Woodthorpe Hospital is an independent health care hospital, based in north Nottingham, which provides services for assessment, diagnosis and treatment of common medical conditions and, is part of Ramsay Health Care UK Operations Limited.

The hospital provides outpatient, inpatient and day case care and treatment for adults 18 years and over for NHS, self-funding and insured patients. Treatments available at the hospital include gastroscopy, flexible sigmoidoscopy, colonoscopy, ear nose and throat (ENT), general surgery, gynaecology, ophthalmology, orthopaedic surgery, podiatric surgery, spinal surgery, urology, vascular and, cosmetic surgery.

Woodthorpe Hospital is registered to provide the following Regulated Activities:

• Diagnostic and screening procedures

• Family Planning

• Surgical procedures

• Treatment of disease, disorder or injury.

The hospital’s senior management team consists of a registered manager, quality improvement manager and matron.

We inspected the hospital on 23 and 24 February 2016 on an announced visit. On 2 March 2016 we carried out an unannounced inspection of the hospital.

We inspected surgery, and outpatients and diagnostic imaging at Woodthorpe Hospital. Our inspection was part of our ongoing programme of comprehensive Independent Health Care inspections. This inspection was also part of a pilot programme testing how we assess the Workforce Race Equality Standard (February 2016). The Workforce Race Equality Standard (WRES) and Equality Delivery System (EDS2) became mandatory in April 2015 for NHS acute providers and independent acute providers that deliver £200k or more of NHS-funded care. Providers must collect, report, monitor and publish their WRES data and take action where needed to improve their workforce race equality.

Overall, Woodthorpe Hospital was rated as good. We found both surgery services and outpatients and diagnostic imaging services were good in all of the five domains we inspected; safe, effective, caring, responsive and well-led. Outpatients and diagnostic imaging services were good in the four domains we inspected; safe, caring, responsive and well-led.

Are services safe at this hospital

We found services at the hospital were safe. Patients were protected from avoidable harm and abuse:

• There was an open and honest culture at all levels within the hospital. Staff were aware of Duty of Candour regulations and the requirements for them to discuss incidents, where patients had been harmed, in an open, honest and timely way with patients, providing explanations and apologies where required.

• Safeguarding was given sufficient priority. Staff had an understanding of how to protect patients from abuse. Staff could describe what safeguarding was and the process to refer concerns. The hospital had a safeguarding lead; staff knew the name of the safeguarding lead and told us they could approach them for advice if they needed to.

• Openness and transparency about safety was encouraged. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses and were fully supported to do so.

• Processes and agreements were in place to transfer patients to an alternative acute hospital if their condition deteriorated.

• Staffing levels and skill mix were planned, implemented and reviewed to keep patient’s safe at all times. A Resident Medical Officer (RMO) provided 24-hour medical and surgical cover for all patients.

• There were systems, processes and standard operating procedures to support effective handover between the RMO, consultants and other clinical staff. They were reliable and appropriate to keep patients safe.

• Systems, processes and standard operating procedures in infection control, medicines management, patient records and, the monitoring and maintenance of equipment were mostly reliable and appropriate to keep patients safe.

• However, clinical areas throughout the hospital were carpeted. This is against advice from HBN 00-09 Infection control in the built environment, which states in clinical areas where spillages are anticipated (including patient rooms, corridors and entrances) carpets should not be used. It was noted during our inspection, that minimal invasive procedures were carried out in areas where carpets were present this minimised the risk of any spillage. There were robust procedures in place to ensure carpets were cleaned and, a process in place to remove and replace sections of carpet if they became contaminated. We saw emails detailing procurement plans for replacing carpets with vinyl flooring but were not made aware of a timescale for completion.

• Performance showed a good track record in safety with harm-free care for pressure ulcers, falls, urinary tract infections in patients with a catheter (CUTI), and blood clots or venous thromboembolism (VTE). There had been no Methicillin Resistant Staphylococcus Aureus (MRSA) and Clostridium Difficile (C.Difficile) infections in the year preceding our inspection.

Are services effective at this hospital

We found services at the hospital were effective:

• Patient’s care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and legislation.

• Local policies and procedures and National Institute for Health and Care Excellence (NICE) guidelines were discussed at clinical meetings and through the hospital medical advisory committee.

• Patient outcomes were good with low numbers of readmissions, unplanned transfers of care and, unplanned returns to the operating theatre. Patient reported outcome measures were within the expected range and the England average.

• Endoscopy services were delivered in line with the British Society of Gastroenterology guidance. The endoscopy services had recently achieved Joint Advisory Group on Gastro-intestinal Endoscopy (JAG) accreditation.

• The hospital participated in a number of national audits, for example Patient Recorded Outcome Measures (PROMS), the National Joint Registry (NJR) and the National Confidential Enquiry into Patient Outcome and Death (NCEPOD). An internal audit programme included theatre audits, consent, patient records and medication.

• Patients had a comprehensive assessment of their needs, which included consideration of pain, nutrition and hydration needs.

• There was a system to ensure qualified doctors, nurses’ and allied health professionals (AHPS) registration status had been renewed on an annual basis.

• There were 136 consultants granted practicing privileges at the hospital. Arrangements for granting and reviewing practising privileges were appropriate and staff were competent and skilled to carry out the care and treatment they provided.

• All staff including black and minority ethnic (BME) staff reported adequate support for continuous professional development in their roles.

• Consent to care and treatment was obtained in line with legislation and guidance including; where ‘Do Not Attempt Cardiopulmonary Resuscitation’ (DNACPR) decisions were made. However, DNACPR decisions were not always reviewed in a timely way upon admission to the hospital.

Are services caring at this hospital

We found services at the hospital were caring:

• Feedback from patients and those close to them was consistently positive about the way they were treated by staff at this hospital.

• Staff treated patients in a respectful, kind and professional manner, maintaining their privacy and dignity at all times.

• Patients and their relatives were pleased with the standard of care they received. The friends and family test (FFT) results were consistently high with between 97% and 100% of NHS patients recommending this hospital to their family and friends.

• Staff helped patients and those close to them to cope emotionally with their care. We saw staff providing reassurance for patients who were anxious and, actively approaching patients after their appointments to make sure that they had no concerns following their consultations.

Are services responsive at this hospital

We found services at the hospital were responsive:

• Services were planned and delivered in a way, which met the needs of the local population and individuals. The importance of flexibility, choice and continuity of care was reflected in the services.

• The needs of different patients were taken into account when planning and delivering services and, the admission process and care provided was the same for self-funded patients and NHS patients.

• The service specification for the community nursing beds and the patients in those beds did not always match; therefore, there was a risk the hospital and the associated environment may not be able to meet the needs of patients outside of the specification.

• The environment on ward two, a ward caring for patients living with dementia was not dementia friendly this meant the full needs of patients living with dementia might not be met.

• Waiting times, delays and cancellations were minimal and managed appropriately. Referral to treatment (RTT) times for both admitted and non-admitted patients were consistently above the national target of 90%. However, waiting times for patients once they had arrived in the outpatient department and cancellation rates of clinics were not routinely monitored.

• The hospital had a policy, which outlined the inclusion and exclusion criteria for patients. Patients with an American Society of Anaesthesiologists (ASA) physical status score of four or greater were excluded.

• It was easy for patients to raise a concern. Complaints and concerns were always listened to taken seriously and responded to in a timely way. Process and systems were in place to agree lessons learned and for sharing of these to ensure improvements were made to care.

Are services well led at this hospital

We found services at the hospital were well led:

• There was a clear statement of vision and values, driven by quality and safety. The hospital had adopted the corporate Ramsay mission known as the “Ramsay Way” this was a culture which recognised patients, staff and doctors were the company’s most important asset and this was said to be key to the organisation’s ongoing success.

• The hospital staff had developed the ‘Woodthorpe’ acronym to underpin the hospital strategy. The values were based on what staff aspired to and included ‘W’ Welcoming, ‘D’ Dedicated to providing an excellent quality service and, ‘R’ responsive to the needs of the patient.

• There was a clear governance structure in place with committees such as clinical governance, senior management and heads of department feeding into the medical advisory committee and hospital management team.

• The hospital senior management team and departmental leaders had the experience, capacity and capability to lead services and prioritised safe, high quality compassionate care. Staff felt there was a culture of openness within the hospital and, described immediate managers and members of the senior team as having adopted an ‘open door’ policy.

• Staff were passionate about patient care. Staff enjoyed working at the hospital, thought it was a happy environment and found their work rewarding. Staff described an open and transparent culture in the hospital where patients were put first. However, there was mixed staff feedback in relation to the hospital taking an interest in the welfare of staff. The staff satisfaction score for the year 2014/2015 was in line with the Ramsay average.

• Senior managers had the capacity, capability, and experience to lead effectively. There were suitable processes in place to check senior managers were of good character, physically and mentally fit, had the necessary qualifications, skills and experience for the role, and had supplied certain information, this included a disclosure and barring service (DBS) check and a full employment history.

• There was no local strategy in place to address the Workforce Race Equality Standard (WRES) requirements. However, black and minority ethnic (BME) staff all reported no concerns and felt they were supported by managers and generally were happy working at this hospital.

Our key findings were as follows:

• Staff morale and motivation were high and staff enjoyed working at the Woodthorpe Hospital. There was supportive management at all levels, effective team-working and an open culture in which staff were able to raise concerns and make suggestions.

• The Woodthorpe Hospital maintained high standards of cleanliness and hygiene. Patient-led assessments of the care environment (PLACE) for 2015 scored above the national average at 100%. There had been no incidents of healthcare acquired infections in the last 15 months and low numbers of surgical site infections. There were sufficient supplies of personal protective equipment available such as gloves and aprons. We saw staff using these and changing them between patients. The cleaning of equipment was monitored effectively.

• Staffing levels in surgery were calculated, using guidance created from the National Institute for Health and Care Excellence (NICE) Safe Staffing Recommendations (July 2014). These were checked and adjusted daily as required depending on changes and or patient requirements. Throughout the hospital usage of agency nurses was minimal. Wherever possible the hospital used regular bank and agency staff. Vacancy rates in outpatient were high as a percentage (33%) however, this equated to less than one whole time equivalent and, there was active ongoing recruitment in the department.

• A Resident Medical Officer (RMO) provided 24-hour medical and surgical cover for all patients. Consultants and anaesthetists could be contacted 24 hours a day and could return to the hospital within 30 minutes.

• There had been no unexpected inpatient deaths in the hospital in the 12 months preceding our inspection. If deaths did occur then these would be reviewed and discussed at the clinical governance and Medical Advisory Committee (MAC) meetings.

• Pre admission information for patients gave them clear instructions on fasting times for food and drink prior to surgery and staff checks were made to ensure patients had adhered to fasting times before surgery went ahead. Patients were screened for malnutrition and the risk of malnutrition on admission to the hospital using a recognised tool. After surgery there were accurate and complete records to monitor fluid intake and output with protocols in place to prevent post-operative urinary and kidney dysfunction

• Most patients commented positively on the choice of food available. The hospital provided three meals a day for in-patients. Choices could be seen on the menus and included choices for those on special diets. The hospital had recently introduced

We saw several areas of outstanding practice including:

• There was a rolling programme in the hospital for staff to attend a “Mental First Aid” course. Mental health first aid is an educational course, which teaches people how to identify, understand and help a person who may be developing a mental health issue.

• An ‘11.15 stand-up huddle’ was held daily with senior managers and matrons of the service. This allowed for a joint approach to addressing issues and concerns within the departments. During the meeting, levels of accountability were clearly defined with individuals taking responsibility for issues within their own clinical areas.

• The hospital arranged bi-monthly infection control meetings with links to microbiologists at a local NHS trust. This was a proactive group with representation from all departments to ensure each part of the patient’s pathway was safeguarded against the risks of infections.

• Patients were asked about smoking and alcohol consumption as part of their pre-operative assessment. All identified smokers and patients who were deemed to be at risk of alcohol related complications were given advice leaflets.

• A target controlled infusion (TCI) system was used in theatres for the administration of anaesthetics. TCI avoids over dosage of a patient with anaesthesia and allows the anaesthetist to adjust the levels of drug administered according to patient need.

• The hospital promoted a ‘policy of the week’; to encourage staff to familiarise themselves with a different policy each week.

• The hospital was undertaking a locally developed (CQUIN) in 2015/16. This involved improving patient experience in endoscopy through recording all patients’ experience of their endoscopy using the Gloucester comfort score.

• The department leader for the Post Anaesthetic Extended Care Unit (PAECU) had forged links with the local critical care network which had allowed all of the nursing staff on the ward to be trained for critical care transfers from the hospital should they be required.

• The physiotherapy department had introduced a physiotherapy joint school. The joint school was a three-day care pathway for patients who had undergone joint surgeries for example knee replacement. As a result of the joint school there had been a reduction in readmission of joint patients.

• The physiotherapists told us that if they had a patient who did not attend (DNA) an appointment, they would call to check the patient was safe and to rebook the appointment.

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

The hospital should:

• The hospital should ensure that they comply with reporting requirements for the Workforce Race Equality Standard.

• The hospital should ensure all medicines on the resuscitation trolleys are in date and ready for use.

• The hospital should ensure medicines trolleys are stored in line with hospital policy, current legislation and best practice guidance.

• The hospital should ensure there are processes in place to assess, monitor and improve the quality of services in the outpatients department including the monitoring of cancellations and delays.

• The hospital should ensure flooring in clinical areas is compliant with HBN 00-09 infection control in the built environment.

• The hospital should ensure medicine prescription pads are stored in a locked cabinet within a lockable room or area locked room in line with NHS guidance (2013).

• The hospital should ensure there is an improvement in mandatory training rates.

• The hospital should consider reviewing the process for admission to the community nursing beds to ensure that the patients admitted to the hospital meet the service specification for the community nursing beds.

• The hospital should consider reviewing the environment on ward two to make it dementia friendly.

• The hospital should consider equipping theatre four with all of the standard equipment associated with a theatre for example piped oxygen and suction units in line with HBN 26 Facilities for surgical procedures.

Professor Sir Mike Richards

Chief Inspector of Hospitals