During this inspection we visited the ward and the out patients department. We spoke with the chief executive, the chief nurse, the ward sister, the pre op assessment nurse, three nurses including the lead nurse for dementia care. We spoke with four patients and looked at the records of four patients particularly in relation to consent to treatment.

We spoke with three patients who were listed for surgery on the day of the inspection and one patient who had undergone surgery that morning and were waiting to be discharged. Patients told us consent to surgical procedures had been explained to them from the outset.

We looked at four patient’s case records to see whether the documentation clearly showed the patients agreement. We found the documentation was clearly recorded around their consent.

This showed that systems were in place to monitor and improve record keeping in relation to consent to treatment.

We saw the hospital had revised their audit tools and in addition were carrying out monthly audits. This meant the governance arrangements had improved and staff told us if managers identified any shortfalls these were discussed at ward, quality or board meetings as appropriate.

Patients and relatives we spoke with told us they were very happy with the care and treatment they had received. One patient said "It has been great. The staff have been really helpful. I’ve no complaints at all. I would recommend this place." Another patient said, “The staff have been very good. They’ve been polite and efficient and checked my details. They confirmed what I was going to have done with me.”

From speaking to people, their relatives and reviewing care records we found that consent was being obtained from people about their care and treatment and people were receiving care and support that met their individual needs. However, the Fairfield consent policy was not being consistently adhered to. We found the discharge arrangements in place within the hospital were working well and that arrangements were in place with NHS acute providers to provide emergency care if this was required.

Effective systems were in place to monitor the quality of care people received at Fairfield. Complaints were being reviewed and responded to within appropriate timescales. However, recording of actions taken following investigations of complaints and incidents was limited, which made it difficult to track whether actions arising had been fully completed.

People we spoke with on the ward said they were given the right amount of information before they had agreed to have their surgical operation which made sense to them and was clear and understandable They said this was supported by information provided by nursing, surgical and anaesthetic staff during the person's consultation sessions with them when they had attended the out-patients clinic for a full pre-admission assessment including blood tests.

One person told us "everything was explained to me" another said “all my questions were answered fully”

People spoken with said “the staff can’t do enough for you” “the place is wonderful” “the care is second to none.”

People spoken with said they felt “safe and cared for”

Fairfield Independent Hospital is a charitable, non-profit making organisation based in St Helens, Merseyside and is part of the Guy Memorial Home Limited.

Fairfield Independent Hospital is registered to provide the following Regulated Activities:

• Diagnostic and screening procedures.

• Surgical procedures.

• Treatment of disease, disorder or injury.

The hospital’s senior management team consists of the Board of Trustees, the Chief Executive, and a team of hospital managers.

We inspected the hospital on 26 and 27 July 2016 on an announced visit. On 10 August 2016, we carried out an unannounced inspection of the hospital.

We inspected all services that were provided by Fairfield Independent Hospital. Our inspection was part of our ongoing programme of comprehensive Independent Health Care inspections.

Additionally, there are services provided by other registered organisations at the hospital which we did not inspect as part of this inspection. However, we looked at the service level agreements that were in place for these and how these were being managed.

We rated Fairfield Independent Hospital as ‘Good’ overall. We rated both surgery and outpatients and diagnostics as good in safe, effective, caring, responsive and well-led. However, this excluded effective in outpatients and diagnostics as we do not currently rate this.

Are services safe at this hospital

We rated safety as ‘good’ in both surgery and outpatients and diagnostic imaging because;

• The hospital had systems in place to manage risk. This included policies describing how to measure and escalate risk as well as reporting incidents. Staff that we spoke to understood how to use the paper based system and were able to give us examples of incidents that they would report. Staff told us that when they had reported incidents they had received feedback from these.

• The hospital had appropriate infection prevention and control procedures in place. There had been no reported incidents of hospital acquired infections between April 2015 and March 2016.

• We found that there were sufficient numbers of appropriately skilled staff to care for patients that were receiving care and treatment. A nursing acuity tool had been used to calculate the current staffing establishment and a weekly planning meeting was held to calculate how many staff were required. We observed staff handovers and found that they were robust and provided continuity of care for patients.

• Staff in theatre followed the ‘five steps to safer surgery’ and on most occasions the ‘WHO’ checklist was followed and completed appropriately.

• There were safeguarding policies and procedures in place to keep patients safe. There was a designated safeguarding lead and there were appropriate numbers of staff trained in safeguarding. Staff we spoke to were able to give us examples of what would constitute a safeguarding referral to be made.

• Patient care was consultant-led and there was 24 hour cover provided by a resident medical officer who was based on site.

Are services effective at this hospital

We inspected but did not rate effective in outpatients and diagnostic imaging. We rated effective as ‘good’ in surgery because;

• The hospital provided care and treatment in line with up to date evidence based practice. We checked a sample of clinical guidelines and found them to be appropriately referenced against up to date guidance on most occasions.

• Patient outcomes were regularly monitored through compliance with key performance indicators and regular data submissions were provided for benchmarking. Records indicated that patient outcomes were similar to other services nationally.

• Local audits were also completed on a regular basis so that performance and compliance in certain areas were monitored and improved when required.

• There were systems in place to check the competencies of consultants who had applied to work under practicing privileges at the hospital. This process involved any application being agreed by the medical advisory committee.

• Staff received a yearly appraisal in line with the hospital policy.

• The hospital had policies and procedures in place for consent, mental capacity and deprivation of liberty. Consent was sought prior to any treatment and patients were required to sign consent forms, which were then confirmed on the day that patients attended the hospital.

Are services caring at this hospital

We rated caring as ‘good’ in both surgery and outpatients and diagnostic imaging because;

• Staff were caring, compassionate and treated patients with dignity and respect.

• Patients' privacy and dignity were maintained while receiving care and treatment.

• Results from the NHS friends and family test were positive with most patients saying that they would recommend the hospital as a place of treatment.

• Staff ensured that patients were involved in how their care was delivered.

Are services responsive at this hospital

We rated responsive as ‘good’ in both surgery and outpatients and diagnostic imaging because;

• National targets for access to outpatient and diagnostic services had been met consistently between April 2015 and March 2016. Additionally, the hospital aimed to see 90% of patients within 30 minutes of arrival. This target had been exceeded between January 2016 and June 2016.

• Referral to treatment times for surgery between April 2015 and March 2016 had also been consistently met.

• Services were mostly delivered in a way that met the needs of patients who attended the hospital.

• A dementia strategy was used to support patients living with dementia. Some hospital facilities had been adapted to meet the needs of patients living with dementia and the hospital ensured that appropriate support was provided when needed.

• The hospital had a clear admissions policy which meant that they were able to exclude patients who they were not able to provide care and treatment for.

• The hospital had a complaints policy that was followed if concerns were raised. Information was available for patients and relatives describing the complaints process. This also included information about who to contact if it was felt that the response was unsatisfactory.

Are services well-led at this hospital

We rated well-led as ‘good’ in both surgery and outpatients and diagnostic imaging because;

• The hospital had a strategic plan from 2015 to 2020. This plan included a mission and a vision for the hospital.

• Areas for further improvements that the hospital could make had been identified and the management team reviewed this on a regular basis.

• Care and treatment provided was monitored so that gaps were identified and improvements could be made.

• The hospital used a risk management policy and system that identified and scored risks for both outpatient and diagnostics as well as surgery. We found that this process had been followed on most occasions. There were designated members of the management team who had responsibility for managing this.

• There was a governance structure in place that allowed information to be fed up to the appropriate members of the management team. Any concerns, incidents or policies and guidelines waiting for approval were discussed as part of the medical advisory committee meetings.

• Fit and proper persons legislation was taken into consideration when recruiting to the management team or the board of trustees. This included conflict of interests, financial background checks and disclosure and barring service (DBS) checks.

• There was a positive culture within the hospital. Staff that we spoke to were proud to work in the hospital and felt that a good standard of patient care was delivered.

• Leaders were visible throughout the hospital and staff felt well supported.

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

The provider should:

• The hospital should take action to address that not all staff are aware of the policy with regards to female genital mutilation (FGM). FGM should form part of the adult safeguarding policy and not just the children’s safeguarding policy.

• The hospital should take action to ensure all consent forms are fully completed.

• The hospital should take action to provide leaflets to patients that are regularly reviewed, and in date with the latest information.

• Risk assessments should be scored appropriately and where necessary escalated to the senior team.

• Risk assessments for the department should be reviewed to ensure that all areas of the service are considered so that risks can be mitigated, and actions put in place to reduce the impact and severity.

• The hospital should consider patients privacy on booking in to the department as there was no privacy line.

• The hospital should consider providing seating for those patients with mobility difficulties.

• The management team should make sure that all consultants sign to confirm final site marking verification during the ‘sign in’ phase of the WHO checklist.

• The hospital is in the process of becoming JAG accredited for endoscopy services and this is planned for May 2017. The hospital should ensure that the implementation plan is achieved.

• The hospital should ensure that all mandatory training for staff is completed in a timely manner and meets the hospital compliance target as a minimum.

Professor Sir Mike Richards

Chief Inspector of Hospitals