This was the first comprehensive inspection of Parkside Hospital, which was part of the CQC’s ongoing programme of comprehensive, independent healthcare acute hospital inspections. We carried out an announced inspection of Parkside Hospital on 24-26 May 2016. Following this inspection an unannounced inspection took place on 6 June 2016.

The inspection team inspected the core services of medicine, surgery and outpatients and diagnostic imaging services.We did not inspect end of life care as a separate core service as it accounted for less than 10% of the services provided at the hospital.

Complex diagnostic investigations such as magnetic resonance imaging (MRI) and computerised tomography (CT) scans were provided by the hospital.

Overall, we have rated Parkside Hospital as good. We found medicine good in all five of the key questions we always ask of every service and provider relating to safe, effective, caring, responsive and well led. Outpatients and diagnostic imaging services was rated good in the four key questions relating to safe, caring, responsive and well led. We inspected but did not rate the key question of effective in outpatient and diagnostic imaging services. We found surgery services were good in four of the key questions of safe, effective, caring and responsive, but requires improvement in well led.

Are services safe at this hospital/service

By safe, we mean that people are protected from abuse and avoidable harm.

• There was a positive culture of incident reporting. Nursing staff understood their responsibilities to raise concerns and report incidents and were supported when they did so.
• There was an effective process for the investigation of serious incidents and a good understanding and use of the Duty of Candour. Staff told us they would apologise and inform the patients or their carers if incidents occurred.
• All patient areas were visibly clean. Infection prevention and control processes were adhered to and equipment had been cleaned and had green labels attached to them in line with the hospital’s policy.
• The hospital monitored patient safety on a day-to-day basis and patients were safeguarded from harm. Staff were aware of their safeguarding adult’s responsibilities. Patients were appropriately escalated and treated if they deteriorated. Medicines were well managed, stored and administered safely.
• Staffing levels and skill mix were planned, implemented and reviewed to ensure patients received safe care and treatment at all times.
• Patients were appropriately risk assessed, their condition was monitored throughout their stay, and there were appropriate procedures and protocols for responding to any deteriorating condition.
• Improvements were needed to the anaesthetic cover of the High Dependency Unit.
• Medicines were managed and stored safely.
• Staff had received up-to-date relevant mandatory training which was relevant to their role, this included level three safeguarding children’s training.
• Some patients did not receive a pre-assessment prior to their operation and this meant that there was a risk that a patient could deteriorate unexpectedly during or after their surgery leading to an unplanned admission to the High Dependency Unit or an emergency transfer.
• There were arrangements for RMO to RMO handover using the situation, background, assessment, recommendation (SBAR) system.

Are services effective at this hospital/service

By effective, we mean that people’s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence.

• Patient care and treatment reflected relevant research and guidance, including the Royal Colleges and National Institute for Health and Care Excellence (NICE) guidance.

• Staff were well supported with access to training, clinical supervision and development. RMOs told us they felt well supported by the senior medical staff and had access to regular training.
• There was an effective multidisciplinary approach to care and treatment with good communication between the teams and out-of-hours services were provided when needed.
• Patients had comprehensive assessments of their needs, which included assessment of their clinical needs, physical health, nutrition and hydration needs.
• Patient’s needs with regard to pain management were addressed. Patients had access to different methods of pain relief. Patients’ pain was monitored and the effectiveness of pain management evaluated.
• Awareness of the Mental Capacity Act and Deprivation of Liberty Safeguards was limited amongst some staff groups.
• Audits and outcomes of care and treatment were monitored and actions were taken to make improvements.
• There was a good multidisciplinary team approach to care and treatment. This involved a range of staff working together to meet the needs of patients using the service.
• There had been a low level of documented consent within the outpatients department for minor procedures. An audit had been introduced to monitor this and actions were being followed up in order to improve compliance.

Are services caring at this hospital/service

By caring, we mean that staff involve and treat patients with compassion, dignity and respect.

• Patients received supportive care and treatment.
• The views of children and young people using the service were requested in an appropriate way.
• Interactions between staff and patients were positive.
• The patients we spoke with told us staff were very caring and respectful, and patients felt they were supported emotionally.
• Patients understood the care and treatment choices available to them and were given appropriate information and support regarding their care or treatment.
• The service was rated very positively in patient feedback provided.

Are services responsive at this hospital/service

By responsive we mean that services are organised so they meet people’s needs.

• Services were planned and delivered to meet the needs of the local population. New services had been introduced in specific response to local demand.
• The flow of admissions and discharges through the hospital was well organised. Oncology and end of life care patients were able to access services when needed and these services were responsive to their individual patient needs.
• Patients had their needs assessed and essential care rounds were undertaken at different times of the day. Patient care was planned and one to one observations were carried out on patients on the oncology and end of life care ward. Patients who had complex needs or who were at risk of deterioration were supported during the day and night with appropriate treatments.
• Patients were aware of how to make complaint or to provide feedback about the service if needed. Complaints and concerns were taken seriously, responded to in a compassionate way, investigated in a timely manner and learning taken to improve future practice. Nursing staff were aware of learning from complaints across the hospital. There was evidence that lessons had been learnt and actions taken as a result.
• We reviewed the provider’s complaints process and this showed that complaints were easy to make, risk assessed, thoroughly investigated, recorded and support was provided to complainants. However, improvements were required to ensure that in most cases, people felt that their complaint made a difference.
• There were facilities available for people from different cultural backgrounds and for whom their first language was not English.
• Services coordinated appointments to enable patients to see a number of health care professionals in one day.
• Patient’s individual needs were taken into consideration when planning care.
• Waiting times for outpatient appointments were within the national referral to treatment time target of 18 weeks.
• Vulnerable adults, such as patients with a learning difficulty and those living with dementia were identified at the referral stage and steps were taken to ensure they were appropriately cared for. This included a longer appointment time and informing carers or representatives of the plan of care.

Are services well led at this hospital/service

By well-led, we mean that the leadership, management and governance of the organisation, assure the delivery of high-quality person-centred care, supports learning and innovation, and promotes an open and fair culture.

• There were quality issues within the service which had been flagged for a substantial period of time by the service’s governance, but at the time of the inspection, they had not been resolved and a clear plan for doing so was not apparent.
• Aspects of the governance system, including the training and workforce activity data, did not provide accurate information and this had to be collected manually which hampered the service’s ability to monitor these aspects.
• There was a clear statement of vision and values, driven by quality, with defined objectives that staff understood. However, the oncology and end of life care service did not have a written strategy for the service to deliver the vision of the hospital.
• The senior management team displayed characteristics of the hospital vision and values on a daily basis.

• Staff were focused on providing the best service they could for all patients regardless of whether the patient funded themselves or was insurance or NHS funded.
• Staff told us that senior and local managers were visible and approachable.
• Staff spoke positively of the open culture within the service and said that senior staff would act on their feedback.
• The service actively engaged individual patients and acted on their feedback.
• There was an open, positive and supportive learning culture, with competent local leadership and a happy work force.
• Patients were given opportunities to provide feedback about their experiences and this was used to improve the service.

We saw several areas of outstanding practice including:

• Changing the pre-assessment for patients having breast surgery to involve a breast care nurse to provide additional emotional support and practical information.
• The ‘one-stop clinic’ operated by the radiology department and breast surgeons operated three to four times per week whereby patients could have a consultation, mammography and ultrasound with options for additional interventional procedures if required during one appointment.
• A feedback questionnaire compiled by the provider for services provided for children and young people asked both parents and children for their opinions with an appropriate language style for children.

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

The provider must:

• Report all patient deaths, both expected and unexpected, that occur at the hospital to CQC.

The provider should:

• Speed up the JAG accreditation process for their endoscopy unit.
• Document and monitor place of death data in order to ascertain how well the service was performing against key benchmarks of the Hospital.
• Implement a written strategy for the oncology and end of life care service to deliver the vision of the hospital. 
• Develop a protocol for informing GP’s about their patients requiring community end of life care.
• Review how they share incidents where patients have deteriorated and review the policy for pre-assessment to make sure all patients who require a pre-assessment have one carried out to the appropriate level.
• Review the treatment area and gym within the physiotherapy department to improve patient privacy and dignity.
• Ensure all relevant staff are made aware of the learning from never events and incidents.
• Address the nursing staff vacancies, particularly in the recovery suite.
• Improve the anaesthetic cover of the High Dependency Unit.
• Improve staff awareness of the Mental Capacity Act and Deprivation of Liberty Safeguards.
• Resolve the ongoing quality issues flagged by the governance system.
• Improve the quality of training and workforce activity data collected by the internal automated systems.

Professor Sir Mike Richards

Chief Inspector of Hospitals