Fitzwilliam Hospital is operated by Ramsay Health Care UK. The hospital has 45 beds. Facilities include a two-bedded high care unit (HCU), three main theatres with laminar flow, a purpose built ambulatory care unit and a day case unit. The hospital provides surgery, outpatients and diagnostic imaging for adults.

We carried out a responsive inspection of surgery services in response to the number of serious incidents in gynaecological surgery reported by the provider between January 2017 and September 2017. We announced the inspection to the provider on the 6 September 2017 and carried out the inspection on the 13 September 2017and inspected the key question of safe in surgery only.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

Services we rate

We rated surgery as good for safe and good for Well led.

We found good practice in relation to surgery:

• Staff understood their responsibility to raise incidents and concerns and the hospital had documented procedures for incident investigation and sharing of learning.

• Staff mandatory training and e-learning compliance was above hospital target (85%).

• The hospital was 100% compliant with intermediate life support (ILS) training.

• Staff knew their responsibility to safeguard vulnerable adults. Safeguarding training compliance was above the hospital target.

• The hospital had processes in place to manage risks to people. Risks were assessed, monitored and managed appropriately.

• Staffing levels and skill mix were appropriate and reflected patient acuity.

• The hospital had a clear governance structure in place with appropriate arrangements for communication. The hospital had committees such as clinical governance, senior management, and heads of department, which all fed into the medical advisory committee (MAC) and hospital management team.

• The theatre department and the ward had dedicated managers who reported to the hospital matron.

• Theatre and ward staff told us they felt valued and well supported by their manager. All the staff we spoke with told us that they were able to raise concerns openly and both managers had an open door policy.

• Staff knew the hospital vision was to be the number one provider of health care in the local area, and to offer high quality, safe, patient centred care.

• The hospital had a variety of mechanisms to gain feedback from patients by means of the friends and family test, monitoring social media comments, the online patient survey and through complaints and complements received.

We found areas of practice that require improvement in surgery:

• Two of the eight duty of candour letters the hospital had sent to patients who suffered serious incidents (SIs) were not accurate. One suggested “patient anatomy” to be the cause and the second did not detail why two procedures had been carried out when one would have sufficed.

• Theatre staff we spoke with said they were not as well informed around previous incidents and their investigation outcomes despite incidents being a standard agenda item at weekly meetings.

• In theatre three anaesthetic room nursing staff recorded the room temperature to be 27°C. We reviewed room temperature records for theatre three anaesthetic areas. Theatre staff had recorded the temperature above 26 degrees on seven days in July, 13 days in August and 15 days in September. This is above recommended limits for storing medications and may impact on medicine efficacy

• The hospital did not keep records of conversations between the hospital general manager, the medical director (MD) and the MD at the local NHS provider regarding concerns around behaviour and performance of consultants.

Following this inspection, we told the provider that it should make other improvements, even though a regulation had not been breached, to help the service improve.

Heidi Smoult

Deputy Chief Inspector of Hospitals

As part of our inspection we spoke with seven people who used the service and four people’s relatives. All of the people we spoke with and their relatives spoke very highly of the care that had been provided. One person we spoke with told us, “This hospital has been magnificent, the treatment has been excellent and all of the staff so helpful.” Another person told us, “It was as good as I expected it to be, they make you feel special.”

We found that before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. All of the people we spoke with were able to tell us about how their consent had been sought and that they had been given an opportunity to ask questions.

We reviewed seven people’s care records and found that people’s needs were assessed and care and treatment was planned and delivered in line with their individual care plan. When we spoke with people we found that care and treatment was planned and delivered in a way that was intended to ensure people’s safety and welfare.

We also found that there were enough skilled, experienced and qualified to staff to meet people’s needs. People’s complaints were fully investigated and resolved, where possible, to their satisfaction.

People told us that procedures and processes had been clearly explained to them and that they had been given opportunities to ask questions. When they had signed consent forms, these had been explained in detail. Nursing staff discussed with them how they were going to carry out care tasks and asked if they had any preferences in how this was completed.

People said they were cared for appropriately and that staff were kind and polite. They had been involved in the planning of their care from the point of admission. All of the people we spoke with said they had received adequate pain relief following their operations and that staff members worked hard to make sure they were pain free.

They said that rooms were thoroughly cleaned every day and that staff members regularly used hand washing facilities.

People we spoke with stated they received medication when they expected it and that pain relief was available when they needed it.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

Fitzwilliam Hospital is operated by Ramsay Health Care UK Operations Limited. The hospital has 41 beds. Facilities include three main theatres with laminar flow, a purpose built ambulatory care unit and a day case unit.

The hospital provides surgery, services for children and young people, and outpatients and diagnostic imaging. We inspected each of these services.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 15 November 2016 along with an unannounced visit to the hospital on 29 November 2016

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and 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.

The main service provided by this hospital was surgery. Where our findings on surgery – for example, management arrangements – also apply to other services, we do not repeat the information but cross-refer to the surgery core service.

Services we rate

We rated this hospital as good overall.

We found good practice in relation to surgery, outpatient and diagnostic care:

• Staff had access to a variety of comprehensive policy documents referencing best practice and legislation and there were mechanisms in place to audit staff compliance to policy. The hospital participated in national and local patient outcome audits. The hospital had joint advisory group (JAG) accreditation for endoscopy services.
• Staff reported good multidisciplinary working with the ward staff, outpatients, theatres, and physiotherapy.
• The hospital managed practicing privileges in line with appropriate guidance, staff checks, and timescales.
• The outpatients and surgery referral to treatment times (RTT) were better than the England average. Patients could attend evening and weekend appointments to promote access to treatment for patients who have work or family commitments. Private patients could be seen in as little as 72 hours following referral.
• Staff knew and understood the hospital vision and values. The hospital had a clear governance structure; staff received feedback via team meetings, emails, and shared information boards across the hospital. Staff spoke highly and were supportive of the leadership style of managers.

We found areas of practice that require improvement in services for surgery, outpatient and diagnostic imaging:

• Venous-thromboembolism risk assessments were not always available in patient records.
• The staff completion rate for safeguarding children training at level three was very low at 9%. The completion rate of advanced life support training for theatre staff was 40%.
• We were not assured regarding the staffing arrangements for patients under the age of 18 years of age having surgery.
• Patient information was misfiled within patient’s healthcare records, making it difficult for staff to find key documents relating to patients care, assessment, or treatment. Whilst consultants routinely signed patient healthcare records where they had provided care, advice, or treatment, they did not print their name nor date the record they had completed. We found that in five of the seven patient healthcare records we reviewed there were no consultant notes available.

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. We also issued the provider with one requirement notice that affected surgery in respect of young people’s services and outpatients in respect of patient records. Details are at the end of the report.

Professor Ted Baker

Deputy Chief Inspector of Hospitals