During our inspection we visited the Day Surgery Unit, two surgical wards and the Critical Care Unit and spoke with patients and staff. We visited the operating theatre suite.

Patients told us that they were well informed about their treatment. One of them told us, “The consultant provided alternative options for my treatment and allowed me time to make a decision”. Patients signed consent forms before surgical procedures were carried out in the outpatient clinic or when the consultant visited the patient before surgery. Staff told us interpreters were used to make sure patients from overseas who did not speak English were fully involved in decisions about their care.

Care and treatment reflected good practice guidance. Patients were monitored after surgery and appropriate health professionals were involved in their care. One patient told us the professionals who cared for them were “excellent and really attentive”.

The provider had policies and procedures in place to ensure that equipment was safe for use and we found evidence that these were adhered to.

There were effective recruitment processes and there were appropriate checks in place before employees started working. There was an approval process for doctors treating patients at the hospital.

Complaints were responded to promptly and there was a process to investigate and learn from them.

On this inspection we visited operating theatres and two surgical wards. The people

we spoke with said they were well informed at all stages of their contact with the hospital.

They said they would be able to talk to staff if they had any concerns about the service.

The people we spoke with praised the nursing and medical staff and the high standard of care and treatment provided. They said continuity of care was good and nurses understood the care they needed.

The London Bridge Hospital, opened in 1986, is operated by HCA Healthcare UK who took over the running of the hospital in 2000. The group provides care at several other hospitals in the UK including locations in London and Manchester.

The hospital has 124 inpatient beds, four renal dialysis chairs and 15 day case trollies. Facilities include six operating theatres, a catheter laboratory for interventional procedures, an 18 bedded level two and three critical care unit and several outpatient and diagnostic imaging facilities.

London Bridge Hospital provides a range of surgical procedures, medical care including oncology and care in the last days of life, a level two and three critical care unit and outpatients and diagnostic imaging. We inspected all the services provided except outpatient chemotherapy.

We inspected this service using the new comprehensive independent hospitals methodology. We carried out an announced inspection on 21 and 22 September 2016, along with two unannounced visits to the hospital on 29 September and 6 October 2016.

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.

Overall we have rated The London Bridge Hospital as Outstanding. For the hospital overall we rated the key questions as follows:

Are services safe?

By safe, we mean that people are protected from abuse and avoidable harm.

We rated safe as Good because:

• There was an established hospital incident reporting system. Incidents were reviewed and monitored and examples of learning were demonstrated. Patient morbidity and mortality meetings were held regularly as part of patient safety measures.
• Areas we visited were visibly clean and tidy and staff adhered to Infection prevention and control (IPC) protocols. Dedicated IPC link nurses and medical staff worked to improve IPC practices in the hospital.
• Equipment was accessible to staff as required and was safety tested and well maintained.
• There were issues with the storage of large items in theatre that were rectified during inspection, and staff told us there was a long term solution for storage of these items.
• Medicines were stored securely and in ward areas were accessed by use of an electronic key system. Pharmacy staff were available to assist in all areas with any concerns, medicines reconciliation or patient discharge.
• Records were stored securely and paper notes were scanned onto the computer so all notes were accessible online.
• Staff were trained to undertake child and adult safeguarding to a level appropriate to their job to ensure patients were protected against abuse.
• Information about patients was recorded including past medical history and risk assessment and was available to staff via an online system.
• There was adequate nursing and allied health professional staffing throughout the hospital to ensure patients were cared for safely. Staff had completed mandatory training and bank staff completed competency checklists before undertaking shifts.
• The hospital employed its own Resident Medical Officers (RMOs). They were highly trained in their speciality and worked rotas on-call 24 hours a day seven days a week. Consultants were available for each speciality within 30 minutes of the hospital and some Consultants such as anaesthetists and intensivists stayed on site during their on call period.

However:

• The five steps to safer surgery checklist were not always completed. Poor completion of the debrief has previously been addressed via an action plan but audits showed that it was still not completed in some cases.

Are services effective?

By effective, we mean that people’s care, treatment and support achieves good outcomes, promotes a good q

uality of life and is based on the best available evidence.

We rated effective as Good because:

• Patient care and treatment was planned and delivered in line with current best practice, evidence based guidance and current legislation. National guidance such as National Institute for Health and Care Excellence and the Royal Colleges was evident.
• There was a local audit system in place. Where concerns were noted, action plans with clear times for completion of change were in place.
• The hospital participated in national audits including the National Institute for Cardiovascular Outcomes Research (NICOR) and Intensive Care National Audit and Research Centre (ICNARC) to benchmark practice against other units in the UK. For those it could not participate in it continued to collected data to internally assess practice for example the National Diabetes Audit framework.
• There were two pain management consultants who attended the hospital, pain clinical nurse specialisits and pain link nurses available on each ward to assist staff in controlling patient’s pain.
• There were a range of clinical nurse specialists within the hospital in areas such as nutrition, diabetes, gastrointestinal and cardiac conditions and symptom control for oncology patients . These nurses assisted in improving care and implementing positive change.
• Consultants practised at the hospital under practising privileges which were reviewed yearly. Any concerns about a consultants practice could be discussed at a decision making forum through the Medical Advisory Committee (MAC).
• There were significant learning opportunities for all staff in both clinical and non - clinical subjects including masters degrees and specialist training in renal dialysis, intensive care nursing and oncology.
• There was a strong multidisciplinary team working ethos within the hospital which was well supported by the senior management and involved both external and internal bodies.
• Staff had a good understanding of the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards (DOLs) throughout the areas we inspected.

Are services caring?

By caring, we mean that staff involve and treat patients with compassion, dignity and respect.

We rated caring as Good because:

• Patients received care from highly motivated individuals who aimed to provide the highest quality care.
• There were good patient feedback channels and staff acted on any concerns patients highlighted throughout their stay.
• Staff were prepared to go the extra mile for patients by accommodating as many requests as possible even if this meant staying behind after shift or it was difficult to organise.
• People were cared for holistically with staff taking into account social, spiritual and cultural needs.
• There was appropriate information available to patients to help them make informed choices about their care. Patients felt they had time to ask questions about their treatment and discuss options.

Are services responsive?

By responsive we mean that services are organised so they meet people’s needs.

We rated responsive as Outstanding because:

• Services were planned in a holistic manner to meet both the local and the international population the hospital served. Some clinics offered a one stop service to make it easier for patients to attend.
• Staff were expected to undertake specialist customer and cultural training. They were supported in learning by the practise development team and local practice development nurses.
• There was a large team of allied health professionals and house keeping including physiotherapists, occupation therapists, dieticians, chefs, receptionists and radiographers. Team work was exemplary and provided a range of therapies and comfort measures to all patients.
• There were no waiting lists for patients in any speciality. Patients could be admitted on the same day or select a day suitable for them and staff told us there was never an issue in admitting at the requested time. Dedicated discharge nurses aimed to ensure a smooth discharge process for staff and patients alike.
• There was an dedicated onsite translation service and hospital signage for those patients who spoke Arabic. All other languages could be accessed via language line which staff used regularly.
• Staff understood that patients living with dementia may require adjustments when using hospital services and told us ways in which they would provide these.
• Staff made arrangements for families to stay with patients where possible and we saw examples of birthday cakes and wedding celebrations catered for within the hospital.
• Complaints were dealt with promptly by the patient experience manager and we saw that where complaints had been raised changes to practice had been made to rectify these quickly.

Are services well-led?

We rated well-led as Outstanding because:

• There was a clear and visible vision and set of values within the London Bridge Hospital. Staff understood and were highly motivated to achieve the corporate and local values in all aspects their work.
• There was strong and visible local leadership and senior management teams. Consistently  across the hospital staff spoke highly of the local leadership and senior management team, they said they were very approachable, open and listened to staff when they had concerns. We saw that the Chief Executive Officer knew staff in clinical areas by name and the Chief Nursing Officer did a daily morning walk round of the clinical areas. There was strong clinical leadership and medical staff across all grades were actively involved in developing and improving patient care and services.
• Managers had an inspiring shared sense of purpose and worked towards shared goals of providing the highest quality patient care possible. They motivated staff to work as a team and encouraged a positive working culture of openness and learning.
• There was an effective governance structure. All meetings within the governance framework were well attended across the hospital. Feedback from the governance meetings was presented at the weekly senior management team meeting and to the board and also fedback to staff in clinical areas.
• The hospital was continually looking to improve and sought feedback from both patients and staff. Where concerns were raised management would aim to make changes to improve care and working conditions across the hospital. Feedback from both patients and staff was overwhelmingly positive.
• Staff were given many opportunities to achieve recognition through an employee of the month scheme, research and further learning. Some staff we spoke to told us about when they had received this award and been mentioned in the "Tooley Times" staff newsletter.
• We saw innovative practice throughout the hospital including new research taking place in theatre, new infection prevention and control practises and safer medicines management through use of an electronic key system.

We saw several areas of outstanding practice including:

• An electronic key for use when obtaining and dispensing medication had been introduced to make medicines management safer. It allowed staff to see which member of staff had accessed medicines cupboards and reduced delays in patients receiving their medications.
• The hospital employed its own RMOs who were highly trained in the speciality in which they worked. Consultants were available for both their own patients and on an on-call basis for example on call intensivists and anaesthetists. Consultants on call would stay on site in the hospital if required.
• We found excellent multidisciplinary team (MDT) working with close collaboration between all staff including live donor liver transplants in conjunction with a local liver specialist team.
• A clinical perfusionist within theatre was being supported to undertake innovative research which would have results published nationally once it was complete.
• HOT boards were available in each clinical area which provided a standard set of information including risk registers, new policies and procedures, incidents and learning from these and new complaints. It allowed staff to learn about risk management and quality improvement and encouraged them to learn about other services within the hospital.
• The hybrid catheterisation laboratory allowed consultants to perform complex medical procedures by both imaging and intervention supported by surgical teams in one session.
• Staff were encouraged and motivated to take part in learning opportunities provided by the hospital. Learning included masters degrees, specialist training in renal, intensive care and cardiac conditions.
• There were no waiting times for patients to be seen in a clinic or admitted to hospital if a procedure was required.
• Leadership at both a local and senior level was visible and motivational and staff were overwhelmingly positive about the support they received from their managers. The felt that they could raise issues in a timely manner and their concerns would be listened to and acted upon.

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

The hospital should:

• Continue to work to ensure the five steps to safer surgery including the debrief after surgery are fully embedded
• Ensure that staff are aware of who to contact and how to care for a patient living with a learning disability being admitted to the hospital.
• Equipment in theatres should be stored in a safe manner to ensure that patient safety is not compromised within the theatre department.

Professor Sir Mike Richards

Chief Inspector of Hospitals