Patients who used the service were given appropriate information and support regarding their care or treatment. We saw patients were able to express their views and were involved in making decisions about the care and treatment provided.

Patients who used the services we inspected all said they had been treated with dignity and respect. They said they had received treatment quickly and staff had kept them informed about their plan of care. One patient told us, “You are not a number you are treated as an individual.”

Another patient told us, “You can’t fault the staff or care provided it is excellent.”

Patients needs were assessed and care and treatment had been planned and delivered as they preferred. We saw, and were told, that patients received the care they needed with their individual preferences taken into account. One patient told us that they did not live locally and preferred to have their physiotherapy appointment local to where they lived, they explained to us that this had been arranged.

Patients were cared for in a clean, hygienic environment. We saw there were effective systems in place to reduce the risk and spread of infection.

We saw records were accurate and fit for purpose. Records were kept securely and could be located promptly when needed.

We spoke with six patients who received a service and two relatives. The feedback we got was very positive that the service provided was very good and staff delivered the care and treatment in a caring way maintaining dignity and privacy. Patients also said they were given choices and listened to. One patient told us, “The staff don’t just say they are doing something, but they explain why they are doing it and always give choices”.

Another patient told us this was their second time in the hospital, that the service had improved greatly and it was excellent. Patients also praised the follow up and after care. One patient told us, “The physiotherapists are excellent they have time to explain and the service is never rushed, I would certainly recommend this hospital.”

Patients who used the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. Staff were very knowledgeable on procedures to follow.

Staff received appropriate professional development. A training programme was in place to provide staff with the training and support they needed. However a number of staff had not completed some of the yearly training updates.

There was an effective system to regularly assess and monitor the quality of service that people received. There was a complaints policy that took account of complaints and comments to improve the service.

Park Hill hospital is part of the Ramsay Healthcare Group and is registered as a provider under the name Independent British Healthcare Limited. Facilities at the hospital included 21 beds, made up of 17 single rooms and one four bedded room; all rooms had en-suite facilities. There were also six outpatient consulting rooms, a treatment room, and dedicated use of a fully-equipped laminar flow theatre on the site of the adjoining NHS hospital trust.

We inspected the hospital as part of our independent hospital inspection programme. The inspection was conducted using the CQC’s comprehensive inspection methodology. It was a routine planned inspection. We inspected the following two core services at the hospital: surgery, and outpatients and diagnostic imaging. We carried out the announced part of the inspection on 3 and 4 August 2016. We also carried out an unannounced visit on 12 August 2016.

We rated the hospital as requires improvement overall. Surgery was rated as requires improvement and outpatient and diagnostic imaging was rated as requires improvement. For the hospital overall we rated the key questions as follows:

Are services safe at this hospital

We rated the safe key question as requires improvement overall. An electronic risk reporting system was in place. However, there was some confusion amongst staff of what constituted an incident and a lack of confidence in reporting this on the hospital’s electronic system. We saw limited examples of learning from incidents being shared with staff or being used to drive improvements. There had been one never event in in the past 12 months. Never Events are serious incidents that are wholly preventable as guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers. The never event involved surgical placement of the wrong implant or prosthesis. There had been a full investigation into the cause of this incident and learning had been identified. Other serious incident investigations reports we reviewed were not robust and did not identify appropriate learning in order to drive improvements. There was a broad understanding of the duty of candour. The duty of candour is a regulatory duty that relates to openness and transparency and requires providers of health and social care services to notify patients (or other relevant persons) of ‘certain notifiable safety incidents’ and provide reasonable support to that person. There was a strong culture of being open and honest with patients. However, there was no formal training or system in place to ensure the duty of candour was consistently applied at the time of inspection.

Medications were stored appropriately and we saw that these were dispensed correctly in the majority of cases. However, there had been no quality assurance or stock check of controlled drugs undertaken by a pharmacist for over six months. The management of medication prescription pads was not in line with national guidance and we saw that intravenous fluids had not been correctly prescribed on the medication charts we reviewed. The hospital was visibly clean and infection rates were in line with other providers. Equipment was appropriately used and maintained. The resident medical officer (RMO) was based in the hospital and provided medical cover 24 hours a day. We reviewed RMO cover and found it was sufficient. Staffing levels and projected occupancy ratios were reviewed regularly and staffing was planned based on the expected activity levels of the service. Mandatory training figures were low. Staff received mandatory training in the safeguarding of vulnerable adults and children and the nursing and medical staff we spoke to were generally aware of their safeguarding responsibilities and of appropriate safeguarding pathways to use to protect vulnerable adults and children. The matron was the named safeguarding lead for the hospital. However, we saw no evidence that they had level four safeguarding training as required by the Intercollegiate Document on Safeguarding Children and Young People (2014). The hospital told us that they were able to seek assistance from a level four trained link nurse within the wider Ramsay group. There was varying compliance with safeguarding training from staff and we were not assured that staff had received the appropriate level of safeguarding training for their role. The records we reviewed were of an appropriate standard and we saw that appropriate risk assessments took place in the majority of the records we reviewed. There was a deteriorating patient pathway and a clinical escalation policy in place. There was a formal arrangement for patients to be transferred to the local NHS hospital if their clinical condition could not be safely managed at the hospital and the resuscitation team from the local NHS hospital would attend emergencies.

Are services effective at this hospital

We rated the effective key question as requires improvement overall. We saw that very few staff had undergone an appraisal within the past two years. The senior team were aware of this issue and had begun to put plans in place to ensure that appraisals were taking place. There was a lack of training and awareness around mental capacity and deprivation of liberty safeguards. The hospital had an annual audit schedule, but this had not been consistently monitored or actions identified to address non-compliance. The hospital also contributed to a small number of national audits, but did not benchmark its performance nationally outside of the Ramsay group. Staff were aware of how to access hospital policies and guidance, and we saw that these were in line with evidence based practise and were prepared nationally by the Ramsay group. All clinical and nursing staff had undergone checks on their professional registrations. Consultants were granted practising privileges to work at the hospital. Practising privileges are when authority is granted to a doctor or dentist to provide patient care in the hospital by a hospital’s governing board. We saw that effective multidisciplinary team working took place between staff at the hospital and also with the local trust. There had been five unplanned transfers of patients in the period April 2015 to March 2016; this was lower than the average for independent hospitals. There had also been five unplanned returns to the operating theatre in the period April 2015 to March 2016. Senior managers were aware of this and had undertaken a review of the reasons for these patients returning for further surgery.

Are services caring at this hospital

We rated the caring key question as good overall. Patients were cared for compassionately and with dignity and respect. Patients spoke positively about care and treatment and felt involved in the planning of their care. Staff gave examples of providing emotional care to patients and we saw staff being flexible around visiting hours for patients who needed this. We observed positive interaction between staff and patients. The hospital had a high score (100%) in the Friends and Family Test but response rates were low (between 40% and 5%). The hospital’s internal patient surveys showed generally high (99%) levels of patient satisfaction.

Are services responsive at this hospital

We rated the responsive key question as requires improvement overall. Services were planned to meet the needs of local people and individual patients. Delays and cancellations to appointments and planned surgery were low and referral to treatment times data showed that the hospital had routinely exceeded the indicators. However, the reasons for cancellations were not formally analysed. There was also an inconsistent system for booking patients for surgery that resulted in peaks and troughs in activity that staff told us were difficult to handle. We also saw that routine calls to patients prior to surgery did not always take place. This meant that some patients were unprepared and that planned surgery was cancelled as a result. There was a lack of formal feedback or evidence of improvements being made as a result of complaints received by the hospital. The arrangements and systems in place to respond to the specific needs of individuals (for example, translators or chaperones) were not systematic. This meant that there was a risk that patients with specific needs would not have these met by the hospital.

Are services well led at this hospital

We rated the well led key question as requires improvement overall. The hospital manager and matron had only been in post for 8-12 weeks at the time of our inspection. This meant that they had not yet had time to fully assess or address any issues they had identified. However, the senior team was proactive in identifying areas for improvement and told us about a range of actions that they planned to take place. There was a regional strategy in place and staff were aware of this. However, senior staff had not yet had time to finalise a local strategy for the hospital. The hospital had a governance structure in place. Although departmental meetings had not always taken place, these were planned to occur more frequently going forward. Heads of Department meetings also took place and fed into the Medical Advisory Committee (MAC). We saw limited evidence that these meetings involved discussion around the quality and outcomes associated with patient care. We also noted that the corporate risk register had been updated in July 2016, but did not highlight mitigating actions being taken to address the risks it identified. Risk management processes were not robust and there was no assurance that lessons learnt from incidents and complaints was cascaded to staff or used to drive improvement. There was a policy in place for the MAC to determine whether a doctor was suitable to practice and we saw that systems were in place for revalidation of medical staffing and for the effective management of doctors’ practising privileges. The hospital had not yet completed the Workforce Race Equality Standard (WRES) data submission and did not have a local action plan in place to address this. Staff spoke positively about the new senior leadership team and felt confident in their ability to make changes and improve working practices. Staff described that they had begun to be engaged about changes within the hospital and felt that this would continue to improve as the senior team further embedded into the hospital.

There were areas of poor practice where the provider needs to make improvements.

Importantly, the provider must:

• Ensure that incident reporting processes are robust so that incidents are appropriately identified and reported, comprehensively investigated and lessons learned are identified and shared with all staff.
• Ensure that all staff have had a meaningful and consistent appraisal and are completed within the timescales determined by the hospital policy.
• Ensure staff competencies are completed in accordance with the hospital policy and professional standards.
• Ensure that mandatory training is completed in accordance with the hospital policy.
• Ensure that staff receive appropriate levels of safeguarding training for their job roles.
• Ensure that infection prevention and control measures are in place.
• Ensure that staff have access to the appropriate manual handling equipment and are properly trained in its use.
• Ensure that patient care is personalised, takes into account individual needs and the assessment of these needs and the care required to meet these needs is recorded.
• Ensure that the Duty of Candour requirements are embedded in policy and practice.
• Ensure that there are in operation effective governance, reporting and assurance mechanisms that provide timely information so that performance and outcomes are monitored effectively and in line with hospital policy and risks can be identified, assessed and managed.
• Ensure that there are alert systems in place to identify when actions are not effective and need to be reviewed, particularly in relation to incidents.

In addition the provider should:

• Ensure that information is available to patients on how to make a complaint and the complaints process and establish and operate effectively an accessible system for identifying, receiving, recording, handling and responding to complaints by service users and other persons
• Provide a system to track the use of prescription pads within the outpatient department and to ensure medication administration and storage compliance has been met.
• Improve the booking arrangements for patients to ensure a more consistent flow of patients attending for surgery.
• Ensure that an appropriate risk register is in place which fully reflects the risks, mitigating actions identified by the hospital, and timescale in which a review of the risk will take place.
• Implement the Workforce Race Equality Standard (WRES).
• Ensure emergency call requests including the use of the crash team have been tested to ensure response times are appropriate and safe.
• Consider the implementation of a system to record data regarding patients who fail to attend appointments.
• Provide staff with the information and training in support of an advocacy service for all patients, should they require one.

Professor Sir Mike Richards

Chief Inspector of Hospitals