 3% of the hospital’s total activity, we have deviated from our usual aggregation of key question ratings to rate this service in a way that properly reflects our findings and is reflective of a proportionate judgment.

We found good practice in relation to surgery:

• Openness and transparency about safety was encouraged. Staff understood their responsibilities in relation to incident reporting. Staffing levels and skill mix were planned and reviewed to keep people safe at all times.

• Decision making about the care and treatment of a patient was clearly documented and record keeping was comprehensive.Staff planned and delivered patient care in line with current evidence-based guidance, standards, best practice and legislation and staff adhered to infection control policies and protocols.

• There was an effective system in place to ensure the monitoring, storage and availability of medicines.

We found good practice in relation to outpatient care:

• There were clearly defined systems, processes and standard operating procedures to provide safe care and respond in emergencies. Staff had a good understanding of how and when to report incidents and reflected that they understood the duty of candour and knew when to apply it.

• Staff worked collaboratively to share best practices and meet the patients’ needs. We saw multi-disciplinary working across departments and with other Ramsay Hospitals.

• The care provided to patients was consistently compassionate, with staff listening to patients’ concerns and responding in a way that reflected they understood and acknowledged the patient’s medical, personal and social needs.

• Services were planned and delivered to meet local needs with appointments available at a range of times to accommodate patient choice.

We found areas of practice that require improvement in services for children and young people:

• A new system of record keeping for children and young people meant that insufficient information was kept on file to provide a full record of the patient’s treatment.

• There was a lack of audits relating to children and young people attending the service which meant there was no effective way of monitoring patient clinical outcomes other than patient feedback.

We found areas of practice that required improvement in outpatients and diagnostic imaging:

• Patient records were not always complete and sometimes excluded consultant’s names, patient condition and treatment. In some cases, the consultant kept original copies of patient records.

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

Professor Edward Baker

Deputy Chief Inspector of Hospitals