At our previous inspection of Barlborough NHS Treatment Centre in March 2013 we found that the provider did not have appropriate arrangements in place for the storage and recording of medicines. We also found that people’s medical records were not being consistently completed.

During this inspection we spoke with three patients and four members of staff about the service provided at Barlborough. We found a number of improvements in the way that medicines were stored and recorded. Patients we spoke with said that they received good care and had been given adequate pain relief.

We also saw improvements in the completion of patient’s medical records, specifically in relation to fluid charts and the recording of blood transfusions. Staff told us they had received additional support and training and that new charts had been introduced which made accurate record keeping easier.

During our inspection we visited a number of areas within the treatment centre including theatres, patient wards and the on site pharmacy. We spoke with five patients who had or were receiving treatment at the centre. Everyone was happy with their care. One person told us, ''The place is spot on, perfect. There was no waiting, plenty of information. I am satisfied with my care.''

We reviewed the care records of four patients and found that appropriate risk assessments had been completed prior to their admission for treatment. Comprehensive records were in place regarding patients treatment at the centre, however we found that some documents were not being completely properly or by the right member of staff.

We looked at the arrangements for the management of medicines at the centre. We found that there were ineffective arrangements for the storage of medicines, including oxygen. Records relating to patients medicines were not always completely accurately or in a timely fashion.

Patients we spoke to said they were satisfied with the care they received which they said was to a high standard.

Barlborough NHS Treatment Centre (the treatment centre) opened in July 2005 and in 2009 was acquired by Care UK Clinical Services Ltd, the largest independent provider of NHS services in England. Independent NHS treatment centres are private-sector owned treatment centres contracted to treat NHS patients free at the point of use. The treatment centre is a dedicated orthopaedic centre and provides in-patient and day case orthopaedic elective surgery with associated outpatient and diagnostic clinics. It provides services to people living in Derbyshire, Lincolnshire, Nottinghamshire and South Yorkshire, and runs some satellite outpatient clinics in Lincolnshire.

The treatment centre has a 40 bed inpatient ward and a six bed day patient ward. There are three theatres that operate Monday to Saturday, and also Sunday on demand. Procedures include minor and intermediate orthopaedic surgery, major joint replacements and revisions, joint arthroscopy, ligament repair, shoulder decompression, repairs and stabilisations, foot and ankle procedures, and hand procedures such as carpal tunnel release. It also carries out non complex spinal surgery.

We carried out a comprehensive inspection of Barlborough NHS Treatment Centre on 17 to 19 and 28 March 2015 as part of our second wave of independent healthcare inspections. We used the new approach to inspections and inspected the following two core services:

• Surgery
• Outpatients and Diagnostic Imaging

Barlborough NHS Treatment Centre has been awarded a shadow rating of good. Shadow ratings apply to inspections which are undertaken during the development of our approach and before our final methods are confirmed and published.

Our key findings were as follows:

• Leadership

Members of the senior leadership team were relatively new in post and roles were being developed. However staff morale and motivation were high and staff enjoyed working at the treatment centre. 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.

• Cleanliness

The treatment centre maintained high standards of cleanliness and hygiene. There had been no incidents of healthcare acquired infections in the last 18 months. There had been no surgical site infections since August 2014. 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.

•  Safety

There had been four never events between October 2013 and September 2014 (never events are serious, largely preventable, patient safety incidents that should not occur). Other serious incidents resulting in harm to patients were not always reported to the Care Quality Commission as required by legislation. Operating staff used the a recognised surgical safety checklist, but this was not the most up to date version. There were systems in place to identify and record patient safety incidents;  thorough investigations were completed and findings were cascaded to staff.

• Nutrition and hydration

Patients were given clear guidance on pre-operative fasting and staff telephoned patients the day before surgery to ensure they were clear about this. Patients were screened for malnutrition and the risk of malnutrition on admission to the treatment centre using a recognised tool. After surgery there were accurate and complete records to monitor fluid intake and output. Where there were concerns nurses followed protocol and scanned patients’ bladders, seeking medical advice as needed, so as to prevent post-operative urinary and kidney dysfunction.

Patients found the choice and quality of meals to be very good. The range available was suitable for patients’ needs and preferences. It included foods suitable for coeliac, diabetic, vegetarian and other diets.

• Staffing levels

Staffing levels were adjusted according to patient numbers and to accommodate patients who needed additional support. There were more nursing staff than the recommended National Institute for health and Care Excellence (NICE) guidelines, and staff confirmed that these levels were consistently maintained. There were low rates of sickness and low staff turnover for all staff groups. Staff were well supported and were able to work flexibly. There was variable use of agency staff in theatres but overall there was a low rate of agency staff employed at the treatment centre. A resident medical officer was available on site 24 hours per day and a consultant anaesthetist and consultant surgeon were on call 24 hours per day. These were permanent staff who worked on a rotating shift basis.

• Mortality rates

There were three unexpected inpatient deaths in the reporting period October 2013 to September 2014. Two of these occurred in 2014. In one case the patient died as a result of an undiagnosed serious condition. Following the second death, as a result of kidney disease, an investigation recommended improved patient monitoring and assessment in certain cases. New procedures have been put in place to ensure swift identification and management of the condition.

We saw several areas of outstanding practice including:

• Staff were exceptionally caring and went the extra mile to provide high quality care.
• Staff were highly motivated to offer care that was respectful and promoted people’s dignity. They took the initiative in seeking solutions to meeting individual patients’ needs.
• There was an ethos of teamwork and supportive management, with effective communication throughout the treatment centre.
• Emergency equipment, including portable oxygen and suction, was kept in the lift used to transport patients between the ward and theatres. This meant that in an emergency patients could be treated without delay.

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

Importantly, the provider must:

• Ensure that all notifiable incidents resulting in harm to patients, including safeguarding incidents, are reported to the Care Quality Commission, so that action can be taken where needed.

In addition, the provider should:

• Update the World Health Organisation (WHO) surgical checklist.

• Continue to improve staff hand hygiene practices.

• Ensure sufficient, suitable storage space for theatre equipment

• Establish an effective formalised system to ensure sufficient out of hours nursing staff when patients have to return unexpectedly to theatre.

• Ensure all staff comply with the requirements of the Mental Capacity Act 2005, when caring for someone who lacks or may lack the capacity to make decisions about their care and treatment.

• Improve staff uptake of dementia awareness training.

• Establish a clear system to ensure ward staff are aware when patients have specific nutritional needs or need assistance with eating.

• Provide nursing staff with regular clinical supervision.

• Provide all staff, including administrative and clerical, with an annual performance appraisal.

• Advise people attending as outpatients in advance about the opportunity for a chaperone to accompany them during their appointment.

• Provide patients with information about how to travel to the treatment centre by public transport and about the availability of provided transport

• Make available patient information leaflets in large print and formats other than written English.

• Ensure patients in all areas have accessible information on how to raise concerns and complaints.

• Strengthen the risk register to include ownership of actions and their timely review.

• Report patient comments, concerns and complaints regularly through the hospital’s governance structure so that systematic and consistent learning can be shared.

Professor Sir Mike Richards

Chief Inspector of Hospitals