We looked at the care records for 10 people who had used the service. In every case we found the records to be accurate and up to date. Comprehensive care records were used depending on whether the person was a day case or staying overnight. These records included health screening and details of all the staff caring for that person during their stay. It was a comprehensive document with care plans and observation charts included.

We spoke to three people who had used the service. One person told us “it’s fantastic, I can’t fault it here. The staff make sure I am always comfortable and they always explain everything fully”. Another person said “There is nothing I don’t like, the staff have put me at ease and it’s just been perfect”. We were also told “I know I am paying for my care here, but they are all just brilliant”.

We saw that the provider had comprehensive polices in place for infection control. As a result they have had no incidences of surgical site infections, MRSA or clostridium Difficile.

We visited the Nuffield Health Cheltenham Hospital on 8 December 2011 and spent the day at the hospital. We met and talked with patients, visitors, and members of the staff team including the matron who was in charge of the hospital that day. The hospital provided treatment for people over the age of 16 years, and provided consultation for children over the age of three years and up to 16 years old. The hospital offered consultant-led consultation, outpatients' clinics and minor operations, and three theatres for surgical procedures. The hospital had one overnight stay ward with 32 ensuite rooms.

We visited all areas of the hospital during our visit, including the theatre suite, the physiotherapy department, the pathology department, imaging, the ward, ambulatory care, and the outpatient/minor operations clinic area. We talked with a number of the theatre staff, administration and support staff, radiography staff, ward staff, clinic staff, the governance lead (who gave us a tour of the hospital), and the matron in charge.

The hospital was clean and in good decorative order. Corridors, patient rooms, clinical areas and other areas were clean, well appointed and equipped. The hospital was free from obstructions and clutter. Cupboards were closed and locked where appropriate.

Patients that we talked with were positive about their experience at the hospital. One person who had visited the hospital on a number of separate occasions said "the staff were extremely helpful. The nursing staff were particularly attentive". This person also said "my stay couldn't be faulted". One person said that the food was "very good" and another said that it was "mostly good, but you don't always feel like food following surgery, so I've not eaten much." Another person said that the administration at the hospital was "excellent" and "my appointment was made very much to suit me and my other priorities." Another person said "the information I have been given was clear and they are very knowledgeable as they have fully answered all my questions".

Staff told us about working for the hospital, how they were supported and about their delivery of care. We were given information about training, development and appraisals; how privacy and dignity was maintained for patients; and how the hospital assessed and monitored care. We also looked at medicines management and checked how the hospital prescribed, stocked and administered medicines.

We inspected the hospital for five of the essential standards of quality and safety and found it to be compliant with all these standards.

We carried out this inspection as part of our programme of independent healthcare inspections under our new methodology. The comprehensive inspection was carried out through an announced visit on 15 and 16 March 2016. We did not carry out an unannounced inspection.

Our key findings were as follows:

We rated the hospital as good overall, with surgery, rated as good in all domains, children and young people’s services and outpatients and diagnostic imaging services were also rated good in all domains except for effective which we did not rate due to insufficient evidence being available.

Are services safe at this hospital/service

• Most staff spoke confidently about the duty of candour and training had been provided in some cases. However some staff were not familiar with the term duty of candour. Staff we spoke with confirmed they informed and apologised to patients when care was not as it should have been.

• Safeguarding practices were clear and staff were aware of the actions needed if they had concerns. Staff demonstrated an understanding of their safeguarding responsibilities and an understanding of safeguarding procedures. There had been no safeguarding concerns relating to adults or children reported to CQC between October 2014 to September 2015.

• The systems in place to monitor patient safety including the World health Organisation (WHO) checklist were mostly in place and well managed.

• The service had a good reporting culture for incidents and took learning from those and incidents which were reported at other Nuffield hospitals. Quarterly governance meetings were held which were attended by representatives of each department and reported incidents were discussed.

• Each patient’s consultant was the overall person in charge of their care and undertook any post treatment reviews. Out of hours the consultant was called if needed and we saw when this had taken place. In the interim the Registered Medical Officer (RMO) was available to provide medical support should the consultant not be available. An escalation procedure was in place for nursing staff to escalate to the RMO and for the RMO to escalate to the consultant for the patient.

Are services effective at this hospital/service:

• Treatment was provided in line with national guidance and staff were aware of the relevant National Institute for Health and Care Excellence (NICE) guidance. Policies and procedures were in place to support staff and were monitored to ensure a consistency of practice.

• Reviews took place of the effectiveness of surgical procedures. The reviews took place through the Medical Advisory Committee meetings which took place quarterly where issues, incidents and clinical outcomes were reviewed to ensure good practice.

• The Hospital participated in the Patient Led Assessment of the Care Environment (PLACE) audit annually which was undertaken by 'expert' patients provided by the Health and Social Care Information Centre together with the Hospital's Infection Prevention Coordinator.'

  The hospital's PLACE scores were the same or higher than the England average for cleanliness, dementia, food, privacy, dignity and wellbeing.

• Some information about patients care and treatment and their outcomes was collected and monitored. There was not always sufficient data to submit to national audits. Local audits were undertaken using a system called GOV14 to review 20 patient records per quarter for venous thrombo embolism (VTE), falls, catheter care and monitoring of the WHO checklist. Local audits were carried out in diagnostic imaging for example monitoring the quality of plain film x-ray results and levels of radiation that staff experienced while carrying out their duties. Cleaning audits were in place to ensure monitoring of the environment.

• Systems were in place to ensure staff were competent to care for children and young people of the age range that visited the hospital as outpatients. Guidance was available and easily accessible for staff to follow if they were unsure of procedures.

• Most of the consultants worked in the NHS and so received their appraisal and revalidation there and the information was forwarded on request to Nuffield Cheltenham. The hospital had a responsible officer in post to ensure those consultants not employed elsewhere for validation purposes were suitably appraised and revalidated.

• Staff were aware of their duties in law when obtaining consent and ensured explanations were given to patients in a way they could understand.

• Nuffield staff told us that the Nuffield Cheltenham does not accept referrals for patients who lack the capacity to consent, however the provider told us they did.

Are services caring at this hospital/service

• Patient feedback about the care provided was positive. Staff were seen to be kind and caring and their focus was on individualised patient care. Patients were kept informed at all times about their plan of care and their relatives and carers were encouraged and supported to be involved in the patients care. This included both the admission and discharge process. Patient’s privacy and confidentiality was respected at all times.

• We saw staff working with patients and those who attended outpatient appointments with them in a respectful and considerate manner. Some patients had mobility issues and staff ensured that patients and those with them were not rushed when they called patients and showed them where they were to go.

• We chose a random selection of ten patient satisfaction survey forms from approximately 100 available in the breast care service in outpatients. All ten were positive comments.

• The Friends and Family Test scoring system was in place for NHS surgical patients. For patients funded by any other method an alternative scoring system was in place to gather patient’s views.

• For NHS patients the sample size was small due to the low numbers of NHS patients but the scores were high which indicated satisfaction with the service.

Are services responsive at this hospital/service

• Services were planned to meet patients’ needs. The flow of admissions and discharges through the hospital was well organised. The needs of different patients were considered in the planning and delivering of the service. The provider was aware of further work needed to develop dementia care as part of the service and was taking action to address this shortfall.

• Complaints were responded to in a timely manner and learning taken to develop future practice. CQC did not directly receive any complaints about the hospital between October 2014 and September 2015. All complaints, investigation findings and lessons learnt were captured centrally with review at quality and safety committee

• Care and treatment was only cancelled or delayed when absolutely necessary. We saw evidence of reasons for when patients had appointments cancelled which were shared with patients for example delays in consultants attending the hospital. The cancellations were explained to people honestly and patients were supported to access care and treatment again as soon as possible.

Are services well led at this hospital/service

• The vision and objectives for the service were evident and understood by staff.

• There were clear governance processes in place to monitor the service provided. However, some areas including the management of Venous Thrombo Embolism needed further development to ensure they were safe.

• Leadership at each level was seen to be visible and responsive. Staff had confidence in leadership at each level.

• The senior management team were aware of the risks in the hospital and there was an effective governance framework to support the delivery of good quality care through actions from meetings.

• Staff we spoke with described feeling part of a team and that they were respected and valued.

Our key findings were as follows:

• Overall the service leadership was good because leaders engaged with staff and people working at the hospital and acted on suggestions and outcomes of learning from incidents and complaints.

• Cleanliness was good in all departments and, infection prevention and control was managed well.

• The systems in place to monitor patient safety including the World health Organisation (WHO) checklist were mostly in place and well managed.

• Full records for children being seen in outpatients were not available to hospital staff.

• Staffing levels in all departments were safe.

• The hospital did not hold morbidity and mortality meetings. There were no unexpected deaths and no cases of mortality between October 2014 and September 2015.

• All patient complications were reviewed by the Medical Advisory Committee (MAC).Patients received treatment which considered their levels of pain and their nutritional and hydration needs.

• The Hospital had established two new services in the previous 12 – 18 months. A private breast care service which included a clinical nurse specialist in breast care, a certified complementary therapist and a private multidisciplinary team to support the four breast surgeons.

• Complaints were managed and investigated with learning being shared within teams.

There were also areas of poor practice where the provider needs to make improvements.

Importantly, the provider MUST take action to:

• Ensure that all records are stored securely and there are no risks of patient confidentiality.

• Ensure that the management and recording of venous thromboembolism prophylaxis is clarified. That risks are appropriately recorded and managed and policies ensure patient safety.

• Maintain secure, accurate and contemporaneous patient records at the hospital, including a record of the care and treatment provided to the service user and decisions taken in relation to the care and treatment provided

• Ensure that World health organisation checklists are signed correctly by all staff including consultant staff working in imaging.

The hospital SHOULD take action to:

• Ensure sufficient World Health Organisation audit records are in place to provide reassurance that sufficient have been completed to provide an accurate measure.
• Ensure that safety audits for non NHS patients are undertaken to ensure safety of all patients.
• Improve the labelling and security of medicines prepared for operating theatres, ensuring they are disposed of within appropriate and safe timeframes.
• Ensure leadership arrangements for services for children and young people’s services are defined.
• Ensure all staff having contact with children and young people are trained as outlined in national guidance - Safeguarding children and young people: roles and competences for health care staff, March 2014.
• Consider improving links with local safeguarding children boards.
• Consider providing information suitable for young people attending as patients.
• Consider how to gather feedback from children and young people.
• Ensure that regular feedback on voluntary monitoring of radiation exposure levels to staff is obtained within recommended time frame.
• Ensure that required mandatory training is completed for outpatients and diagnostic imaging staff.
• Ensure that major incident scenarios and practice include outpatient department and imaging staff and are held to supplement the business continuity plans.

Professor Sir Mike Richards

Chief Inspector of Hospitals