The Nottingham NHS Treatment Centre provides termination of pregnancy services in Nottingham and the surrounding areas for women who are 18 years and over and are under 14 weeks of pregnancy.

This follow-up inspection was undertaken following an inspection in January 2015 as part of the CQC’s ongoing programme of comprehensive, independent healthcare acute hospital inspections. In January 2015 we found the safe and caring domains were good. We also found the effective, responsive and well led domains as requires improvement. Overall we rated the core service of providing termination of pregnancy treatment as requiring improvement in January 2015.

We did not look at all of the key lines of enquiry during this inspection in May 2016 because we were following up on a previous inspection. For the effective domain, we looked at the use of evidence based care and treatment and the competence of staff. For responsive, we looked at whether access to termination of pregnancy procedures met current Department of Health requirements and whether women were given the correct telephone number in the event that they wished to make a complaint about the service. In well-led, we looked at whether the leadership of the service had improved and if there were robust governance processes in place. We also looked at whether patients were actively involved in giving feedback of the service.

We found termination of pregnancy services had improved in the specific parts of the three key areas that we looked at within the domains of effective, responsive and well led.

We have not applied a rating to the termination of pregnancy services as a result of this focussed inspection. This is because we did not re-inspect the whole service and therefore did not gain enough evidence to be able to apply a rating on this occasion.

Is the Termination of pregnancy service effective at this hospital

• There had been improvements in the working relationships with the clinical commissioning group (CCG) and another NHS provider acting as a referral agency. This had led to more robust audit data and oversight of the service’s compliance with the Department of Health required standard operating procedures (RSOP) for termination of pregnancies.
• There were improvements in the process for administering Anti-D injections.
• There were improvements in the process for ensuring blood results were available for all women prior to their procedure.
• Patients were being offered appropriate counselling at all stages in the care pathway..

However we also found:

• Some medicine administration records were not completed in accordance with best practice because doctor’s signatures were not written clearly.

Is the Termination of pregnancy service responsive at this hospital

• The centre was working more closely with partners involved in the termination of pregnancy pathway, leading to improvements in the quality of audit data. This meant the centre had oversight of the reasons for delays and was able to identify areas for improvement.
• Complaint leaflets had been updated to ensure correct telephone numbers were given to patients. Staff told us they were familiar with the complaints’ procedure and were able to describe the process.

Is the Termination of pregnancy service well-led at this hospital

• Although no clear vision and strategy for the service was yet in place, discussions with partners in the patient pathway on the future vision and strategy were planned for June 2016.
• Comprehensive governance, risk management and quality measurements were in place to monitor risks to patients with actions in place to reduce them.
• Medical and Nursing leads had been identified for the service. Staff told us they knew who they were and that they were approachable.
• Staff told us they felt involved in the delivery, development and improvement of the service.
• Patients were actively involved in giving feedback about the care they received.

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

The provider should:

• Ensure a clear vision and strategy is put in place as soon as possible for the termination of pregnancies.

• Ensure all medical staff sign prescription charts clearly..

Professor Sir Mike Richards

Chief Inspector of Hospitals

Our inspection focussed on Skin Surgery and the Day Case Unit.

All patients spoke positively in respect of their care and treatment. Patients also told us they did not have to wait long for assistance and that staff were available to support them when needed.

Patients told us they felt the staff were skilled and knowledgeable. One patient said, “Everything has been very good, if I had any concerns I know I could contact my consultant’s secretary.” Another patient said, “I have been given a feedback form to complete.”

We found that patients experienced care, treatment and support that met their needs and protected their rights. We also found that there were enough qualified, skilled and experienced staff to meet patients’ needs. However, staff were not fully supported to deliver care and treatment safely and to an appropriate standard.

We found that the provider took steps to assess the quality of the service being provided. However, patients were not fully protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were not fully maintained.

We visited the location to carry out a planned review. We had also received some concerning information in regard to staff not following the correct procedures in respect of people’s capacity to consent and possible breeches in confidentiality due to the layout of the building.

The treatment centre was designed to offer different services and facilities in different areas of the building. These areas were called ‘gateways’. Due to this and the layout of the treatment centre we were not able to fully observe the care and support that people received all the time.

The provider directly employed some of the staff whereas others were employed by the NHS Trust and were on secondment to the service.

We spoke with the Head of Healthcare Governance, the Registered Manager and the Integrated Governance Lead during our visit. In addition to this we also spoke with the Lead Nurse for the treatment centre, Human Resource Manager and three staff directly employed by the service and five members of staff employed by the NHS Trust.

We spoke with four people using the service to gain their views and experiences.

All four people spoken with said they had received enough information about their treatment and they had been enabled to make an informed choice.

One person said, “They explained everything that would happen and talked things through. I got all the information that I needed. We talked about consent at my pre op appointment.” Another person said they had attended an appointment with their relative who had a learning disability. They said time had been taken to make sure the information was discussed in a way they understood.

Three out of the four people spoken with said the consent form had been explained to them and they had been given time to ask any questions. This area was not applicable to the other person we spoke with so they were unable to comment in respect of the consent form.

Three people said that staff asked their permission before they carried out any procedure. One person said, “I have not had my treatment yet, but I feel that they would ask my permission before they did anything.”

All four people said staff had been very supportive of their needs, their experience was positive and their needs were met.

One person said staff were always there to reassure them if needed and the care and support they had received was excellent. “Staff have been very supportive and understanding of my needs. I have had good experiences. The staff are always friendly and polite and they have supported me and helped me where needed.”

We saw people being talked with and cared for appropriately and staff interacted with people in a polite and friendly manner.

All four people said they were happy with the service they had received and if they were unhappy they would be able to approach staff to discuss this. Two people also said they felt safe whilst using the service.

People said the staff were confident and competent in their job roles and they were well trained. One person said, “I think all the staff I have come into contact with are competent.” Another said, “I feel the staff are good at their jobs, they appear relaxed and confident. They have supported me as needed and showed me compassion.”

All four people said the quality of the service they had received was excellent and they were happy with their experience. They all felt that they could offer feedback and this would be listened to.

The Nottingham NHS treatment centre is run by Circle Nottingham Ltd which belongs to a group of companies owned by Circle. Independent NHS treatment centres provide services to NHS patients but are owned and run by organisations outside of the NHS. They have a contract with the NHS to treat NHS patients. The Nottingham centre opened in 2008 and is the largest independent treatment centre in Europe. Circle Nottingham Ltd was awarded the contract to provide services from the centre in July 2013 for five years. Although it predominantly provides services for NHS patients, the centre does provide services to patients who wish to pay privately for their treatment. The treatment centre is currently registered to provide services to children, however the centre was in the process of altering its registration and did not provide services to children at the time of our inspection.

The centre offers a variety of services including outpatients, surgery, termination of pregnancy and diagnostic tests. There were 60 outpatient consultation rooms, five operating theatres, three skin surgery theatres, four endoscopy rooms and dedicated diagnostic facilities such as scans and x-rays. In addition, the centre has an 11 bedded short stay ward for patients who have undergone surgery and need an inpatient stay.

The Nottingham NHS Treatment Centre was selected for a comprehensive inspection as part of the second wave of independent healthcare inspection. The inspection was conducted using the Care Quality Commissions new methodology. The inspection team inspected the following core services:

• Surgery
• Outpatients and diagnostic imaging
• Termination of pregnancy

We rated the Nottingham NHS Treatment Centre as “Good” overall but the termination of pregnancy service required improvement. The safety, caring and leadership in the surgical service were rated as "Outstanding."

Our key findings were as follows:

Care and Compassion

• Without exception staff were caring and compassionate. Patients reported very high levels of satisfaction with the care they received.
• We saw people being treated as individuals and staff spoke about patients in a kind and sensitive manner.

Cleanliness and inspection control

• The treatment centre had reported no incidence of MRSA, clostridium difficile (C.difficile) or Meticillin- sensitive Staphylococcus Aureus (MSSA) in the reporting period April 2013 to September 2014. MRSA, MSSA and C.difficile are infections that can cause harm to patients. MRSA is a type of bacterial infection that is resistant to many antibiotics. MSSA is a type of bacteria in the same family as MRSA but it can be more easily treated. C.difficile is a bacterium that can affect the digestive system; it often affects people who have been given antibiotics.
• In all areas we observed staff to be complying with best practice with regard to infection prevention and control policies. Staff were observed to wash or apply gel to their hands between patients. There was access to hand washing facilities and a supply of personal protective equipment, which included gloves and aprons. The majority of staff were observed adhering to the dress code, which was to be bare below the elbow.
• Staff in operating theatres and endoscopy were observed to be following the correct technical procedures prior to undertaking sterile procedures in surgery.
• Most of the areas we visited were clean and well maintained. There were procedures for the management, storage and disposal of clinical waste, environmental cleanliness and the prevention of healthcare acquired infection guidance. However, in endoscopy we found storage within the decontamination areas made it difficult to ensure all areas were sufficiently clean. During our inspection we noticed the floor area under the sinks was stained and white powder was visible. We discussed this with the nurse in charge who told us the metal racking stored within this area had probably not been moved to allow for effective cleaning of this area. We saw this had already been identified in the environmental hygiene audit in November 2014. We also saw the plans that were in place to improve the endoscopy area so this issue could be rectified. The work was due for completion by August 2015.
• Patients were given wound management advice following surgery. Verbal instructions were supported through the use of an information leaflet given to the patient when they were discharged. The information included details of what the patient should do if there were any wound complications after their discharge from the treatment centre.
• The cleaning of endoscopes met national decontamination standards for flexible endoscopes and we saw only appropriately trained staff were responsible for the decontamination of equipment.

Complaints

• There were quality monitoring structures in place to monitor any complaints. We found information throughout the centre that told patients how they could raise a concern, complaints or compliment. Staff had a good understanding of the complaints process and received regular feedback following complaints. The treatment centre analysed feedback and monitored themes. We saw evidence of changes to practice being undertaken in response to complaints and patient feedback. The treatment centre actively promoted the “Four Cs” process (complaints, concerns, comments and compliments). We saw these were reported quarterly as part of the treatment centre’s ‘quality quartet’ scorecard.

• We found areas in the complaints process that could be improved further because they were not consistently following their internal complaints policy. We found the treatment centre was not providing advice on how to obtain advocacy. The complaints leaflet that was being sent with the complaint acknowledgement letter was out of date and referred to an independent complaints advocacy service that was not longer in existence. We looked at a final response letter that contained no information about the Parliamentary and Health Service Ombudsman We also found not all complaints were being acknowledged within the required two day standard. We looked at one complaint where the final response deadline was not met and a letter sent to apologise for this and to extend the deadline was not sent until two weeks after the deadline had initially passed.

Staffing Levels

• Throughout our inspection both patients and staff told us they thought the treatment centre had sufficient staff. There were some concerns about the numbers of consultant dermatologists but this was being managed with the use of long term locums.
• Nurse staffing levels were in accordance with national guidance issued by the National Institute of Health and Clinical Excellence (NICE). There were escalations arrangements in place so that additional staff could be brought into an area should there be either a gap in the planned staffing or the level of dependency of the patients had increased.
• Where locum medical staff or bank or agency nursing staff were used a named individual would be requested from an agency approved by the treatment centre. This meant temporary staff were already familiar with the area in which they were working. The treatment centre had a robust system in place to ensure agency staff were appropriately inducted to the service. This included a dedicated induction programme and competency framework documentation for each gateway of the treatment centre.
• There was a Resident Medical Officer (RMO) based on the short stay unit who reported any changes in the patient’s condition to the consultants, and together with the nursing team provided 24 hour medical support to patients.

Mortality rates and outcomes for patients

• The treatment centre had reported no incidence of either day case or overnight inpatient mortality in the reporting period April 2013 to September 2014.
• There had been no unexpected patient deaths from April 2013 to December 2014. One had been reported to the CQC in January 2015. We were told a full investigation had been undertaken by the senior management team at the treatment centre and they were currently awaiting the outcome of a post mortem.
• Transfers of care to a nearby trust had reduced since the opening of the short stay unit in April 2014. Information received prior to our inspection showed there had been two unplanned transfers of inpatients to other hospitals between April 2013 to December 2014. A senior manager told us this had been due to having no facilities for the provision of emergency care at the treatment centre. The transfer of these two patients was appropriate.
• There had been no unplanned readmissions within 29 days of discharge in the reporting period April 2013 to September 2014.
• Patient reported outcome measures (PROMS) for the period April 2013 to March 2014 indicated patient outcomes for groin hernia were worse than the England average. However for the reporting period April to June 2014 patient outcomes for groin hernia had improved and were in line with the England average. Outcomes for varicose veins surgery were similar to the England average.
• The treatment centre had started performing joint replacement procedures on knees in the six weeks preceding our inspection. Hip replacement surgery was due to commence at the end of February 2014. It was too early for any patient reported outcome data to be assessed at the time of the inspection.

Leadership

• There was good leadership throughout the treatment centre. Morale amongst individuals and in teams was extremely high. Staff felt very engaged and numerous staff told us how they felt listened too. There was a culture in the hospital where everyone was valued regardless of their position or grade.
• The treatment centre had a “Credo.” This was displayed in the treatment centre and staff knew about it. The credo set out three main principles that underpinned their work. It puts patients at the centre of their care, empowers staff to do their best and pursues excellence. From our conversations with staff and patients we could see how the credo was put into practice.

We saw several areas of outstanding practice including:

• The treatment centre was piloting the implementation of a care certificate for healthcare assistants (HCA’s) achieved through a HCA training programme which offered specialty training and skills development.
• The centre had an initiative called ‘Stop the Line.’ Any member of staff could stop activity if they felt patient safety may have been compromised. When “Stop the line” was triggered, there was immediate escalation of the issue and a resolution was developed immediately. All the staff we spoke with were enthusiastic about this initiative and were able to give examples of where they had used ‘Stop the line.’ The examples they gave demonstrated staff felt confident to use the process and most importantly that action was taken to respond to concerns. The treatment centre used a process called Swarm. Staff at different levels attended the swarm which was a meeting following a stop the line which was designed to assess the risk and put immediate control measures in place to reduce those risks. We saw evidence of this being used in practice.
• The treatment centre undertook a 28 day post-operative call to patients to monitor clinical outcome data that included surgical site infections. This patient self-reported data was shared with the commissioners of the service. Information received following our inspection indicated a decline in surgical site infections, with 13 reported in November 2014; nine reported in December 2014 and; three reported in January 2015.

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

Importantly, the provider must:

• Ensure medication administration records within the termination of pregnancy service are clearly legible and written in accordance with GMC guidance, “Good practice in prescribing and managing medicines and devices.”
• Ensure the prescribing of Anti-D immunoglobulin medication within the termination of pregnancy service only takes place when it has been established that it is a clinically suitable treatment for the patient.

In addition the provider should:

• Ensure complaints are managed in accordance with the treatment centre policy so that patients have up to date information about how they can access the support of complaints advocacy services.
• Ensure there is timely access to termination of pregnancy procedures, which should meet Department of Health required standard operating procedures (RSOP11 – access to timely abortions).
• Ensure the governance and leadership in the termination of pregnancy service is strengthened to ensure there is effective monitoring and response to the findings of audits.
• Ensure there is a system for checking the accuracy of HAS4 forms used in the termination of pregnancy service to ensure that accurate information is provided to the Department of Health.
• Ensure systems are developed so that sessional staff working in the termination of pregnancy service receive feedback and learning from incidents.
• Ensure a review of the risks associated with the use of the lifting and handling equipment within the imaging department takes place so that patients who have mobility difficulties can be safely assisted onto the imaging beds.
• Consider introducing team development initiatives within the termination of pregnancy service to enable cohesive working practices.
• Consider working with partner providers and commissioners of termination of pregnancy services to ensure the patients care pathway is one which meets required standards.

Professor Sir Mike Richards

Chief Inspector of Hospitals