We looked at four care files and found that these were well documented by the staff that looked after the patient. All patients confirmed they had consented to the treatment during the pre-operation appointment. We also looked at four staff files and found that they were well organised and most of the information was available, however two files had limited evidence of conduct in previous employment and we raised this with the provider during this visit.

We spoke with three patients and four staff members during this visit. They all agreed that the staff were very attentive, kind and polite. Other comments included “The food is very good. You can have anything you want”, “Staff respond to the call bell quickly”, “The staff are lovely and the room is fine” and “Visitors are made welcome.”

We received positive feedback about the staff team and we observed staff carrying out their duties. The staff appeared organised and attentive to patients needs.

On discussions with the staff team it was evident that they were aware of the patients needs and that they had taken time to read their care records. Other staff comments included “The staff team are brilliant. They all work in a professional manner”, “The new matron is approachable, full of energy and dynamic”, “The work is varied and there is lots of different things to do. The staff are a nice group of people” and “We are well staffed and have a good mix of skills.”

We spoke with some of the patients who were on the ward and they all agreed that the staff were very nice, polite and respectful and we observed staff responding to patients with patience and kindness.

Patients told us that they felt well cared for and safe and they were satisfied with the support they received.

We received positive feedback about the staff team and we observed staff carrying out their duties. The staff appeared organised and there were sufficient numbers of staff on duty to meet the needs of the patients. We were told that there is an open atmosphere and that the manager and staff team were approachable. Other comments included “Excellent can’t fault it. Had a booklet with information of procedure. All explained prior to coming in. Staff answers the buzzers quickly. Food okay, fair choice”, “First class food. Excellent care. Staff are absolutely wonderful. Everything explained fully staff have looked after husband as well. Would recommend it” and “You choose meals from a menu and the choice is good. The food is very nice here. My pre-assessment was completed over the phone with the nurse and then I signed to agree to treatment when I was admitted. The staff are very good. They are polite and friendly. I have no complaints. I think the room and general environment is good.”

On discussions with the staff team it was evident that they were aware of the patients needs and that they had taken time to read their care records. Other staff comments included “It is a nice place to work. The staff are friendly”, “The hygiene of the ward has improved since the new head housekeeper has been appointed and there have been many staff changes recently and new rotas, which I prefer”, “The training is good. We have mandatory training each year and other training that we complete. We get regular meetings and supervision sessions”, “The company are good to work for and very good about being flexible for me. The staff team are brilliant and work well together” and “The matron is very supportive and will help out when needed. I enjoy coming to work and there is a good team spirit here.”

On discussion with the Matron, who is the head of clinical governance, she showed us provider compliance assessments (PCA) that had been completed for many of the outcome areas. The areas we looked at during this visit had been completed well and showed where further evidence could be found. This demonstrated that the Matron was aware of the regulations and outcomes with regard to registration with the commission and she was able to show good evidence of compliance. She said that she used the tools as part of the audit process.

Nuffield Health, The Grosvenor Hospital, Chester is an independent hospital, based in a semi-rural location in Chester and is part of Nuffield Health. The hospital is registered to provide the following regulated activities:

• Diagnostic and screening procedures

• Family planning services

• Surgical procedures

• Treatment of disease, disorder or injury.

The hospital director is the registered manager, supported by a senior management team. The hospital director also managed another Nuffield Health hospital at the time of the inspection.

This inspection was carried out as part of our ongoing programme of comprehensive independent health care inspections. We inspected the hospital on 26 and 27 July 2016 as an announced visit. During the inspection there were scheduled surgical procedures and outpatient clinics taking place and also radiological investigations and physiotherapy clinical sessions. On 4 August 2016 we also carried out an unannounced inspection when there were surgical procedures, radiological investigations, physiotherapy clinical sessions and outpatient clinics taking place.

We inspected the core services of medicine, surgery and outpatients and diagnostics at the hospital.

Are services safe at this hospital

• There were good systems in place to prevent avoidable harm. These were being implemented appropriately at the time of the inspection.

• There was a culture of openness, reporting and investigation of incidents amongst staff. There were systems and processes in place to report incidents and to ensure learning from them. There was evidence of positive improvements and changes made as a result of incidents. Learning was disseminated to staff both within the various departments in the hospital and where relevant to other Nuffield hospitals to help prevent future occurrences.

• There were 261 clinical incidents in the reporting period (Apr 15 to Mar 16). Out of those, 49% (128 incidents) occurred in surgery or inpatients and 32% (83 incidents) in other services. The remaining 19% of all clinical incidents occurred in Outpatients and Diagnostics (50 incidents). The hospital reported no incidents as severe or death. For the time period April 15 to March 16, the assessed rate of clinical incidents in surgery, inpatients and other services was not high when compared to the average rates of other independent acute hospitals.

• The hospital provided a system to identify and safeguard the needs of vulnerable adults, children and young people. Staff were aware of their responsibilities and the correct procedures to follow if a patient was at risk. Safeguarding training formed part of the hospital’s mandatory training programme and included information on Female Genital Mutilation and Child Sexual Exploitation. There was a lead nurse for safeguarding and there was evidence that safeguarding concerns had been raised appropriately.

• Systems were in place to protect people from the risk of healthcare related infections. There were no reported healthcare related infections at the hospital in the period April 2015 to March 2016 and there were no reported incidents of acquired venous thromboembolism or pulmonary embolism in the same period.

• Risk assessments were carried out for patients and stored in patient records. The hospitals reported that 100% of patients had been screened for venous thromboembolism (VTE) in the period April 2015 to March 2016.

• The environment was generally visibly clean and tidy; w Action plans were in place, if necessary and were reviewed regularly.

• The hospital performed well in the Person-Led Assessment of the Care Environment (PLACE) audits. The results showed that the hospital performed better than the national average for cleanliness, and condition appearance and maintenance.

• Records were kept securely and contained all the relevant information required; they were generally comprehensive and legible.

• Medicines were stored securely and there were processes in place to ensure they remained suitable for use. There were pharmacy audits and controlled drugs audits completed.

• Staffing levels were planned and implemented to ensure that there was sufficient staff on duty to provide safe care. This included the resident medical officer (RMO) cover. There was very low use of agency staff.

• During the inspection, we found that the ‘duty of candour’ regulations were being implemented appropriately following patient harm. The duty of candour is a regulatory duty that relates to openness and transparency and requires providers of health and social care services to notify patients (or other relevant persons) of ‘certain notifiable safety incidents’ and provide reasonable support to that person. We saw examples of this process and were satisfied that the process was in line with organisational policy and national guidance. Records showed that patients were involved and updated about investigations, invited to discuss the circumstances with senior staff and received an appropriate apology for the harm caused.

• However, the presence of carpet flooring in some clinical and ward areas were contrary to infection control best practice.

• There were some areas of low compliance with mandatory training in the hospital, including Mental Capacity Act, Consent, Deprivation of Liberties, and basic and immediate life support.

Are services effective at this hospital

• There were local policies and procedures in place and we saw evidence that departments followed relevant guidelines. The hospital kept their practices up to date and current by ensuring they were consistent with latest guidance such as those from the National Institute of Health and Care Excellence (NICE) and the relevant Royal Colleges’.

• Patients were prescribed analgesia to relieve pain and received the medication in a timely manner.

• Nutrition and hydration was assessed, information on fasting for surgery was available and there was dietician support and advice available for patients.

• There was a comprehensive induction programme in place for new staff.

• The hospital was generally performing similar to, or better than the England average, for outcomes in relation to knee and hip replacements.

• Staff were observed working in partnership with a range of staff from other teams and disciplines including allied health professional, consultants and administration staff. Staff told us there were very good working relationships and a culture of respect and collaboration. There was a good external working relationship with the local NHS acute hospital and staff were able to access necessary services. There were several service levels agreements in place.

• The hospital performed well in the Person-Led Assessment of the Care Environment (PLACE) audits. The results showed that the hospital performed better than the national average for food, organisational food and ward food.

• Mandatory training subjects included the Mental Capacity Act (2005), the deprivation of liberty safeguards and consent. However, we found inconsistency amongst staff and uncertainty over who was responsible for determining patients’ capacity to consent and how assessments were conducted in practice.

• Where patients had signed the consent form in advance of the day of surgery the confirmation of consent was not always completed on the day they were admitted to receive the surgery.

• Patients’ undergoing cosmetic surgery were not always assessed psychologically before their surgery, there was no formal system in place to monitor the necessary cooling off period and the hospital did not have a cosmetic surgery specialist nurse.

Are services caring at this hospital

• Patients we spoke to were positive about staff and confirmed that staff were kind, considerate and treated them with dignity and respect.

• We observed staff being attentive and caring to patients during the inspection.

• The NHS friends and family test (FFT) is a survey, which asks NHS patients whether they would recommend the service they have used to their friends and family. From April 2015 to March 2016, hospital wide, 100% of NHS patients would recommend the service to their family or friends, the response rate was 49.9%.

• All patients were provided with a satisfaction survey following treatment. At May 2016 patient satisfaction was 96% which was better than the Nuffield hospitals as a whole and was better than the internal target of 95%.

• The hospital performed well in the Person-Led Assessment of the Care Environment (PLACE) audits. The results showed that the hospital performed better than the national average for privacy, dignity and wellbeing.

Are services responsive at this hospital

• The hospital had service level agreements in place with local NHS providers to meet the demands of the local population.

• Information provided regarding waiting times for treatment for NHS patients, also known as referral to treatment times (RTT) showed that from April 2015 to March 2016, on average 91% of patients referred to the Grosvenor Hospital were admitted for treatment within 18 weeks of referral.

• The hospital had introduced a health MOT for patients attending for pre-operative assessments. This was a comprehensive assessment of the patients holistic health and well-being including exercise, diet and lifestyle factors. A report and associate advice and guidance were provided to the patient in order to optimise their health for surgery but also for their future health and wellbeing.

• There were systems in place to support vulnerable patients and care was planned based on a patients individual needs.

• The hospital offered a professional face to face interpreter service for patients whose first language was not English. They were able to use the services of a telephone translation service where an interpreter was required at short notice.

• The hospital performed well in the Person-Led Assessment of the Care Environment (PLACE) audits. The results showed that the hospital performed better than the national average for dementia care.

• The hospital received 54 formal complaints between April 2015 and March 2016 for the whole hospital. The rate of complaints (per 100 day case and inpatient discharges) was not considered high when compared with other independent acute hospitals we hold this type of data for.

• The overall responsibility for managing complaints was part of the hospital director’s role. The hospital matron took the lead if complaints were in relation to clinical care but they were all signed off by the hospital director. We reviewed a sample of complaints and saw that in each case, the level of risk for each complaint was reviewed. Appropriate investigations were undertaken and lessons learnt were recorded. Most complainants were invited to meet a representative from the hospital. The final letter issued to complainants included details of how to further pursue the complaint if they were still not satisfied. Patients who had complained were invited to join the patient forum group to attend meetings and give feedback on patient care.

• Meeting minutes we reviewed indicated that complaints were discussed at the Senior Management Team (SMT) meeting. They were also discussed through the integrated governance and medical advisory committee (MAC) meetings, which were held regularly.

Are services well led at this hospital

• Staff were aware of the Nuffield Chester vision, values, and strategy.

• Nuffield health had values that they termed ‘Everyday Epic’ which were used to shape their decisions, and guided the way they behaved when treating patients and colleagues. The values were based on being enterprising, passionate, independent, and caring (EPIC).

• The leadership, governance and culture at the hospital promoted the delivery of high quality, person-centred care. There was a cohesive management team, which included the Medical Advisory Committee (MAC) Chair. Members of the leadership team were well respected amongst both staff and patients.

• An audit programme was in place to evaluate the hospitals compliance with key processes to promote safe, high quality care.

• There were integrated governance committee meetings held within the hospital. We reviewed the minutes of meetings from February 2016 and June 2016. The minutes were comprehensive. However, the structure meant it wasn’t always clear who was presenting and discussing the items. In addition, actions, target dates for actions and the responsible person for completing them were not recorded consistently.

• There was a risk register in place at the time of the inspection. It contained details of risks and actions but the hospital was not using the Nuffield Health Group risk register template as set out in the Nuffield Corporate Risk Management Strategy. As a result, key information such as controls and gaps in controls for each risk were not included. We raised this with the Matron at the time of the inspection and the risk register was transposed onto the corporate template the next day. It was planned that this would be used as the risk register in future hospital governance meetings and heads of department meetings.

• Key risks to the hospital, such as the ageing theatres were known to leaders and they could describe the actions in place to mitigate risks to patients.

• The MAC monitored compliance with practicing privileges and there was evidence of action taken by the Hospital Director in consultation with the MAC Chair and corporate executive directors when competence issues arose.

• The leadership team at the hospital had taken the decision in May 2016 to suspend the paediatric service following the departure of the paediatric lead nurse. A new lead nurse had been appointed at the time of the inspection, but hadn’t started. Leaders had conducted a gap analysis of service provision and planned a thorough review with the lead nurse before re-starting the service.

• The hospital engaged with a wide range of stakeholders, including patients, GP’s, local NHS trusts and commissioners. Senior managers were active in promoting the services of the hospital. The hospital also engaged the community wherever possible. For example, we were told of an example where 15-17 year old students who were interested in healthcare were invited into the hospital for a question and answer session.

• Leaders were keen to develop services further following the successful innovative programme of Health MOT’s being provided at the hospital to actively promote a healthy lifestyle for patients.

• The hospital participated in a leadership MOT, which was a survey for staff to complete that could be compared against other Nuffield Hospitals in the group. We reviewed the results of the leadership MOT for October 2015. The overall results for the Nuffield Grosvenor Chester showed that the hospital performed better than the average in every question.

• The hospital participated in a Nuffield-wide consultant survey. The results from the 2015 survey were mixed, with some responses to questions better than other Nuffield hospitals and some worse. The hospital had developed a robust action plan in response and the majority of actions were complete at the time of the inspection. The main ones left open related to the paediatric service that had been suspended in May 2016 and was not in operation at the time of the inspection.

• There was evidence of an open culture. Senior managers held a monthly 360 feedback session with staff, which staff found positive.

We saw some areas of outstanding practice including:

• The Nuffield Grosvenor introduced a health MOT for patients attending for pre-operative assessments. This was a comprehensive assessment of the patients holistic health and well-being including exercise, diet and lifestyle factors. A report and associate advice and guidance were provided to the patient in order to optimise their health for surgery but also for their future health and wellbeing.

However, there were areas we feel the provider should make improvements;

In surgery

• Patients that sign the consent form in advance of the day of surgery should have confirmation of the consent documented on the day of surgery by a consultant or nurse.

• The hospital should ensure that the psychological aspects around cosmetic surgery are being considered during the consultation process, they should ensure a two week cooling off period is provided and establish a system of monitoring that these two practises are being achieved. They should consider the role of cosmetic surgery specialist nurse.

• The hospital should improve compliance with mandatory training in the areas where compliance is low, such as Mental Capacity Act, Consent, Deprivation of Liberties, and basic and immediate life support.

• All staff should adhere to the ‘bare below the elbows’ protocol.

• The Resident Medical Officer and ward staff should be trained and be aware of the process to perform a mental capacity assessment in the event that an assessment is required out of hours.

• The hospital should consider providing training for theatre staff in pain assessment for children and young people should the service recommence as planned.

• The hospital should record allergy status in all children and young people’s records should the service recommence as planned.

• All paediatric early warning scores should be documented as per the hospital policy should the service for children and young people recommence as planned.

• A registered children’s nurse should be available to document updates in the patient record should the service for children and young people recommence as planned.

• All patient letters should be filed in the correct medical record.

In outpatients and diagnostic imaging

• The outpatients and diagnostics departments should reinforce the principles of the Mental Capacity Act 2005 in relation to the application of a test for capacity to consent to treatment. Further education regarding informal consent to treatment may be beneficial to eradicate any misconceptions about how consent may be gained.

• The outpatients and diagnostics departments should consider the replacement of carpets in clinical areas for infection control purposes.

• The department should ensure that the room used for laser procedures has the appropriate signage in place.

Professor Sir Mike Richards

Chief Inspector of Hospitals