We spoke with people and staff at Duchy Hospital. We visited the ward area, theatres and recovery. Patients told us they were happy with the care they had received and one person told us “the staff are all angels” and “nothing is too much trouble – that goes for all staff”. Another person told us “I can’t fault it in any way” and another person said “you get a good service, both as an in-patient and an out-patient”. Comments gathered from the NHS Choices website since the last inspection in January 2013 included “They listened to my questions and concerns and addressed them all, very much putting my mind at rest”.

Patients were protected by a clean environment and medicines were well managed. The hospital also adhered to a robust recruitment procedure in order to protect patients.

The staff told us they enjoyed working at the hospital, and most said they felt supported, both by their colleagues and seniors, and also by Ramsay Healthcare UK Operations Limited.

We spoke with people and staff at Duchy Hospital. We visited the ward area, theatres and recovery. We saw feedback provided by patients about their care at Duchy Hospital.

The staff told us they enjoyed working at the hospital, and they felt supported, both by their colleagues and seniors and also by Duchy Hospital.

Comments gathered from the NHS Choices website over the last six months included: “The whole experience was made that more bearable by the efficiency and care given by the Hospital staff”, and “Everyone, (the catering team, the physiotherapists and nurses) was brilliant and I couldn't thank them enough! They were friendly and caring and made, what was for me a very difficult time, easier to deal with”. Two people made comment about uncomfortable plastic mattress covers. One person made comment about perceived differences in the way NHS and private patients were treated, specifically the restricted visiting for NHS patients.

We saw people’s privacy and dignity were protected and we found the care documentation identified that people's care needs were consistently met.

People were protected from abuse and staff were trained and supported to carry out their roles.

The hospital was hygienic and clean, and on the day of our inspection free from odours.

We found there were systems in place to monitor the quality of care provided at the Duchy Hospital.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that treatment for the termination of pregnancy was not commenced unless two certificated opinions from doctors had been obtained.

We reviewed all the information we hold about this provider, carried out a visit on 7 February 2012, observed how people were being cared for, talked to people who use services, talked to staff, and checked the provider’s records.

We spoke with people about the service they received. They told us that they have confidence in the staff and the service offered. People said they were very happy with the care provided and the kindness and politeness of the staff. One patient described the nursing staff as “wonderful”. Without exception, everyone who expressed an opinion had a positive experience.

Staff told us they enjoyed working at the hospital, and all the staff we spoke with said that they would feel able to report any concerns to the manager or matron. Staff told us that they had ready and frequent access to training.

Duchy Hospital is an independent hospital operated by Ramsay Health Care. We carried out a comprehensive inspection as part of our national programme to inspect and rate all independent hospitals. We carried out the announced part of the inspection on 11 and 12 October 2016, along with an unannounced visit to the hospital on 14 October 2016.

The hospital provided surgery, and outpatients and diagnostic imaging service to NHS patients and privately funded patients, including self-funded and medical insured. At the time of the inspection, the hospital did not provide care and treatment to patients under the age of eighteen. The surgical specialties treated were orthopaedics, spinal, urology, gynaecology, ophthalmology, oral & maxillo-facial, general surgery, gastroenterology, ENT, dermatology, cosmetic & plastic surgery. Medical specialties included cardiology, respiratory and neurology. The hospital also had an in-house physiotherapy department, X-ray & diagnostic unit and an outpatient department.

The hospital had 31 beds with 26 en-suite rooms and 12 day case beds. Facilities included three operating theatres and a day case theatre/endoscopy room, a cardiac catheter laboratory, and X-ray, outpatient and diagnostic facilities with 11 consulting rooms and two treatment rooms.

We rated the service overall as requires improvement. We rated surgery as requires improvement, and outpatients and diagnostic imaging as good. This was because we had concerns about aspects of safety at the hospital in both the surgical services, and outpatients and diagnostics services, and in the effectiveness and leadership of surgical services. We found the management of incidents, patient records, the deteriorating patient, some consent processes, resuscitation equipment, and governance processes required improvement. However, we found the service provided outstanding care for its patients and those close to them, and services were planned and delivered in a way that met the needs of the local people.

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.

The hospital also had a cardiac catheter laboratory where coronary angiography investigations are carried out for patients with suspected coronary heart disease. The diagnostic imaging manager was responsible for the imaging equipment in the laboratory. Therefore information about activity in the laboratory is included in the outpatients and diagnostic imaging section.

Services we rate

We rated this hospital as requires improvement overall.

We found areas of practice that require improvement in surgery services and outpatient and diagnostic imaging:

• Resuscitation equipment and storage arrangements were not safely managed.

• The management and storage of records was not effective. Records of procedures such as invasive procedures in outpatients and the administration of intravenous fluids in surgery, were not well documented.

• The safeguarding lead for the hospital was not level 3 safeguarding trained.

• Consent processes did not always follow guidelines or hospital policy.

• Governance arrangements, audit and risk management processes to monitor quality and safety within the hospital were not always effectively implemented or actions monitored.

• There was a lack of a coordinated response team for responding to medical emergencies.

• Patient leaflets and information were not available in other formats such as other languages, pictorial or braille or in large print.

In surgery:

• The management of incidents and investigations did not consistently follow the incident reporting and being open policies.

• Duty of candour was not fully implemented and did not follow hospital policy.

• The provision of cover by an anaesthetist in the 24 hours following patients’ treatment was not clear.

• Mandatory training and appraisal levels were not achieved.

• The management of the deteriorating patient was poorly understood by staff, and issues where identified during audits and investigations, were not addressed.

In outpatients and Diagnostic Imaging:

• Medical records generated by staff holding practising privileges were not always available to staff (or other providers) who may be required to provide care or treatment to the patient

• It was not clear to the staff we spoke with, who the laser protection supervisor was.

• The National Safety Standards for Invasive Procedures were not yet implemented in the main outpatients department.

However,

We found outstanding practice in relation to patient care in outpatient and diagnostic imaging:

• Staff worked especially hard to make the patient experience as pleasant as possible. Staff went out of their way to ensure patients and those close to them were involved in their care and feedback from them was continually positive.

We found good practice in relation to surgical services and outpatient and diagnostic imaging:

• The service always had enough staff to meet patients care needs and worked effectively within hospital teams, the local acute trust and ongoing services.

• Pain was managed effectively to ensure patients remained comfortable.

• Patients were well cared for and services were planned and delivered in a way that met the needs of the local population. Waiting times were minimised where possible.

• Staff spoke highly of the leadership in the organisation who were visible and approachable.

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 twelve requirement notice(s) that affected surgery and outpatient and diagnostic imaging services. Details are at the end of the report.

Name of signatory

Ted Baker Deputy Chief Inspector of Hospitals