The inspection focused on cancer services provided by The Harley Street Clinic. As some adult cancer services were sub-contracted to other registered providers we did not visit these as they are inspected separately by the Care Quality Commission. During this inspection we visited the Diagnostic Centre, the oncology ward and the paediatric chemotherapy day unit. We spoke with 17 staff, including nurses, ward managers, pharmacists and senior management. We also spoke with the three people and/ or their relatives who were available during our inspection and looked at the October 2013 feedback survey results. People were positive about the care and treatment they had received, rating the quality of care as "very good" or "excellent".

People received safe, effective care that was planned in a way that ensured their safety and welfare. Peoples' needs were assessed and reviewed by a multi-disciplinary team. Information was provided in a format that met people's needs to ensure they understood and were able to make decisions. There were arrangements in place to deal with medical emergencies. Treatment protocols and procedures reflected national guidelines and medications were safely administered. Medicines were stored securely in most areas.

People were cared for by suitably qualified staff who had undergone the necessary pre-employment checks. There were systems in place to monitor the quality of service provided and to benchmark its performance nationally.

This inspection focused on the paediatric services provided at The Harley Street Clinic. We visited the new paediatric intensive care unit (PICU), the paediatric ward and the paediatric outpatient facilities. We spoke with some parents of children who were being treated at the hospital. Overall, they were very satisfied with the quality of care provided. They confirmed that staff had explained their child's treatment in a way that they could understand and they had consented to their child’s treatment. We saw consent had been obtained for each procedure undertaken. Consent forms had been signed by the relevant consultant and person with parental responsibility.

There were systems in place to protect people from the risk of infection. There were adequate handwashing facilities available and cleaners were allocated to each area of the hospital. We saw that infection control audits were regularly undertaken. Staff were able to describe the process should if someone had an infection.

There were a sufficient number of suitably skilled staff on each unit. The provider had risk assessed the needs of the people who use the service and the risks associated with the procedures carried out to determine the number of staff required. There were systems in place to plan staff numbers to meet the needs of patients.

The provider had systems to monitor the quality of the service it provided and we saw evidence that complaints were fully investigated.

People who used the service told us that they were generally happy with the care they had received. Staff had been supportive, treated them with respect and involved them in their care. The majority of people felt they were kept informed and given enough information to make decisions.

The Harley Street clinic is part of HCA International group, who also provide care at five other hospitals in London.

We carried out this inspection as part of the CQC's ongoing programme of comprehensive, independent healthcare acute hospital inspections under the new methodology.

The Harley Street Clinic undertakes a range of surgical procedures and provides medical and critical care, to adults. The hospital also provides services to children and young people, carries out outpatient consultations and provides critical care services to children. The hospital has the largest independent healthcare paediatric intensive care unit (PICU). The hospital therefore provides five of the eight core services that are inspected by the Care Quality Commission as part of its new approach to hospital inspection.

The Harley Street Clinic has 103 beds, four operating theatres, three catheter laboratories and six treatment rooms. The hospital provides 93 inpatient and ten day case beds. Specialities treated include oncology, cardiac and neurosciences for both adults and paediatrics. At the time of the inspection the hospital was not providing any NHS funded care.

We inspected the Harley Street Clinic as part of our planned inspection programme, visiting 3-5 August 2016 followed by an unannounced visit 17 August 2016. This was a comprehensive inspection and we looked at five core services provided by the hospital: medical care, surgery, critical care, services for children and young people and outpatients and diagnostic imaging.

We rated the safety, effectiveness and responsiveness of this hospital as good. We found the leadership and caring aspects of this hospital to be outstanding. Overall, we have rated The Harley Street Clinic as ‘outstanding’.

Are services safe at this hospital?

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

• There was a hospital wide electronic incident reporting system and staff were aware of how to report incidents. Staff reported incidents and openness about safety was encouraged. Incidents were monitored and reviewed and staff clearly demonstrated examples of learning from these. Senior management understood and adhered to the duty of candour appropriately.

• Clinical areas were visibly clean and tidy. Hospital infection prevention and control practices were followed and these were regularly monitored, to reduce the risk of spread of infections.

• Staff had access to a range appropriate equipment to care for patients safely. Equipment was safety tested and well maintained, in line with manufacturer’s guidance.

• Medicines were stored securely and managed safely. Pharmacy staff were actively involved in the pre-admission, admission, inpatient and discharge processes.

• Records were managed safely, securely stored on site and available when needed. The radiotherapy departmenthad implemented a fully paperless system of working. This system mitigates the paper based system risks and is also better for the environment. The department has assisted other independent and NHS departments in the implementing the system.

• Staff were knowledgeable about the hospital’s safeguarding policy and clear about their responsibilities to report concerns.

• 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.

• We had concerns that staffing in the paediatric intensive care unit (PICU) did not meet Royal College of Nursing (RCN) guidance, as the majority of nurses were not trained specifically in paediatrics. In all other areas, staffing levels and skill mix were planned, implemented and reviewed to ensure patients received safe care and treatment at all times.

• Staff received appropriate training to perform their role safely and were supported to keep their skills up to date.

• Plans and arrangements were in place to respond to emergency situations.

Are services effective at this hospital?

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.

• Patients care and treatment was planned and delivered in line with current best practice, evidence based guidance and legislation. Performance was monitored and improved in line with national guidance from organisations such as the National Institute for Clinical Excellence (NICE) and the Royal Colleges.

• Patients’ pain was monitored and the effectiveness of pain management evaluated. Patients had access to different methods of pain relief.

• The hospital offered a range of meals and drinks and hospitality team were always available. Patients had comprehensive assessments of their needs, which included assessment of their clinical needs, physical health, nutrition and hydration needs.

• Oncology patient outcomes were monitored at cancer multi-disciplinary (MDT) meetings

• The hospital surgery participated in a range of national audits and benchmarking, including: the Public Health England (PHE) surgical site surveillance for benchmarking for coronary artery bypass grafting (CABG) and total abdominal hysterectomy (TAH). We found the hospital had performed better than the national average for CABG. For example, the PHE SSI audit from April 2015 to March 2016 indicated that there had been 0% infections compared to the five year average for all hospitals of 4.3%.

• The Adult intensive care unit (AITU) contributed to the Intensive Care National Audit Research Centre (ICNARC), which meant that the outcomes of care delivered and patient mortality could be benchmarked against similar units nationwide. The hospital performed better than similar units in unplanned readmissions and non-clinical transfers out of the unit in 2015/16.

• The National Congenital Heart Disease Audit Report 2012 -15 demonstrated the hospital had a 98.8% survival rate for patients admitted with this condition. This was better than the expected predicted survival rate of 97.3%.

• The hospital published the Breast Quality Framework Report; containing outcome data collected as a retrospective audit of breast cancer patients treated in the period of 2010 to 2014. The hospital is working collaboratively with Public Health England to collate and publish patient survival rates.

• Consultants were granted practicing privileges after a lengthy application process supported and verified by the medical advisory committee (MAC). Those privileges were then reviewed once a year. The MAC also reviewed policies and guidance and advised on effective care and treatment.

• There was good communication between the MAC and hospital medical directors and this was maintained through coordinated consultant engagement.

• Practice facilitators and educators ensured that nursing staff were supported through the revalidation process.

• Staff worked well within teams and across different services to plan and deliver patients' care and treatment in a coordinated way.

• The consent process for patients was well structured, audited and reviewed to improve how people are involved in making decisions about their care and treatment.

• Staff were trained in the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLs), although rarely used as the vast majority of patients treated had capacity to give their informed consent.

Are services caring at this hospital?

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

• Staff were highly motivated and inspired to offer care that was kind and promoted people’s dignity and were willing to go the extra mile to meet individuals’ needs. We saw incidences of staff changing their shifts or working additional shifts in order to offer anxious patients continuity of care. We saw examples of pro-bono patient care to accommodate individual needs.

• Staff always took people’s personal, cultural, social and religious needs into account. For example, care plans for patients observing Shabbat included instructions on how staff could support them to avoid use of technology such as call bells by increasing the frequency of checks. We saw examples of ‘weddings’ that had been organised on the ward to accommodate immobile patients’ last wishes and hosting an event so one patient could fulfil their role as 'mother of the bride' at their daughter's wedding.

• People’s emotional and social needs were highly valued by staff and are embedded in their care and treatment. For example, the ‘rainbow beads’ project provided an opportunity to recognise the courage and strength of children and young people who were accessing the hospital for long term treatments. Children and young people were rewarded with a bead for each treatment or intervention.We saw examples of patients supported to have visits from loved pets.

• Patients understood the care and treatment choices available to them and were given appropriate information and support regarding their care and treatment.

• The hospital used patient feedback to ensure they were addressing patients’ needs.

Are services responsive at this hospital?

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

• The complex and differing needs of patients were central to the planning and delivery of the tailored service that the hospital provided. Pre-assessment nurses pro-actively provided individual patient-centred care before admission and after discharge.

• The provider approached care and treatment for their patients in a truly holistic and individualised way. We found excellent multidisciplinary team (MDT) working with close collaboration between all staff. National experts in their field with access to latest diagnostic and treatment methods attended regular MDT meetings. We saw the multidisciplinary team working together to provide the best care available and working to ensure all needs of patients were met.

• Patient admissions were arranged in a timely manner, with minimal delays. The outpatient service ensured that waiting times were kept at a minimum.

• There were allocated appointment slots for patients that wanted same day diagnostic procedures.

• All radiological imaging results were available within 24 hours or earlier if requested.

• There were facilities in place and readily available for patients from different cultural backgrounds and for whom their first language was not English.

• The hospital did not treat many patients with dementia or complex mental health needs but staff were aware of who to escalate concerns to regarding these patients.

• Complaints were dealt with by the CNO and CEO and the service ensured that complaint responses were timely and well managed.

• Learning from complaints was assessed and shared with staff via both email and monthly ward meetings.

Are services well led at this hospital?

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.

• We found approachable and motivational leadership that promoted staff development and career progression, teamwork and high-quality patient-centred care.

• Staff were aware of the corporate vision and all staff were aware of their unit vision and strategy. The vision and strategy of the service was embedded into practice by staff.

• The corporate governance structure ensured that there was a vast amount of cross over in-between key groups.

• The governance team had hired new members of staff to maintain the risk register and oversee other areas. The handover process was sound and the reporting mechanisms in place were of a high quality.

• Service managers had monthly meetings with the CEO where issues were actively discussed and best practice was encouraged to be implemented. Staff felt they could engage with the CEO and felt they managers could raise issues on their behalf and they would be listened to.

• All staff were able to name the CEO and reported that the senior management team were visible and accessible. Staff felt as though there was an open ‘family’-like culture.

• We saw new leaders and managers in the paediatric services who were driving forward change to improve staff development and patient care. We saw and heard about the improvements to the working culture and how staff satisfaction had improved. New ways of working had been introduced to promote safe and effective patient care.

• A “Nurse in charge” work initiative was in place in the outpatients department specifically tailored to encourage junior staff nurses to develop leadership skills. This initiative contributed to the five new outpatient senior nurse roles and has allowed the department to promote internally.

• There were world class, first of their kind innovations taking place at the hospital and staff were proud to say they worked there.

• The radiotherapy department in collaboration with a London NHS trust has lead a unique scalp sparing technique study. The study is aimed at improving the quality of life of patients requiring whole brain radiotherapy treatment, by trying to remove the side effect of hair loss at such an emotional time in the patient’s life. The study was the winner of the LangBuisson 2015 award for Innovation in Care.

• The cancer service offered innovative patient-centred care through access to latest diagnostic and therapeutic methods and by seeking out new treatment options and taking a holistic approach to patient care. This high quality care included psychological support and complementary therapies such as relaxation or aromatherapy for example. Patients were given access to early phase clinical trials for new cancer drugs through partnership with a cancer research institute.

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

Importantly, the hospital must make the following improvements:

• The provider must take action to ensure the skill mix of staff in the paediatric intensive care reflects current recommendations.

In addition the hospital should:

• Ensure that the multi-faith rooms are appropriate to meet patients’ spiritual needs.

• Provide more adequate storage space in theatres.

• Ensure that the theatre doors fully close and do not overlap one another.

• Ensure all staff that have contact with patients under the age of 18 are trained to a minimum of level 3 safeguarding training.

• Ensure all staff are up to date with mandatory training requirements.

•    Ensure all department risk registers reflect the current risks to their service.

Professor Sir Mike Richards

Chief Inspector of Hospitals