The Foscote Hospital opened in Banbury, Oxfordshire, in 1981. In October 2014, the hospital came out of a ten-year management contract with a large healthcare company and returned to being independently managed. The Foscote Private Hospital is a charitable trust providing services to patients in Banbury, Oxfordshire and the surrounding areas of, Northamptonshire, Warwickshire, Gloucestershire and Buckinghamshire.

The hospital provides surgical and medical treatments for patients using private medical insurance. Some procedures are offered under the NHS Any Qualified Provider Contract as well as a self-pay option for those patients who prefer to fund themselves.

The on-site facilities include an endoscopy suite, an operating theatre with laminar air-flow and consulting rooms supported by an imaging department offering X-ray and ultrasound. Physiotherapy treatment is offered as an inpatient and outpatient service in its own dedicated and fully-equipped physiotherapy suite. There are 12 patient bedrooms, all with a nurse-call system, en-suite bathrooms, free Wi-Fi access, a television and a telephone.

Services offered include cardiology, cosmetic surgery, dermatology, general medicine, general surgery, gynaecology, ophthalmology, oral & maxillofacial surgery, orthopaedics, rheumatology, respiratory medicine, urology, radiology and physiotherapy. There are no emergency facilities at this hospital.

We undertook a comprehensive inspection of The Foscote Private Hospital in July 2015. At that inspection, we rated the hospital overall as inadequate. Surgery was rated as inadequate and outpatients and diagnostic imaging as requires improvement. We rated safety, effective and well-led as inadequate for the surgical service. This was because the staffing levels, the skills and training levels, working practices in the operating department and medicines were not always safely managed. There was not a consistent approach to the use of national guidance to ensure patients received effective care and treatment. In the operating department, staff were undertaking roles which they were either not qualified for or not assessed as competent to perform.

Governance practices to monitor risk and quality were not embedded across the whole hospital, including in the endoscopy department and theatres. The quality of the service was not being monitored effectively through audit and some working practices were out of line with hospital policies and national guidance. Risks were not adequately identified, assessed or managed.

We undertook an unannounced focused inspection of the surgery service at The Foscote Private Hospital in August 2015. At that inspection, we concentrated on specific areas of noncompliance identified during the comprehensive inspection around surgery. Some improvements had been made, but there had been insufficient changes in the six week period since the comprehensive inspection for these changes to be fully embedded. There was not sufficient evidence to change the ratings applied at the comprehensive inspection and the overall rating of inadequate remained.

We undertook a further unannounced comprehensive inspection of the surgery and outpatients and diagnostic imaging services on 19 January 2016. The inspection team of five included an inspection manager, two CQC inspectors and two specialist advisers, an operating department manager and an infection control lead nurse with outpatients experience.

Our overall rating for this hospital was “good”.

Are services safe at this hospital?

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

We rated safety as “good” in both surgery and outpatients and diagnostic imaging.

• There were sufficient staff in all areas. Staff followed relevant infection control practices and all clinical areas were clean and tidy. All theatre staff participated in the Five Steps to Safer Surgery. Staff had access to the equipment they needed and medical equipment was in date for servicing.
• Staff reported incidents in line with hospital policy and the learning was shared to improve services. Staff understood the principles of openness and transparency that are encompassed within duty of candour.
• Risk assessments for patients were completed and there were processes in place to support patients who became unwell. Staff were able to describe the different types of abuse and understood the importance of raising a safeguarding concern.

Are services effective at this hospital?

By effective, we mean that people’s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence.

We rated effectiveness “good” in surgery. We inspected but did not rate effectiveness in outpatients and diagnostic imaging.

Staff received an annual appraisal and were able to access relevant training to update their clinical skills specific to their roles, such as the surgical first assistant programme. Medical staff were only granted practising privileges to work at the hospital if all pre-employment checks demonstrated they were competent. There was good multidisciplinary working across all teams in the hospital so patients received co-ordinated care and treatment. Patients’ care and treatment was planned and delivered using evidence based guidance, standards and best practice. Staff worked effectively within their teams and across the hospital as a whole to support patient care.

Are services caring at this hospital?

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

We rated caring as “good” in both surgery and outpatients and diagnostic imaging.

Staff were caring, compassionate, and treated patients with dignity and respect. Patient feedback was universally positive, with patients reporting that staff took the time to talk with them and treated them holistically.

Are services responsive at this hospital?

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

We rated responsive as “good” in both surgery and outpatients and diagnostic imaging.

There was prompt access to outpatient appointments after referral, both in the daytime and the evening. Patients told us the processes relating to their surgery including booking, admission and discharge had been efficient, and they felt fully informed at each step in the process. Waiting times for surgery from referral were in general four weeks or less. The hospital had strict selection criteria for patients to be accepted for admission, this meant the patient type was carefully managed to ensure that the hospital could meet their needs.The hospital had systems in place to support patients with additional needs, including those living with dementia or with a mobility need. There was an established complaints system. Complaints were investigated and learning shared, with changes implemented as required.

Are services well-led at this hospital?

By well-led, we mean that the leadership, management and governance of the organisation assure the delivery of high-quality person-centred care, supports learning and innovation and promotes an open and fair culture.

We rated well-led “good” in surgery and in outpatients and diagnostic imaging.

Staff were informed about the vision and values for the hospital and were aware of possible development plans for the hospital. Governance processes were overall well developed to manage risks and quality. Although patient outcome data was collected and submitted to a number of national databases, it was not used locally to keep staff informed about how effective care and treatment had been.

Staff spoke positively about the leadership at a local level and the visibility and support of the senior team. There was an open culture and staff felt they could make suggestions to improve services for patients. Staff acknowledged the last few months had been challenging with all the changes but the culture had changed positively and the hospital was a different place to work at.

Our key findings were as follows:

• Staffing levels on the ward were maintained at a safe level and those in the operating department were in line with national guidance.
• The principles of the Five Steps to Safer Surgery, designed to reduce harm by consistent use of best practice, were being adhered to.
• A full review of hospital polices was being conducted, including a review against national guidance. Systems were in place to monitor practice such as adherence to the Five Steps to Safer Surgery and instrument counts.
• Staff were being supported to develop in their role. For example, staff in the operating department were under taking training to act as a surgical first assistant.
• Most staff were up to date with their mandatory training.
• There was an established system for the servicing and maintenance of equipment. Staff had received training in the use of equipment.
• There was limited storage space in theatres, which meant sterile and non-sterile items were stored together in the same area. Staff had managed the risk by segregation. There was no fume cabinet in theatres to protect staff when using formalin. This risk had been assessed and additional measures were in place to protect staff, while the hospital reviewed the purchasing of a cabinet.
• Medicines were being stored and managed safely.
• Staff followed relevant infection control practices and all clinical areas were clean and tidy.
• Staff were clear about their role and responsibilities under the principles of the duty of candour.
• The hospital had safeguarding procedures, staff had received training and there was a named safeguarding lead. Staff were able to define abuse and how to identify adults at risk. They were also clear about the procedures to follow.
• Staff completed Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) training. Staff we spoke with had an understanding of how this applied to patient consent but told us they implement the training infrequently as the majority of patients had capacity.
• The hospital submitted patient outcome data to a number of national audits and had subscribed to a national database to enable it to benchmark against other similar services providing private healthcare.
• Staff in different disciplines worked well together. The hospital worked flexibly, including the opening times, according to the needs of their current patient group.
• Staff were caring and compassionate and treated patients with dignity and respect. Patients told us they felt informed about their treatment plan and had been actively involved in decisions about their care. Patients were encouraged to consider their overall wellbeing as part of their treatment plan.
• Patients had prompt access to appointments after referral, with patients able to choose daytime and evening appointments. However, there was not always timely access to test results at follow-up appointments in the outpatients and diagnostic imaging department. This was due to delays in reporting by the provider for this service.
• Patient’s pain and the effectiveness of pain management was assessed and monitored.
• The hospital was responsive to patient needs. A professional interpreter service was available to enable staff to communicate with patients for whom English was not their first language. Patients were provided with written information about their diagnosis or planned procedure. This information was available in languages other than English on request.
• Staff spoke positively about the leadership at a local level and the visibility and support of the senior team. There was an open culture and staff felt they could make suggestions to improve services for patients.
• There was a system for the recording of events, which included incidents. Incidents were investigated and learning shared.
• A review of the committee structure and governance process had resulted in a streamlined reporting system and refreshed committee structure.
• Risks were captured on a risk register, which included action taken to mitigate the risk and was reflective of the risk identified during the inspection.

However, there were also areas of poor practice where the provider needs to make improvements.

The provider should:

• Introduce a clinical audit programme to monitor the standard of care, treatment and outcomes and take action in response to areas of poor performance.
• Ensure plans for safe handling of specimens in the operating theatre are implemented and ensure the hospital is compliant with any guidance.
• Ensure all staff are up to date with their mandatory training.
• Review the level of training provided for staff in the endoscopy unit and consider the provision of additional training.

Professor Sir Mike Richards

Chief Inspector of Hospitals

The Foscote Hospital opened in Banbury, Oxfordshire, in 1981. The hospital has recently come out of a 10 year management contract with a large healthcare company and has returned to being independently managed. The Foscote Private Hospital is a charitable trust providing services to patients in Banbury, Oxfordshire and the surrounding areas of Northants, Warwickshire, Gloucestershire and Buckinghamshire. The hospital provides surgical and medical treatments for patients. The on-site facilities include an endoscopy suite, an operating theatre with laminar air-flow and consulting rooms supported by an imaging department offering X-ray and ultrasound. There are 12 patient bedrooms with en-suite.

We undertook a comprehensive inspection of The Foscote Private Hospital in July 2015. At this inspection we judged safety, effective and well-led as inadequate for the surgical service. This was because the staffing levels, the skills and training levels, working practices in the operating department and medicines that were not always safely managed. There was not a consistent approach to the use of national guidance to ensure patients received effective care and treatment. In the operating department staff were undertaking roles which they were either not qualified or assessed as competent to perform.

Governance practices to monitor risk and quality were not embedded across the whole hospital, including in the endoscopy department and theatres. The quality of the service was not being monitored effectively through audit and some working practices were out of line with hospital policies and national guidance. Risks were not adequately identified, assessed or managed.

In July 2015, we served three warning notices against the hospital; under standards for ‘’staffing’’ and ‘’safe care and treatment’’ for the regulated activity surgical procedures. The third notice was served under ‘’governance’’ for the regulated activities surgical procedures and treatment of disease, disorder or injury. The warning notices required the hospital to take immediate action to improve the safety of patient care.

We undertook this unannounced focused inspection of The Foscote Private Hospital to follow-up on the warning notices served.

The inspection took place on 19 August 2015. The inspection team of four included two CQC inspectors and two specialist advisors who were a nurse theatre manager and a governance lead.

Following the comprehensive inspection conducted on the 7 and 8 July 2015 we rated this service as inadequate. After the focused inspection there was not sufficient evidence to change the rating applied at the comprehensive inspection, therefore these ratings will stand. Some improvements had been made as documented in the report, but there had been insufficient changes in the six week period since the comprehensive inspection for these changes to be fully embedded. We concentrated on specific areas of noncompliance identified during the comprehensive inspection. The service will have a further comprehensive inspection when ratings will be applied.

Our key findings were as follows:

• During the inspection we found that the hospital had made improvements, but there remained concerns around the effectiveness of the governance procedures and processes and some operational practices in theatre to keep patients safe.

• Staffing levels in the operating theatre were not consistently in line with national guidance. The Five Steps to Safer Surgery checklist was being used but was not always completed appropriately as part of normal practice

• Medicines management had improved

• Staff had received training to safely use equipment.

• Polices referenced relevant national guidance, but staff did not demonstrate a clear understanding of why national guidance should be adhered to ensure the patient was receiving the ‘best’ care and treatment, such as completion of the Five Steps to Safer Surgery.

• A training programme had been introduced for staff acting as surgical first assistant (SFA). Competency assessments were in place for the staff in the operating department.

• Governance processes were not effective in monitoring the risk and quality of providing the service. The hospital clinical audit programme had not been agreed and the business risk register was under development.

Importantly, the hospital must ensure:

• Staffing levels in the operating theatre are in line with current national guidance at all times.
• Staff in the operating theatre fully comply with the five steps of safer surgery.
• Instrument counts in the operating theatre fully comply with national guidance and hospital policy.
• There is a written policy to support staff undertaking dual roles in the operating theatre to ensure staff work safely and in line with national guidance.
• There is clear guidance and staff understand their responsibility under the ‘Duty of Candour.’
• Working practices in the operating theatre reflect the hospital policy and procedures and are in line with current national guidance.
• The effectiveness of the clinical governance group is reviewed and there is robust monitoring of safety and quality of the service, that risks are identified, that timely actions are taken to manage risks and that decision-making is recorded clearly.
• There is an effective and comprehensive audit programme and audit of practices in the operating department.
• The risk register reflects the current risks faced by the hospital.

In addition the provider should ensure:

• There are clear procedures and processes to follow if temperature and humidity readings are not within normal limits, once a patient is in the operating theatre.
• Staff fully understand the procedure to follow if there are concerns about an adult’s welfare.
• Staff are deemed competent to sign off competencies for other staff within the operating department.
• Storage arrangements for the transfer board in the operating department are appropriate.
• Staff competencies are appropriately assessed, including the competencies of staff from other providers, to confirm they are competent for their roles.

Professor Sir Mike Richards

Chief Inspector of Hospitals

We spoke with three people who used the service and two relatives. They told us how they were very happy with the care and treatment they received, that they felt involved in their care and they felt safe. One person said "excellent, everything is explained and the service is very personal". Another person said "I feel well informed and well cared for".

We spoke with eight nursing staff who told us they liked working at the hospital. One nurse said "because we are a small hospital we get more time to talk to the patients".

We found the nursing staff to be well trained and supported and we saw that records, files and policies were well managed and maintained. This meant that people were cared for appropriately, there needs were met and they were safe from abuse.

We met with ten staff and six service users as part of the inspection. We inspected the premises and had access to the clinical and non clinical areas.

Service users were unanimous in their praise for the quality of care that they received. One described the care as “first class” and said they were treated with dignity. We were told by a service user that staff managed their pain effectively and requested to calls for assistance promptly.

Service users said they felt involved in their care and some told us that they had been offered a choice with regard aspects of their treatment. One service user, however, said that they had not been provided with information ahead of the procedure but felt able to discuss this with the clinical staff.

We saw staff from a range of disciplines speak to service users in a friendly, polite and professional manner. We observed staff showing respect for service users and service users, in turn, said they felt that they were well cared for.

The hospital was well maintained and clean. One service user said the hospital was “spotless”. The maintenance manager felt involved in the running of the site and had effective processes in place to maintain the fabric of the building.

Meals were well presented and menus well coordinated with a range of options. Other food was available on request.

We saw that there were effective governance arrangement in place to monitor quality and outcomes.