The Holly Private Hospital is operated by Aspen Healthcare Limited. The hospital has 42 inpatient beds, eight day case beds and two beds and four chairs for oncology day case services. Facilities include five operating theatres, an X-ray department, outpatient and diagnostic facilities.

The hospital provides surgery, medical care, services for children and young people, and outpatients and diagnostic imaging. We inspected all four of these services.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 24 January 2017, along with an unannounced visit to the hospital on 7 February 2017.

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. 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.

Services we rate

We rated this hospital/service as Good overall.

We found good practice in relation to medicine:

• Staff had a good understanding of incident reporting and duty of candour.
• Patient areas were clean and well equipped and staff followed infection prevention and control procedures.
• The oncology consultants prescribed all chemotherapy treatments using the relevant and current evidence based guidance.
• The chemotherapy suite staff were all trained in oncology and palliative care and had several years experience in the treatment of patients with malignant disease.
• Staff provided patients with a ‘chemotherapy record book’, which they brought to each appointment. This was updated by the nurse and ensured that the patient always had a record of the treatments given, possible symptoms and side effects and 24-hour contact details should they feel unwell
• The hospital had introduced the UK Oncology Nursing Tool (UKONS) to triage all patients in December 2016, along with a 24 hour on call rota, to ensure patients had access to specialist advice 24 hours a day, seven days per week.
• There were appropriate systems in place to ensure effective decontamination and storage of endoscopy equipment in accordance with Department of Health, Health Building Notes Technical Memorandum 01-06: decontamination of flexible endoscopes.
• The endoscopy service was in the process of reviewing facilities to fulfil Joint Advisory Group on Gastrointestinal Endoscopy (JAG) criteria for accreditation.

We found areas of practice that required improvement in medicine:

• The dirty utility room in the chemotherapy suite had damaged tiling behind the taps and damage to the flooring making it difficult to ensure these areas were sufficiently cleaned and taps did not conform to Department of Health standards.

• Chemotherapy patient outcomes were not routinely recorded. Staff did not participate in any internal audits, for example in the use of the cool cap.
• Ensure that there is adequate representation at governance meetings.

We found areas of Good practice in surgery:

• 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.
• The hospital exceeded the referral to treatment target of 18 weeks for NHS patients every month between January 2016 and November 2016.

• The NHS Safety Thermometer provides a monthly ‘temperature check" on harms such as pressure ulcers, falls, urinary infection and venous thromboembolism (VTE). Between January 2016 and December 2016 data showed that patients had received 100% harm free care.

• The hospital reported that there were 11 surgical site infections between October 2015 and September 2016. All of the reported surgical site infections were following orthopaedic surgeries; all of the infections were investigated and no common themes or trends were found to link the infections
• The hospital participated in national audits for example patient reported outcome measures (PROMs) for patients who had primary hip replacements, primary knee replacements, and hernia repairs.
• The hospital completed the World Health Organisation (WHO) five steps to safer surgery checklist for each surgical procedure undertaken. The surgical safety checklist audit undertaken by the hospital in September 2016 scored 98% compliance in the completion of the checklist.
• Fasting audits for February, August and November 2016 showed that compliance with the pre-operative fasting guideline policy, and the documentation of fasting time on patients notes were between 95-100%.
• The friends and family test results between April 2016 and September 2016 showed that 99% of patients would recommend this hospital for April and May, 98% for July and August and 97% for June and September.
• There was a clear governance process in place with clear lines of communication between heads of departments, senior management team and the medical advisory committee (MAC).
• The senior management team, although relatively new to the hospital, were all respected by the staff and the positive impact they had on the hospital since their appointments into post.

We found outstanding areas of practice is surgery:

• the hospital had been awarded the Worldhost© customer care recognition status ( the same customer care training the London 2012 Olympic Games Makers received) reflecting the work of staff going the “extra mile” to improve patient experience.
• There were systems in place to engage staff at all levels and recognise commitment and achievement. For example there was a ‘6E’s’ staff recognition scheme in place, which involved staff obtaining evidence through their work that they were displaying the service’s core behaviours of ‘exceptional, effective, expert, energetic, efficient, everyone’.
• Monthly observational audits were carried out in patient areas, in which a member of staff would observe interactions between staff and patients, as well as the environmental factors over a set period of time, to drive improvements in patient experience throughout the hospital.

We found areas of practice that required improvement in surgery:

• The hospital cancelled 26 procedures between January 2016 and January 2017 for non-clinical reasons for example consultants starting late. All of the patients were offered another appointment within 28 days of the cancelled procedure in accordance with national guidelines.

We found areas of Good practice in Childrens and Young People:

• Policies in use were evidence based and reflected best practice and national guidance.
• All inpatient nurses had received an appraisal in the current year to date (April 2016 to January 2017)
• The hospital was working towards all registered staff receiving PILS training. This was to ensure that all staff were able to manage a deteriorating child. This training had been rolled out with a target completion of 90% compliance by March 2017.
• The hospital carried out quarterly audits to monitor compliance with peadiatric early warning scores (PEWS) to identify deteriorating children. Audit results for the months of January 2016, April 2016 and July 2016 showed compliance was 100%.
• The hospital maintained oversight of consultants with practising privileges to ensure they were regularly practicing in their specialist fields to ensure competence.
• Staff had access to a policy relating to obtaining consent from children and young people. The consent policy referenced the Gillick competence with staff demonstrating a working knowledge.
• The hospital undertook a dedicated inpatient survey for children and young people with 99% of patients reporting they felt ‘very well looked after’.
• Staff treated patients and their relatives/carers with dignity and respect.
• The service provided a dedicated paediatric nurse, prior to and after surgical procedures to provide emotional support for children and young people.
• The service was meeting patients individual needs through the provision of age appropriate menu choices and environments in both the ward and theatre areas.
• Relatives and carers had access to information to aid understanding of their child’s treatment or procedure including post-operative information.
• The children and young person’s service had received no complaints in the 12 months prior to our inspection. Patients and their relatives had access to information on how to complain with a clear complaints policy in place to guide staff on the handling of complaints
• The service had a specific paediatric strategy in place.
• In 2016, the hospital launched a new paediatric speech and language service in the aim to complement existing paediatric services.

We found areas of practice that required improvement in childrens and young people:

• The lack of security restricted areas had been recorded on the hospital’s risk register in October 2016 however there was no estimated date of completion for this work.

We found areas of Good practice in Outpatients and Diagnostics:

• There was good track record of safety in outpatients and diagnostic imaging department. Three incidents had been reported to the radiation protection advisor (RPA), and deemed low risk and investigated appropriately.
• Areas we visited were visiblyclean and we saw good infection control techniques in line with policy and national guidance.
• Radiology staff all carried film badge dosimeters whilst working clinically which registered the amount of personal radiation exposure they had been subjected to and these were reviewed regularly to ensure staff safety.
• The hospital carried out internal monthly audits on medical records. The most recent audit that included outpatients’ notes was in July 2016 and scored 96%.
• Safeguarding training data for the outpatient and diagnostic imaging department showed 100% compliance.
• The hospital used the “World Health Organisation (WHO) Surgical Checklist, Five Steps to Safer Surgery” for interventional radiological procedures.
• For the period October 2015 to September 2016, the hospital performed between 94% and 97%, exceeding the target of 92% for referral to treatment (RTT) waiting times in less than 18 weeks for incomplete patients. These figures related to NHS funded patients only.
• Outpatient staff spoke of a strong team ethos across the hospital and felt well supported by their managers, and that managers were accessible, approachable and friendly.

We found outstanding procatice in outpatients and diagnostics:

• The diagnostic imaging team won the Aspen quality award for their cardiac MRI service which demonstrated the hospital’s priorities of safety, effectiveness and improving patient experience. Cardiac MRI provides an alternative to invasive angiography. Patients which normally would be referred to other hospitals for a cardiac MRI scan now can be offered this service at the Holly.

Following this inspection, we told the provider that it should make other improvements, even though a regulation had not been breached, to help the service improve.

Professor Sir Mike Richards

Chief Inspector of Hospitals