This was a focused, unannounced inspection, which looked at surgery services. As such, we focused on specific aspects of four out of the five domains to assess whether surgery services were safe, effective, caring and well led. We did not examine the responsive domain to assess whether the service was organised in a way that met people’s needs.

Overall we found that the service was not always protecting people from risk of harm because:

• The routine management of infection control was on-going with audit tools to monitor the infection prevention practice. However, prior to and during the building work, minimal expert advice was sought and we saw that areas of the theatre department were not monitored to ensure good infection control practice during the project.
• Reliable systems were not in place to protect staff and patients from the risks associated with inappropriate waste storage.
• The security of the hospital and theatre areas in the day could not be assured and fire safety and storage of equipment was not consistently safe.

• Arrangements for managing medicines, which included handling and storage, did not always keep people safe. Staff pre prepared syringes for use and were seen to leave them unattended for periods of time. Medicine audits had not been completed to provide the service with assurance about their medicine systems.
• Not all entries in people’s individual care records were consistently written and managed in a way that keeps people safe.
• The systems used to assess if a patient was deteriorating (National Early Warning Scores) were not fully completed and placed the patient at risk.
• Theatre staff were seen to engage fully in the World Health Organisation checklist (WHO) to ensure safe practice in theatre. However audits of records were not well maintained for the provider to assure themselves that this practice was consistent.
• Staff we spoke with said their competencies had not been assessed by line management.
• We were not assured staff received a regular appraisal. In 2014, 75% of staff received an appraisal. The appraisal system was changed in 2015 and it was difficult to assess how many staff had received an annual appraisal.
• The hospital did not give due regard to providing an environment in which patients’ privacy and dignity could be maintained at all times during their care and treatment in theatre. The positioning of theatre windows in theatres one and two meant that staff could see into theatre from the main theatre corridor. Other staff could see into theatre from the rear access corridor.
• There was an annual audit programme in place in which a variety of outcomes and data were audited to monitor quality and safety. However, some audits identified areas that were not performing well, and there were no actions to show how the hospital were going to make improvements in these areas. A number of these audits were not completed at all, and some were not completed in line with their schedule

However:

• There was a governance structure in place to support the provision of good care. Staff understood who to report to and how information was shared to improve performance.
• The hospital promoted a culture of reporting and learning from incidents.

This inspection was undertaken in response to information received by CQC from the registered provider relating to cataract procedures during surgery. This information related to incidents which had affected a number of patients. We saw immediate action had been taken to ensure the safety of people using the service. A full investigation had taken place and an action plan implemented to reduce any further risks. Learning from the incidents had been identified and changes made to practices at the hospital, staff members had been updated and further training provided.

During this inspection we spoke with two patients and one visitor on the ward, we also spoke with seven members of staff. We looked at the environment of the hospital and reviewed two sets of records for patients who had received care and treatment.

Patients told us that they were very happy with the care they had received and felt the hospital staff had provided them with good care. They told us “They couldn’t do better here, everything is excellent”.

We saw appropriate arrangements were in place for the safe management of medicines.

Systems were in place in the hospital to identify, assess and manage risks relating to patients health, welfare and safety. Further monitoring of the quality of the service enabled changes to be identified and be made to improve the service when needed.

On the day of our visit we walked around the hospital, we visited the wards and the outpatients department. There were 22 inpatients and five people receiving day care surgery.

We spoke with nine patients. We also spoke with the manager, matron, registered nurses, care staff and ancillary staff in outpatients and on the ward.

We saw that staff treated people with respect and kindness. Staff responded to people's requests and listened to what they had to say. People told us they were very well cared for. One person said "I think the whole place is exceptional, the staff present well and you know who they are. The standards and the environment is exceptional absolutely outstanding”

We looked at the care records for five of the people who were inpatients at the hospital following surgery to find out how their health and personal care needs had been assessed, and how the hospital staff planned to meet those needs. We saw evidence that care records were completed well and updated as people's needs changed.

People were protected from the risk of infection because appropriate guidance had been followed. People were cared for in a clean, hygienic environment.

The provider had effective recruitment procedures to ensure that staff were suitable to work with vulnerable people. Staff turnover was low, which supported consistent care. The service was well lead with a robust system of monitoring of the quality of care.

On the day of our visit we walked around the hospital, we visited the wards, the outpatients department and the cosmetic suite.

We visited both theatres. We looked at how the operating theatre staff ensured safe surgery by using a safe surgery checklist.

We spoke with five patients and one relative. We also spoke with the manager, matron, registered nurses and care staff in all areas. We also spoke with a physiotherapist.

We saw that staff treated people with respect and kindness. Staff responded to people's requests and listened to what they had to say. People told us they were very well cared for. One person said “The staff are just fantastic, so kind”.

We looked at the care records for three of the people who were inpatients at the hospital following surgery to find out how their health and personal care needs had been assessed, and how the hospital staff planned to meet those needs. We saw evidence that care records were completed well and updated as people's needs changed.

One person we spoke with told us “I cannot wish for any better care, they are always popping in to check on me, it’s marvellous”.

People using this service felt safe and were confident that staff had the skills needed to safeguard them and to meet their needs. Staff training, supervision and annual appraisals were linked to ensuring that staff had the skills to meet people’s needs.

Records were kept securely and could be located promptly.

On the day of our visit we walked around the hospital spoke with 6 patients and one relative. We also spoke with the manager, matron, three staff nurses, two care staff and a physiotherapist.

All patients said they felt safe and said staff were very kind to them. We had many positive comments about staff. One patient said, 'The staff are really lovely”.

Patients said their privacy was protected and that they felt staff were respectful during their visit to the hospital. Patients also told us that they had felt involved in planning their care or treatment.

Patients told us that Mount Stuart was "Wonderful" and said "Its first class". One

person said she got " Everything she needed and more ".

Throughout the visit we saw staff talking to patients in a kind and friendly way and caring for them in a polite and professional manner. The staff said that they enjoyed working at the hospital and supporting the patients. The atmosphere throughout the hospital was professional, friendly yet organised and calm.

We saw that the hospital was clean and hygienic throughout and that the building, facilities and equipment were being well maintained.

Patients said they knew how and to whom to complain.

Mount Stuart Hospital is operated by Ramsay Health Care.

This inspection was a follow-up to our 2016 inspection and we only looked at areas previously found to need action.

We carried out a comprehensive announced inspection of Mount Stuart Hospital on 6 and 7 September 2016, and an unannounced inspection on 15 September 2016. We found that safety, effectiveness and well-led had areas for improvement and breaches were found under four regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. An extensive action plan was provided by the service to meet those areas and it is recognised that significant improvements have been made.

We inspected surgery and outpatients under the domains of safe, effective and well-led. We did not inspect any elements of caring or responsive.

Surgery, and outpatient and diagnostic services are provided at the hospital. Day case and inpatient surgery specialities included general surgery, major and minor orthopaedic surgery, ophthalmology, ear nose and throat surgery, gynaecology, urology, dermatology, endoscopy and cosmetic surgery.

The hospital has 26 single room inpatient beds of which 23 are currently in use and 12 ambulatory care spaces. There are three main operating theatres each with air flow systems suitable for their use, one day case theatre, and a recovery area.

Outpatient and diagnostic services are delivered in consulting rooms and include orthopaedics, general surgery, gynaecology and obstetrics, cosmetic surgery, ear nose and throat, urology, oral and maxilla, ophthalmology, gastroenterology, dermatology, and facial surgery.

Diagnostic imaging services include plain x-ray, ultrasound, and fluoroscopy, magnetic resonance imaging (MRI) and computed tomography (CT) is provided from a mobile unit. There was a private physiotherapy service for outpatient and inpatient services. Non-surgical cosmetic treatments are delivered by the cosmetic suit.

We inspected this service using our inspection methodology. We carried out an unannounced visit to the hospital on the 25 and 26 June 2018.

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

Services we rate

We rated this hospital/service as good overall.

• Staff were suitably skilled to meet the needs of the patients. Mandatory training was provided for all staff and monitored to ensure all staff remained suitably skilled and updated. Staffing was planned and managed to ensure sufficient staff were available. Staff were appraised to ensure they had the skills, knowledge and experience to deliver effective care.
• Systems were followed to ensure cleanliness of the departments and promote infection control. The arrangements for managing waste in the hospital environment kept people safe. The systems and processes to manage the environment and equipment kept patients safe.
• Patients were suitably assessed and systems were provided to respond to risks to ensure patient safety. Risk assessments were completed to measure and manage patient risks. The safeguarding systems and processes ensured patient safety.
• Care and treatment was provided using best practice standards and evidence based guidance. Management of medicines was safe. The nutritional needs of patients were reviewed, assessed, monitored and met and patients’ pain was assessed and managed to ensure patients were comfortable.
• The outcomes of patients’ care and treatment were collected and monitored to measure the quality of the service provided. Incidents were recorded and reviewed to provide learning and prevent reoccurrence.
• Staff worked well between departments and with external services. Patient records were well maintained and stored securely.
• Consent was appropriately sought for each aspect of care and treatment.
• We saw leadership of each department was well organised and proactive. The senior staff had developed a local vision to complement the corporate vision and strategy.
• There were clear governance processes to monitor the service provided. Risks and audits were used to prompt remedial action and change practices to improve the service.

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

• The lack of permanent theatre staff impacted on procedures being undertaken. The fragility of theatre staffing had a direct impact on patients as procedures sometimes had to be cancelled.
• Cosmetic surgery practice was not monitored to ensure practice was in line with the Professional Standards for Cosmetic Practice – Cosmetics Surgical Practice Working Party, Royal College of Surgeons (RCS) Professional Standards.
• The matron had the responsibility to decide which incidents had an investigation. This response was not formalised to ensure a standardised approach was taken.
• There continued to be no assurance to confirm the photographs taken by consultants on their own cameras were held securely and images were deleted from the device or memory card immediately after they had been printed or sent to the patient.
• On call arrangements were not well organised to ensure patient safety and clear decision making processes
• The risk register recorded risks and action which were not all addressed in a timely manner.
• The staff survey results for 2018 showed that some areas of senior and corporate management scored poorly.

Following this inspection, we told the provider it should make improvements, even though a regulation had not been breached, to help the service improve. Details are at the end of the report.

Amanda Stanford

Deputy Chief Inspector of Hospitals (South)