Tarporley War Memorial Hospital was founded in 1919 by local subscription; it is funded by a small NHS grant, which covers one third of its operating costs. The remaining funding is achieved through private self-paying patients, one off payments from NHS commissioners and charity fundraising. The hospitals registered charity fundraises through a local charity shop and other charitable initiatives. The In-patient unit specialises in the rehabilitation of the elderly, intermediate care and supporting terminally ill and palliative patients. There is also a day care facility, they offer respite care and deal with mini minor injuries.

The hospital is registered to provide the following regulated activities:

• Diagnostic and screening procedures

• Surgical procedures

• Treatment of disease, disorder or injury.

The hospital director is the registered manager, supported by a senior management team.

A warning notice was issued to the provider on 1 February 2017 setting out improvements that were required.

During our focussed follow up inspection on 11 September 2017, we found the provider was compliant with the requirements of the warning notice.

The warning notice issued 1 February 2017 highlighted areas where the provider was required to make improvements. These included:

• Ensure effective correct control measures are in place to mitigate the risk of pressure damage for those persons deemed at risk of pressure ulcers, such as monitoring and implementing a repositioning regime, these should be clearly documented in patients’ records.

• ‘Do not attempt cardiopulmonary resuscitation’ (DNACPR) forms must be quality assessed to ensure they are correctly completed.

• Ensure the hospital undertake a comprehensive and effective auditing programme.

• Ensure the hospital implement a policy and procedure that meets ‘duty of candour’ requirements.

• Ensure compliance with the Mental Capacity Act legislation and must ensure that the two stage mental capacity assessment is completed and clearly documented in patients’ records.

• Health care assistants acting as second checker for medicines must receive appropriate training and be assessed as competent to carry out the role. This process should be clearly documented.

• Ensure to ensure robust policies, procedures and guidelines are in place, including; equality and diversity issues are considered and addressed for patients, guidelines are in place and followed in relation to meeting the needs of people in vulnerable circumstances and the complaints policy is accessible and provides accurate information about the next step if patients are not satisfied with the outcome of an investigation.

• The risk register must be robust and identify clear processes for mitigating risks and ongoing monitoring with given time scales. The process for staff to escalate local level ideas and risks must be clear.

We found the following areas of improvement:

• The hospital had reviewed a number of policies, which they deemed high priority, for example the duty of candour policy, mental capacity policy and deprivation of liberty policy. These were in line with national guidance and good practice. There were actions in place to ensure all policies had been reviewed by end of October 2017.

• There was now a process in place to ensure that policies were developed and reviewed to reflect changes in practice and the management team had identified leads for each policy.

• All appropriate staff had completed level three safeguarding training and there were plans in place to ensure all registered nurses had received this training by end of October 2017.

• There were improvements in the safe care and treatment to patients who were at risk of developing pressure ulcers, by introducing a skin care bundle, repositioning regime and documentation package and staff had undertaken appropriate training.

• Implementation and monitoring of audits and evidenced based care had improved. Audit results were displayed for staff and actions to improve standards had been identified where required.

• The management team had identified leads for specific topics of any current evidenced based practice, legislation and National Institute For Health and Clinical Excellence (NICE) guidance.

• Health care assistants had undertaken appropriate competency training to act as a second checker for medicines administered in the absence of a second registered nurse.

• We found improvements in the completion of ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) forms.

• There was now a more robust and reliable on call system in place, which included how staff would escalate incidents to a senior member of staff.

• Improvements had been made in the management of risk at the hospital. The risk register accurately reflected all the clinical risks within the hospital and now included the condition, cause and consequence of the risk.

  Ellen Armistead

  Deputy Chief Inspector of Hospitals

The inpatient unit mainly specialises in rehabilitation of older people who have been ill or had surgery. It also cares for older people who are terminally ill and offers private respite care for people who are being cared for by a family member who may need a break.

We spoke with seven patients, who told us that staff always consulted them about their individual needs and involved them in decisions about their care and treatment.

We asked patients for their views of the service. One person said "It's first class, they really do look after you". Another said "It's very friendly, the best hospital I've ever been in."

Patients said that they enjoyed the meals. Comments included: "The food is excellent"; "The meals are very nice and they're always hot"; "The cook is wonderful".

The patients we spoke with all said that they thought the hospital had enough staff to meet their needs. Comments included "The staff are marvellous and very kind" and "As soon as you ring the bell, they're there".

We reviewed the hospital's complaints records. There had been 4 complaints the previous year, none of which related to the standard of care. All had been resolved.

We asked people for their views of the service. Patients told us that a nurse had discussed their needs on admission and told them how the hospital could meet their needs. They said that their care plans were agreed before being implemented. They told us that staff treated them with respect and helped them to maintain their independence as much as possible.

One person said "They look after me very well, they always come when I ring the bell and I'll miss it when I go home." Another said "It's absolutely fabulous. They treat me well and I'm lucky to be here. I've been very pleasantly surprised at how good it is."

Patients told us they felt safe and had no concerns about the care and treatment they received from the staff. They said if they had concerns they would tell one of the staff. They said the staff were very good and they got on really well with them all. They said they had no problems with any of the staff and the standard of care provided by the staff was good. One person said "The staff are very good and very patient" and another said "The staff are very kind and they always have time for you".

Patients told us they were happy with the facilities and that they was always very clean and tidy.

Staff told us they enjoyed working for the service. Staff confirmed that they had received regular training and felt very happy about the standard of training and support offered.

We spoke to two patients and a visiting therapist during our visit to the hospital. We asked their views about the service.

They told us they were “very good”; and had “everything needed”.

They told us they were receiving “excellent care”.

They told us the staff explained everything to them and that they were always available to help them when needed.

They told us they were consulted and included regarding their plan of care and that they were always asked for their consent.

Patients told us they felt safe and had no concerns about the care and treatment they received from the staff. They said if they had concerns they would tell one of the staff.

People told us that the staff were very good and they got on really well with them all. They said they had no problems with any of the staff

They felt the standard of care provided by the staff was very good.

We had also contacted the infection control team before we visited the hospital. They had no issues of concern to report about the hospital.

Tarporley War Memorial Hospital was rated ‘Requires Improvement’. The regulated activities we inspected were; diagnostic and screening procedures, treatment of disease, disorder or injury.

Our findings were as follows:

we found the following issues that the service provider needs to improve:

• Although there was an incident reporting system in place, we found that there was limited assurance that all incidents were reported and that learning took place following incidents that were reported.

• The main incidents reported were medicine errors and patient falls, we saw some evidence that these had been analysed for trends and patterns. However, in response to medication incidents we saw that the hospital advised ‘we will remind staff to take extra care when administering medicines’, as opposed to reviewing practices and competencies of staff.

• Information provided by the hospital showed that there had been no cases of MRSA and clostridium difficile (c.difficile) for the period April 2016 to December 2016. An audit for infection control was undertaken in November 2015, the audit showed good compliance with standards, however further audits have not since been completed.

• The risk register was not robust and did not identify clear processes for mitigating risks and ongoing monitoring with given time scales. The process for staff to escalate local level ideas and risks was unclear.

• The hospital did not always follow evidence based care and treatment guidance and the National Institute for Health and Care Excellence (NICE) guidance. The hospital did not participate in national audits, but they undertook some local audits. They have recently started following aspects of the safety thermometer which was submitted to the Quality advisory group and Trustee board.

• There was evidence of multidisciplinary input and involvement in patient care. A multidisciplinary meeting was undertaken every Monday to discuss the plan of care for each patient. This involved occupational therapists, physiotherapists and registered nurses.

• We spoke to trustees of the hospital who had strong ideas on the vision for the future of the hospital; however, the hospital staff could not describe the overarching vision or stated values. There was no quality strategy or clearly articulated quality priorities.

We found the following areas of good practice:

• Data provided by the hospital showed that 85% of staff had received an appraisal in the last twelve months.

• Patients were extremely positive about the care provided by staff. We saw that patients were treated with care and compassion and that their privacy and dignity was maintained. The hospital had very good patient feedback and positive feedback on their patient satisfaction surveys.

• Patients who were suitable for rehabilitation were assessed by physiotherapists and occupational therapist within 48 hours of admission. Individualised rehabilitation care plan were implemented.

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, to help it move to a higher rating. Details are at the end of the report.

Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.