Nuffield Health Hospital Shrewsbury is operated by Nuffield Health. The hospital has a 30 bedded ward. Facilities include three operating theatres, X-ray and outpatient and diagnostic facilities. The hospital provides surgery, and outpatients and diagnostic imaging.

During our inspection we inspected surgery only. We inspected this service using our focussed inspection methodology. We carried out the unannounced visit to the hospital on 19 July 2018.

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. The hospital provided an outpatient service but we did not inspect it on this occasion.

This was a focussed follow up inspection looking particularly at surgery.

Throughout this inspection, we also followed up on concerns raised at the previous CQC inspection conducted in November 2016. We found:

• On the last inspection we told the hospital they must ensure that the World Health Organisation (WHO) Five Steps to Safer Surgery checklist is consistently completed and adhered to at the hospital.

• During this inspection we saw live examples of the WHO checklist being carried out, however, some of the paperwork in a record we reviewed had incomplete WHO checklist paperwork.

• On the last inspection we told the hospital they must ensure steps are taken to improve the infection rates for surgical procedures.

• During this inspection we saw the hospital had greatly improved the level of audit around infection prevention control and audit results were much better. They had also bought in an infection prevention control lead.

• On the last inspection we told the hospital they must ensure all policies are complied with, specifically the antimicrobial policy, fasting arrangements and ensuring patients had sufficient information and time to provide informed consent about their operation.

• During this inspection found that the hospital complied with the antimicrobial policy, fasting arrangements and ensuring patients had sufficient information and time to provide informed consent about their operation.

We rated this hospital as good overall.

We found good practice in relation to surgery:

• Infection prevention and control was well managed; and was regularly audited to ensure staff compliance. This had been an big improvement from the last inspection.

• We found incidents were managed appropriately. Staff were aware of how to report incidents; and supported to do so. Learning was shared to all staff; including learning from incidents which had occurred within other Nuffield Health locations.

• Staff undertook a range of mandatory training subjects, including appropriate safeguarding training for their grade. We saw that staff training compliance was above target.

• Staff were assessed for their competency to undertake their roles. Staff received yearly appraisals.

• Patient outcomes for certain surgical procedures were measured using the Patient Reported Outcome Measures Tool (PROMs).

• Staff were consistently caring and respectful towards patients. We observed direct patient care whereby staff were compassionate and engaged with patient needs and treated patients with dignity.

• The hospital provides dementia friendly treatment and being a dementia friendly environment. The hospitals dementia toolkit was provided along with a ‘This is Me’ form, dignity audit and the dementia letter they shared within the hospital. They were also engaging with Dementia Friends and had pledged to train all hospital staff by the end of 2018.

• Staff worked to meet patients’ individual needs including dietary requirements; spiritual needs and helped them access support.

• The culture of the service was centred on the needs and experience of their patients which also promoted openness and honesty. Leaders encouraged staff to be open and honest with patients when things did go wrong. Staff were proud of the care they provided.

• Senior management had a good understanding of the challenges that the service faced. We found the senior management of the hospital were proactive and sought to rectify concerns quickly.

We found areas of practice that require improvement in surgery:

• WHO checklist paperwork was not always completed in records we reviewed.

• The level of night staffing meant that when one nurse was pulled from the ward then only one staff member would be left to provide patient care on the ward.

• On one occasion we saw the nurse’s office door was left unlocked when no nurse’s were present and anyone on site could have accessed patient records.

• The latest audit results for records were at 67% for the records on the wards and at 68% for theatres.

• One staff member we spoke to was not aware of the translation service and used a family member to translate.

Heidi Smoult

Deputy Chief Inspector of Hospitals (Central Region)

We spoke with three patients who had been admitted to the hospital and one patient who attended the out-patient department. They told us they were happy with the care and treatment provided. Patients praised the staff and the support they had received. For example, one patient told us that staff were “Amazing, very pleasant and very professional”. Another patient told us, “Nothing is too much bother for them”.

Patients’ needs were assessed and care and treatment planned and delivered in line with their individual plan of care. Patients told us they felt safe using the service and had confidence in the staff. Everyone said they would recommend the hospital to others.

Patients considered the service was clean and hygienic. For example, one patient described the hospital as “spotless.”

The hospital had suitable arrangements for the safe storage, handling, administration and disposal of medication. This ensured patients' safety.

There was a system in place for assessing and monitoring the quality of the service. This ensured patients received a service which was of high quality and met their needs.

We spent a day at the hospital, speaking with people using the service and with staff. We also looked at some records to make sure that these accurately reflected people’s care and treatment.

People told us that staff had given them full explanations about their treatment. They said that they were encouraged to ask as many questions as they wanted. We saw that people had signed to indicate their consent to treatment.

People were very positive about the service they received from the hospital. They said that staff responded promptly to any requests for assistance. One person said, “Staff are so polite and very kind".

Effective recruitment systems were in place to make sure that staff were suitable to work at the service.

Measures were in place to reduce the risk of healthcare associated infections.

The service did not have effective systems in place to monitor and address issues when medical staff had not completed the required surgical paperwork.

People told us that they knew who they could talk to if they had any concerns or complaints. They said that they would feel comfortable raising concerns and that they were confident that they would be listened to. Records showed that the service fully investigated any concerns or complaints.

Patients told us that the staff had explained what care they would be receiving. They also told us that their privacy and dignity was always respected by the staff and that the staff were always friendly and professional. All of the patients we spoke to made it very clear that their needs were being met.

Patients told us that they enjoyed the food and made comments such as “Excellent; just like a five star hotel”

They all said that the hospital had identified their medical as well as any personal needs and made every effort to meet them.

They also said that they felt safe and they and their relatives were quite clear that they had no concerns about raising any issues with the matron or her staff.

All of the patients were very complimentary about the staff making comments such as: “All staff are attentive – they always remember requests,” “Staff are excellent” and “Staff are very pleasant”.

Nuffield Health Shrewsbury Hospital is one of 31 in the Nuffield Health Group. It was opened in 1965 and is situated on the south-west outskirts of Shrewsbury.

We inspected the core services of surgical services and outpatients and diagnostic services as these incorporated the activity undertaken by the provider at this location.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 22 September 2016, along with an unannounced visit to the hospital on 7 October 2016.

We rated both core services, and the hospital as good overall. However, we found that safety in surgical services required improvement because we had concerns that safety checks in theatres were not consistently completed and infection rates for some procedures were higher than the national average.

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? 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 section.

We rated this hospital as good overall because:

• Staff worked especially hard to make the patient experience as pleasant as possible. Staff recognised and responded to the holistic needs of their patients from the first referral before admission to checks on their wellbeing after they were discharged from the hospital.
• There were systems and processes in place to promote practices that protected patients from the risk of harm. Openness and transparency about safety was encouraged. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. When something went wrong, people received an explanation, and a sincere and timely apology. There were sufficient and appropriately qualified and experienced staff working on the ward and in theatres to keep people safe at all times.
• The hospital had systems in place to provide care and treatment in line with national guidance. There was effective multi-disciplinary working with informative handovers, good record keeping and communication Staff were able to respond to signs of a deteriorating patient and medical emergencies.
• There was a stable leadership team who were highly regarded by staff. Staff felt supported and proud to work within the hospital. They were very positive about the matron who had been in post for 12 months and made positive changes to the hospital.
• There were sufficient numbers of trained staff to meet the needs of patients. We saw that equipment in all areas was well maintained and kept clean to minimise the risk of infection. Records were available and well maintained.

We found areas of practice that require improvement in both surgery and in outpatients and diagnostic imaging services.

• The World Health Organisation (WHO) Five Steps to Safer Surgery checklist was not consistently completed or adhered to.
• Infection rates for some surgery (primary knee arthroplasty and breast procedures) were higher than the national average.
• We saw that all nursing staff demonstrated good hand hygiene, however, we also observed a consultant wearing a suit jacket whilst applying eye drops for a patient which does not comply with infection control standards.
• Staff mainly understood and their responsibilities to raise concerns and report incidents and near misses but if an incident had not caused harm or disruption to the service they may not always report it.
• There was a lack of compliance with some policies such as the antimicrobial policy, fasting arrangements and ensuring patients had sufficient information and time to provide informed consent about their operation.
• The hospital did not provide a translation service for patients whose first language was not English.
• The ambulatory care unit did not always ensure patients privacy and dignity when treatment was being administered or care discussed.
• The flooring and hand washing sinks in outpatients did not meet current guidelines but the hospital was in the process of replacing them.
• Not all staff we spoke to in outpatients demonstrated full understanding of the Mental Capacity Act.
• 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 one requirement notice that affected surgical services. Details are at the end of the report.

Ellen Armistead

Deputy Chief Inspector of Hospitals