Winfield Hospital is operated by Ramsay Health Care UK. The hospital provides surgery for adults, outpatient care and diagnostic imaging.

We completed a comprehensive inspection in August 2016 as part of our national programme to inspect and rate all independent hospitals. We returned to the hospital on 27 February 2018 when we conducted a focused inspection on surgical services. This was an unannounced inspection (they did not know we were coming) which enabled us to observe routine activity. We did not inspect outpatients and diagnostic imaging on this occasion. We carried out this focused inspection to follow-up on the areas that had been identified as requiring improvement at the last inspection and in response to concerns raised with us about surgical services and intelligence we hold through ongoing monitoring.

We asked two questions of the service during this focused inspection: are they safe and are they 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.

We found the following areas of good practice:

• The service had a good reporting culture and learned from things that went wrong, they reported and investigated incidents and made recommendations for improvements.
• There were good infection control procedures. Staff and premises were clean and regular checks ensured standards were maintained.
• Medicines were managed in a way to ensure patients were safe. They were stored securely, controlled drug records were regularly audited and charts were checked daily to ensure medicines were correctly administered.
• There were effective safeguarding processes helping to protect people from abuse.
• There was a well-defined strategy and vision for the service prioritising high quality care. There was also a well-embedded set of organisational values so staff knew what was expected.
• There was a comprehensive audit programme to ensure quality was routinely monitored.
• Managers had the skills and experience to lead effectively; there was a desire to continuously improve and there was a respectful culture between managers and staff.
• The hospital sought feedback from patients and staff to learn how they could improve the service. We saw staff were consulted over changes and had the opportunity to contribute when things affected them.

We found areas of practice that required improvement in services:

• The way the hospital applied duty of candour did not meet the regulatory requirements. Where the relevant person had not been notified in line with the regulatory requirements for specific reasons, there was no audit trail that explained why this was the case. The hospital did not always provide an apology and some records were not held in a place where they were accessible.
• There was no evidence that the hospital had monitored actions following serious incident investigations to ensure improvements had been completed.
• The audit programme was not always delivered in line with the company's expectations.  Some audits had been missed and it was not always clear what action was going to be taken, by whom and when it was due to be completed.
• Risk registers were not used effectively to monitor and escalate risks. The hospital had not been following the company’s processes to manage risk, although they had started to address this.
• Compliance with mandatory training was poor in some subjects, particularly for face to face training.

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. Details are at the end of the report.

Amanda Standford

Deputy Chief Inspector of Hospitals, on behalf of the Chief inspector of Hospitals

We visited Winfield Hospital in Gloucester on 22 February 2012 and spent the day at the service. We met and talked with patients and members of the staff team. We inspected the premises, looked at medicines management, and examined patient records. We asked the service how it assessed and monitored the quality and safety of care.

We asked patients if their confidentiality, privacy and dignity were respected. We asked if they were given enough information to make an informed decision about their treatment. We talked with patients about giving consent and if they were told about the risks of their treatment. Patients told us about their experiences of the care and treatment they had been given and if it had met their needs and expectations.

We discussed training, development and support with members of staff from different departments of the hospital. We talked with patients about whether staff seemed experienced, knowledgeable and skilled in their work.

Patients told us that the service was "amazing" and "everything went so smoothly". We were told that staff were "kind and efficient" and that there was "an extraordinary caring attitude in all staff". One patient said that their care was "rushed" at the end of the day when they were being discharged. One person said that the food was "great" and another said it was "ropey". In a recent patient survey, patients who had taken part had scored the food and refreshments as 9.1 out of 10, although 18% had said that special diets were not catered for.

Patients said that the hospital was "clean" and "my room seems exemplary". In a recent patient survey, 97% of patients who had taken part said they were satisfied with the hospital's cleanliness. We were told that staff seemed "very well trained and skilled". A patient said that "staff work as a team and it seems that one part of the procedure flows into another without interruption".

We talked with a consultant surgeon and consultant anaesthetist who said that the hospital provided them with the staff and equipment they needed. We heard that surgery was "never" cancelled through a lack of staff or equipment, and only when the patient had become unsuitable or there were unavoidable circumstances beyond anyone's control. Staff said that they received regular appraisal, support from their managers, training, and professional development opportunities.

We found the hospital had a transparent and robust system of governance that assessed and monitored the quality of the service. We inspected the pharmacy and other clinical rooms and found medicines to be well stocked, audited, and stored safely in line with regulations.

The hospital was mostly clean and tidy. There were some areas that needed dusting and more attention to regular cleaning routines. Some rooms and cupboards that should have been locked were left open, with some locks not functioning. A fire door in theatre was propped open with boxes. This was addressed while we were at the hospital. One sluice room in theatre was cluttered with equipment and items that should have been stored elsewhere, and the sink was not accessible. One member of staff raised concerns about the cleaning regime in theatre and there not being enough time or staff to carry out the job effectively. This concern was raised with senior management who would address this immediately. Some areas of the hospital were showing signs of wear and tear. The carpet in reception was frayed in one area and some parts of theatre had damaged paintwork. We saw that this had already been noted at a governance meeting and a budget made available to address this in 2012.

Resuscitation trolleys were available in appropriate areas with the right equipment. We saw that checks on the trolleys and equipment were not carried out every day in February 2012 and some checks had been missed for three consecutive days.

Patient records were complete, legible and in good condition. Some records were seen to be unattended at a nursing station, but these were removed during our inspection. Staff were reminded by hospital management during our visit of the need to keep records confidential and available only to authorised staff.

We found hospital management to be cooperative, approachable, open, and focused upon delivering a safe and quality service. Medical, nursing, pharmacy, physiotherapy, health care, reception and administration staff were also cooperative and approachable. We observed care delivered with warmth and professionalism.

We inspected Winfield Hospital as part of our programme of comprehensive inspections of acute independent health hospitals. We visited the hospital on 9 and 10 of August and carried out an unannounced inspection on 18 August 2016.

We rated the hospital as requires improvement overall, with both surgery and outpatients and diagnostic imaging rated as requires improvement.

Are services safe at this hospital?

• Following a never event, duty of candour had not been applied in a timely manner and we were not assured the process was fully embedded.

• Staff were trained to the appropriate level of safeguarding and were able to describe the process for reporting a concern.

• The hospital had a good safety culture, where staff were encouraged to report incidents. However, staff were not trained in root cause analysis investigation.

• Some staff in theatres were not up to date with infection control training. Actions were in place to address this, with additional time allocated.

• There were arrangements for transferring patients for emergency care. The hospital had a service level agreement with the nearby NHS acute hospital.

• There were not robust systems in place to track medicines and prescription pads in the outpatients department.

• Staffing needs and patient acuity on the ward were assessed up to a week in advance and the off duty was adjusted to reflect this. We saw that staff were flexible to help cover shifts. Staffing levels on the ward and in theatres were adjusted to the needs of the service and during a day of increased activity more staff would be asked to work the shift. The hospital used minimal agency and bank staffing and were actively recruiting during the time of the inspection

• Consultants worked at the hospital under practising privileges and were supported by a resident medical officer who covered the service at all times.

Are services effective at this hospital?

• Patients had good outcomes from hip and knee replacement surgery and the hospital was benchmarked against other Ramsay hospitals.

• In line with the NHS Institute for Innovation and Improvement guidance, the hospital used the enhanced recovery programme (ERP) for patients who underwent orthopaedic surgery. This care pathway was designed to encourage a quicker recovery following major surgery and a shorter hospital stay.

• The medical advisory committee oversaw and approved practising privileges at each meeting ensuring medical staff had appropriate skills and experience of the procedures they wanted to undertake.

• The recording of appraisals did not always reflect the scope of practice the surgeon carried out at the hospital.

• There was good multidisciplinary working and staff were positive about the ‘daily huddles’, where key updates were communicated.

• An audit undertaken of screening in theatre had shown a reduced radiation dose when screening was undertaken by radiographers and this was now standard practice.

• Nursing staff had a clear understanding of what consent was and when it was required. All staff we spoke with had awareness of the Mental Capacity Act 2005 and could explain what a best interest decision involved.

Are services caring at this hospital?

• In the first quarter of 2016 satisfaction survey results showed that between 99% and 100% of NHS day case, inpatient and private patients would recommend the service.

• Patients and their relatives were kept informed and involved in decisions about their care and treatment. We spoke with one patient who stated that staff had been caring and thoughtful towards their relative.

• Patients attending the diagnostic imaging department, who were required to undress, were not offered sufficient privacy while waiting for their treatment. However, plans were in place to reconfigure the department to address this.

Are services responsive at this hospital?

• The needs of different patients were considered in the planning and delivery of the service.

• Services were planned to meet patients’ needs. The hospital had worked with the local clinical commissioning group to identify the needs of patients who were waiting for cardiology diagnostic investigations.

• Both NHS and private patients told us that they did not have to wait a long time for an appointment to see a consultant and that the most suitable admission dates had been discussed and agreed with them, before being finalised. The hospital consistently met the NHS standard which measures the time that people wait from referral by their GP to consultant-led treatment.

• If patients were identified as having complex needs, staff told us that any issues were discussed with patients’ families to determine whether additional support or adjustments were needed.

• People who complained were offered meetings, where appropriate. We saw that responses to complaints contained an apology and there was evidence that the concerns raised had been fully investigated. Information on how to make a complaint was not well publicised in outpatients.

Are services well led at this hospital?

• Clinical incidents were reviewed by the hospital’s clinical governance committee and medical advisory committee. Standard agenda items for these meetings reflected this.

• Minutes of the clinical governance committee and senior management team meetings did not record sufficient detail of discussion of all agenda items. This did not provide a robust audit trail and evidence that the planned agenda items and risks were regularly reviewed.

• Minutes of the MAC meetings recorded poor attendance with, in the main, a core of consultants regularly attending. This did not reflect the hospital policy that all consultants should attend the MAC as part of being granted practising privileges at the hospital.

• Staff told us the registered manager and matron were visible and accessible and had an ‘open door’ policy.

• Results of the most recent staff survey showed low scores for communication and feeling valued by the corporate group and that local leaders did not take the views of staff seriously. The senior management team was working on a new staff engagement strategy, responding to the themes highlighted in the staff survey.

Our key findings were as follows:

• There had been changes to the management at the hospital which had led to a review of the services by the provider. The resulting action plan had identified a range of issues to be addressed and the registered manager and clinical leads were working on improvements.

• The registered manager was visible and had a plan to relocate their office so as to be more easily accessible to staff.

• In the outpatients department there had been a difficult transition period while a new radiology manager managers settled in there had been no permanent outpatients manager for some months. Staff meetings did not occur regularly and some staff consequently felt they did not a have a voice.

• The recent staff survey had yielded a disappointing response and highlighted some worrying themes. Staff engagement and involvement needed to improve to address issues which affected staff morale and make them feel more valued.

• ‘Daily huddles’ had been introduced to help inter-departmental working and heads of department were engaged in team building and looking at ways to better support each other and

• work cohesively. Staff told us that the huddles provided a good mechanism for communication across the hospital departments.

• All areas we visited were visibly clean and staff demonstrated the processes in place for cleaning.Oversight and monitoring of cleaning standards was not recorded or fed back to staff in charge of departments.

• Not all patient records we viewed were accurate, comprehensive, legible or contemporaneous. We were concerned about the systems for taking and storing photographs for those patients undergoing cosmetic surgery.

• We observed good practice among theatre teams when using the World Health Organisation (WHO) five steps to safer surgery safety checklist in the operating theatres. We observed conversations around patient consent, the surgical site was marked, and risks of venous thromboembolism (blood clots) had been anticipated. Staff were all present for completion of the whole checklist.

• The hospital strategy identified that patient satisfaction results, environmental and clinical audits should be discussed at team meetings. Patient satisfaction was identified as a standard agenda item on the clinical governance committee minutes but in minutes we reviewed there was no information or evidence of discussion at the meetings.

• There was evidence of learning and improvement following two incidents in diagnostic imaging and an incident in the physiotherapy department.

• In a patient satisfaction survey in outpatients in May 2016: 100% of respondents said they were involved in decisions about their care and treatment and 100% said the staff told them how they would find out their test results.

• There was insufficient evidence that managers had oversight of all performance, including risks to quality and safety. The recent provider visit had highlighted weakness in governance processes which still needed to be improved. For example, there was insufficient oversight of mandatory staff training and little evidence that audits were consistently taking place as planned or learning was taking place following these audits.

• The hospital had recently appointed to the post of clinical quality lead to monitor and oversee of the clinical audit programme and ensure action plans from departments were progressed. Additional audits could be added if required. This was a developing role and it was planned to encompass oversight of complaints, clinical audit and patient satisfaction

There are areas where the provider needs to make improvements.

Importantly, the provider must:

• Ensure that all medicines held within the diagnostic imaging department, are stored correctly, in accordance with manufacturers’ guidance.

• Ensure there are robust systems in place to track medicines and prescription pads in outpatients in order to prevent theft or misuse.

• Take action to ensure that patient records are legible accurate, comprehensive and contemporaneous and completed by all members of the multidisciplinary team.

• Ensure that consent for medical photography is obtained and clearly documented in the patient record. Ensure that medical photographs are stored safely and securely in line with policy

• Ensure compliance to the surgical safety checklist and audit appropriately to provide assurances

• Ensure that the duty of candour is implemented in a timely manner for those incidents where regulation 20 applies.

• The provider must ensure that audits provide the evidence that the governance systems are effective.

• Ensure that all equipment such as commodes are properly decontaminated.

• Ensure systems are in place to maintain an overview of the compliance data with cleaning standards.

• Ensure that reporting and assurance from audits completed on the ward and in theatres provide the evidence that the governance systems are effective.

  Ensure meetings follow the corporate standard agenda and that all items are discussed and recorded with sufficient detail to provide assurance and actions

In addition, the provider should:

• Consider the removal of carpets in patients’ rooms to ensure adequate cleaning.

• Consider remedial improvements to the walls in the dirty utility room.

• Ensure better attendance at medical advisory committee meetings.

• Ensure that staff consistently receive feedback about adverse incidents to ensure learning and improvement.

• Proceed with planned replacement of the imaging table with a height-adjustable table to reduce the risk of falls and staff injury.

• Take steps to support people in vulnerable circumstances, such as patients living with dementia or patients with a learning disability.

• Review patient information leaflets and ensure that information is made available in languages other than English and other formats, such as large print, braille or easy read.

• Take steps to better publicise the complaints system to patients, inform patients of sources of support with their complaint and reassure them that their care and treatment will not be affected by the fact that they have made a complaint.

• Proceed with planned works to improve the privacy and dignity of patients who are required to undress in the diagnostic imaging department.

• Ensure management oversight of mandatory training compliance and take steps to improve compliance.

• Continue to develop staff engagement, explore reasons for poor staff survey results and take actions to address these. 

Professor Sir Mike Richards

Chief Inspector of Hospitals