We carried out an unannounced inspection the Nuffield Bristol hospital on 14th April 2016. The purpose of this inspection was to follow up on our last inspection in February 2015 where we found concerns with the services for children and young people.

The concerns were inadequate provision of resuscitation equipment for children under the age of 12 years and there were insufficient numbers of staff trained in paediatric life support. There was only occasional practice at the hospital which limited staffs ability to maintain their skills and experience. Some consultants were only engaging in occasional practice with respect to services for children and young people. National guidance identifies occasional practice should not occur. We also found the competency tool used to train staff to manage the care of children and young people was poor and did not properly assess the skills needed. The hospital did not have appropriate staffing or skill mix to provide safe care and treatment for children and young people.

We carried out this focused inspection of the hospital to follow up on the areas rated as inadequate in our inspection in February 2015 The inspection team inspected the Children’s and Young Peoples service.

Are services safe at this hospital/service

We found that there were sufficient suitably qualified, competent and experienced staff managing the care of children and young people and there was sufficient equipment available to respond in an emergency. Patient records were filled in correctly and assessments based on the clinical need of patients.

Are services well led at this hospital/service

We found that there was sufficient oversight and senior leadership to provide the expertise and accountability to ensure that the children’s and young people’s service was well led. Governance process were children and young people focused and there was sufficient time given in the MAC for children and young people.

Our key findings were as follows:

• There was adequate resuscitation equipment for children and young people.

• There were suitable numbers of qualified, competent and experienced staff for children and young people.

• Records and risks were appropriately managed to meet the needs of children and young people.

• There were sufficient governance processes in place to ensure that children and young people had adequate oversight on the MAC.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Nuffield Health Bristol - The Chesterfield is an independent hospital run by the Nuffield Health corporate group. It opened in November 2013 following the redevelopment of the site, although there had previously been a hospital there until 2010. The hospital provides inpatient surgical treatment to adults and children over the age of 12 years and outpatient treatment to adults and children from birth upwards. Surgical specialities at the hospital include orthopaedics, including spinal orthopaedics, spinal neurosurgery, general surgery, breast surgery, ear, nose and throat surgery, gynaecology, urology, cosmetic surgery, ophthalmology, vascular surgery, gastroenterology, and pain management. We carried out this comprehensive inspection as part of our wave 2 pilot of in-depth reviews of independent hospitals. Our inspection was carried out in two parts: the announced visit, which took place on 24 and 25 February 2015 and the unannounced visit, which took place on 10 March 2015. Our key findings were as follows: Safety

• There was a good safety culture within the hospital. Staff were aware of how to report incidents and felt supported to do so. Incidents were investigated and learning was shared with staff.
• Infection control practices were effective within the hospital. Premises were clean and uncluttered, with alcohol gel and hand-washing facilities available throughout. Staff used personal protective equipment and observed ‘bare below the elbow’ policies.
• There were risks to security out of hours, which meant that patients may be unsafe.
• Surgical safety systems were embedded in practice to support patient safety.
• There were sufficient levels of staff in all areas of the hospital. However, staff did not have sufficient qualifications, skills and experience to care for children and young people in a surgical setting. Only occasional practice took place at the hospital which limited staff ability to maintain their skills and experience. Some consultants were only engaging in occasional practice with respect to services for children and young people. National guidance identifies that occasional practice should not occur. Not all consultants who were providing care for children and young people, undertook NHS practice and the majority of the surgical work they carried out was on adults. We were not assured that they had sufficient skills and experience to provide care and treatment to children.
• Children and young people receiving surgical treatment were assessed against criteria including age, weight and height and considered as the same as adults. There was little consideration that children, no matter their weight and height, deteriorate in a different manner to adults and that, despite their physical appearance, may not be as psychologically or emotionally mature as adults.
• Although appropriate resuscitation equipment was available on the ward for the age, size and weight of the children admitted as in-patients not all the required resuscitation equipment was in place for children under 12 years of age on the hospital site. Not all key staff who were providing care for children and young people had been trained in basic paediatric life support, although, this had been identified and training sessions had been booked for the month following our inspection.
• We wrote to the provider (Nuffield Health) to make them aware of our concerns regarding the care and treatment of children at this hospital. They agreed not to provide any services to children and young people until the concerns raised were rectified. As a result we did not undertake any enforcement action at this stage.

Effective

• Improvement was required in the effectiveness domain because the hospital was not monitoring outcomes sufficiently to provide assurance of the quality and safety of the service. There was no evidence that patient outcome data was used to improve the quality and safety of the service. The provider participated in some national audits relating to surgery, although not all data was available to us. There were benchmarking audits undertaken within the Nuffield Health group. However, despite our requests, data regarding patient outcomes and external benchmarking data and information was not made available to us during the inspection process.
• There were effective pain management practices on the wards. Patients received pain relief promptly and when required in an outpatient setting. This was managed on an individual basis by the consultant and resident medical officer.
• Patients were monitored well to ensure they had sufficient nutrition and hydration.
• Although not all services were available on seven days of the week, there was flexibility. Theatres were open from Monday to Friday between 8am and 8pm and on Saturday between 8am and 4pm. There was on-call provision to ensure that where required, a patient could return to theatre in an emergency 24 hours a day and seven days a week. There was specialist pharmacy and pathology advice available on an on-call basis.
• There was good multidisciplinary working throughout the hospital.
• Consent for surgical procedures was taken on the day of surgery, although patients told us they had discussed the procedure with the consultant prior to this. Documentation relating to consent for children and young people having surgery showed that although consent had been sought from parents, there was no record that the child or young person’s view had been sought.
• Staff demonstrated variable understanding of the Mental Capacity Act 2005 and further training was planned for the week after our inspection. There was a dementia lead in the hospital, who was used as a source of reference for staff.

Caring

• We saw staff throughout the hospital treating patients with kindness and compassion. This included housekeeping and catering staff. As there were no children or young people receiving care within the hospital at the time of our inspection we were unable to assess the caring nature of this service.
• There was support available for adult patients who were vulnerable or had extra care needs. Visiting hours were flexible and there were facilities for relatives to stay overnight to support their emotional wellbeing.
• Information was provided to patients in a way that they understood and appreciated. Procedures were explained thoroughly at pre-assessment and again when patients were admitted to the ward prior to surgery. Patients were encouraged to bring a relative or friend with them to appointments and we observed that where appropriate, the relative or friend was engaged in the discussion about care and treatment.

Responsive

• The hospital was responsive to the needs of patients using the services. Admission, treatment and discharge pathways were well organised and flexible so that they were responsive to patients’ changing needs.
• Outpatient capacity was managed well and patients were given flexibility to make choices about their care and treatment times.
• Staff worked in a flexible manner to meet the theatre schedule and ensure that patients’ needs were met.
• Patients had a choice of menu which met their needs. Food to meet people’s special dietary requirements and religious or cultural needs was provided. We saw examples where the menus were changed to meet people’s needs and if they stayed in hospital for a longer period of time.

Well led

• Staff throughout the hospital felt supported by both their line managers and the senior leadership team in the hospital. The hospital director had developed a supportive and empowering culture where staff felt able to raise concerns and to suggest improvements or changes.
• Staff were aware of and worked in accordance with the values and principles of the hospital.
• There was a governance structure in place where key performance indicators were reviewed and discussed through the integrated governance committee, hospital management operations group and the medical advisory committee. However, there was insufficient oversight of the service for children and young people. For example, there was no lead consultant to provide advice and oversight of the service for children and young people on the medial advisory committee. The risks to children and young people were not managed appropriately or in accordance with Nuffield Health corporate policy. Few of the concerns regarding the service for children and young people, including the non-compliance with Nuffield Health policy, had been identified.
• When we raised concerns with the senior management team during the inspection, our concerns were not immediately recognised and the management team’s response showed a lack of insight and understanding of the issues raised.
• There was evidence that, with exception of the services for children and young people, the governance structure worked well. Key risks were identified and managed

We saw several areas of outstanding practice, including:

• The number and flexibility of staffing in adult services were excellent. Staffing levels were adjusted for according to patient numbers, dependency and acuity. Staff were allowed to leave early if workload permitted, but equally stayed late if required.
• The choice and quality of food provided to patients in the hospital was excellent. There was flexibility within the menu to provide food that met people’s needs and was not repetitive for those patients who stayed in the hospital for longer periods of time.

However, there were also areas of poor practice where the provider needs to make improvements. Importantly, the provider must:

• Ensure that there is sufficient data collection, external benchmarking and monitoring of outcomes for patients in order to provide assurance of the effectiveness of the service. Insufficient data was available to identify patients’ outcomes in all areas.
• Ensure that there are sufficient numbers suitably qualified, skilled and experienced staff, employed by the provider to ensure standards of safety of children and young people are met and are meeting the requirements set out in national guidance, prior to providing any further services to children and young people.
• Ensure that there is adequate resuscitation equipment and medicines to ensure safety of children and young people, prior to providing any further services to children and young people.
• Ensure that consent of children and young people is appropriate, with consideration to the capacity of the child, prior to providing any further services to children and young people.
• Ensure that there is sufficient leadership and oversight of services provided to children and young people, prior to providing any further services to children and young people.

In addition the provider should:

• Provide sufficient training to make sure that all staff have a clear understanding of the Mental Capacity Act 2005.
• Provide sufficient mandatory training in basic life support.

Professor Sir Mike Richards

Chief Inspector of Hospitals