This inspection focused on the women’s services provided by The Portland Hospital for Women and Children. We visited the gynaecological ward, labour ward, postnatal ward and outpatient areas including antenatal clinic. We had inspected paediatric services at our last inspection in December 2012.

We spoke with women who were being treated at the hospital. Overall, they were very satisfied with the quality of care provided. They were complimentary about staff, the information and care they had received and levels of cleanliness. One person said ““Everything’s been fine”, they described staff as “lovely” and the hospital was “very clean”.

Interpreters were available daily to assist with discussions about care and treatment. People were encouraged to be involved in making their own decisions about treatment and women and babies were at the centre of the care provided by maternity staff.

There were effective systems in place for the safe care of women and babies, including warning scores, risk assessments, training for staff so that they could manage a medical emergency and suitable, checked equipment. Staff were well trained with processes for supervision and appraisal.

There were adequate hand washing facilities in clinical areas and cleaners were allocated to each area. Infection control audits were regularly undertaken with specialist infection control advice and support available.

The provider had systems to monitor the quality of the service provided and we saw evidence that incidents were fully investigated. There were processes to review national guidance and feed into national data collections to ensure the hospital was providing safe up to date care and treatment. People’s feedback was requested and the hospital reviewed this and acted to improve the service.

This inspection focused on the paediatric services provided by The Portland Hospital for Women and Children. We visited the paediatric wards, neonatal and paediatric intensive care units, new paediatric day unit and operating theatres.

We spoke with parents of children who were being treated at the hospital. Overall, they were very satisfied with the quality of care provided. They were complimentary about staff and levels of cleanliness. One parent said “it’s always reassuring and relaxing to come here”. 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. Consent had been obtained for each procedure undertaken.

There were adequate handwashing facilities available and cleaners were allocated to each area. Infection control audits were regularly undertaken. Staff described the process should someone have an infection. There was enough equipment to meet people's needs and this was stored appropriately.

There were a sufficient number of suitably skilled staff on each unit and parents described staff as “very good”. The provider had risk assessed patients' needs and there were systems to plan staff numbers required. The provider had systems to monitor the quality of the service it provided and we saw evidence that complaints were fully investigated.

We saw evidence that the improvements suggested when we last inspected in January 2012 had been implemented.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

People we spoke with on the day of our visit rated the care and treatment they had received highly. We saw evidence that people are able to give feedback about the hospital and that people using the service were generally satisfied with the service offered.

The Portland Hospital for Women and Children is the largest private children’s hospital in the UK and is owned and run by HCA International Ltd.

The hospital/service opened in 1983, and has been part of HCA healthcare for the past 10 years. The hospital has 76 in-patient beds, 20 day-case beds and four theatres. It is situated in central London, on Great Portland Street, in the West End, with easy access to public transport and main driving routes. Services are provided from four buildings: 205-209 Great Portland Street, 212 Great Portland Street, 234 Great Portland Street and 215 Great Portland Street. There is also a small paediatric outpatient service located within The Shard.

The Portland Hospital for Women and Children provides surgery, maternity care, services for children and young people, termination of pregnancy services and outpatients and diagnostic imaging. All services at this hospital were inspected during our visit.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 1 – 3 November 2016, along with an unannounced visit to the hospital on 10 November 2016.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

Services we rate

We rated this hospital as good overall because:

• The hospital was managed by a team who had the confidence of patients and their teams. Both senior and junior nurses as well as doctors working in the service embedded the vision and strategy for the service into practice. Staff were encouraged to voice concerns or new ideas to improve patient experience. New staff spoke excitedly at the prospect of being a part of a team where the Chief Executive Officer (CEO) and Chief Nursing Officer (CNO) really cared and their opinions mattered.

• Care was planned and delivered in line with current evidence-based guidance, standards and best practice. Information about patient care, treatment and outcomes was routinely collected, monitored and used to improve care.

• Patients were treated with compassion and their privacy and dignity were maintained. Patient feedback surveys were positive about the care they received whilst in hospital.

• All patients were provided with individualised care. Translation services were readily available for those whose first language was not English. Meal plans and medications were tailored to the individual, to ensure that cultural and religious needs were met and maintained.

• Patients could access care when they needed it, often on the same day. There was choice and flexibility around appointments and elective procedures.

• All complaints were dealt with in an efficient manner within time scales set by the hospital.

• The midwife led services held meet and greet clinics for patients interested in the hospital maternity services. The sessions were free of charge and allowed the patients to have a tour of the facilities and ask any questions they may have. Patients found this service reassuring and positive. In addition, dedicated Spinal Dorsal Rhizotomy (SDR) open days were held where patients were asked to provide feedback on how services could be improved.

• There was a midwifery lactation team responsible for the oversight of infant feeding.

  The midwifery lactation team were supernumerary to ward staffing numbers to ensure that women could go home with knowledge and ability to feed their babies confidently and successfully. We saw that the initiation of breast feeding rate was 80%, which was better than the national average of 75%.

• There was a dedicated family room on both paediatric inpatient ward floors. The children’s outpatients department had tailored their environment for children and scheduled clinics outside of normal hours to accommodate patients and their families.

• There were systems to keep people safe and to learn from critical incidents. In maternity services, a computerised monitoring tool was used that allowed an overview of emerging themes and lessons learned to be shared widely with staff.

• The hospital environment was visibly clean and well maintained and there were adequate measures to prevent the spread of infection.

• There were systems to ensure the safe storage, use and administration of medicines, including controlled drugs. Regular audits took place to ensure that standards and best practice were maintained.

We found areas of outstanding practice in both the children and young people's services and the outpatients department:

• There were strong displays of innovative techniques from the hospital’s paediatric therapies team. Staff were encouraged to input to innovative change within the service and this was evident in the celebration of new ideas from staff at all levels.

• Multidisciplinary input in paediatrics was well structured, well coordinated and attended by a wide variety of clinical specialities and therapies. The meetings were structured around the holistic needs of the patients.

• Services were tailored and planned to fit the needs of the patients using the services. There was an impressive degree of clinical input and care for complex patients.

• The hospital had implemented a specialist, sensitive birthmark screening and treatment program for paediatric outpatients.

• The security and safety of patients was important to the service. The service had put in additional measures to ensure that children in their service were protected from harm. The Hugs and Kisses security system tracked and monitored patients throughout their pathway.

• A new training and practice device was developed in the colposcopy service. This device was sponsored and developed in partnership with a medical equipment manufacturer. The device was designed to be a colposcopy simulator, which had since aided in the training and development of skills for doctors and nurses in both the NHS and independent sectors.

• The radiology department used a lot of innovative techniques to ensure a smooth process of paediatric diagnostic procedures. This included the implementation of play therapist support and ‘feed and wrap’ scans to negate the need of anaesthesia for children.

• Consultants representing the hospital regularly provided continued professional development through master classes for GPs . They delivered training conferences four times a year for up to 200 doctors in order to educate and train GPs in issues relating to paediatric and women’s health.

• The hospital facilitated the training placements for student midwives and student nurses from a London based university. This collaboration resulted in staff developing their teaching skills and students successfully completing their second year with experience in the independent sector.

• The governance team conducted a comprehensive qualitative research study into the ‘Use of Team Debriefing Following a Serious Incident’. This project resulted in the development and implementation of the HCA Corporate Debriefing policy and staff information leaflet, which resulted in change of practice across all HCA sites.

• We were provided with a number of positive examples of staff development, which all included staff members from support services (identified by the CEO and other managers) as wanting to join clinical services. The staff members were supported and provided with funding to complete qualifications, allowing them to join as clinical staff.

• We were shown evidence of activities and excursions organised by the therapies department to support parents and children’s psychosocial wellbeing that were planned based on individual patient needs. Trips to venues such as Regents Park and London Zoo were arranged to meet specific clinical patient goals.

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

• There was lack of space in some clinical areas in the main hospital building. Some staff were concerned that this may impede the care being provided to the patients. In theatres, items were stored in corridors as there was not sufficient storage space.

• There was no integrated record keeping system, which meant that not all staff had access to up-to-date risk assessments and notes. This included agency staff and resident medical officers (RMOs), who may be attending for an emergency. Post-inspection, we were informed that the hospital was investing in a new record keeping system to ensure that patient records were consolidated in future.

• There was a high use of bank staff across the children and young people’s (CYP) service. Frequently, bank staff were not available, which in turn led to a high usage of agency staff. However, bank and agency staff  had an induction and shadowed a permanent member of staff on their first shift. They received the same training as permanent staff.

• We identified risks in the resuscitation trolleys throughout the paediatric service as they contained equipment and medicines for both adults and children. We observed a copy of the risk assessment and found

  they were in accordance with the UK Resuscitation Council guidelines to ensure appropriate use for both patient types.

• There was poor documentation from consultants in the maternity service in six of the 12 sets of notes we looked at.

• On the labour ward, medical gases were stored in an area which did not have appropriate signage on the door.

• Compliance rates of pre-assessment before surgery were low, ranging between 50% and 78% in the two months prior to our inspection. To improve this, the hospital recruited a dedicated pre-assessment nurse, scheduled to start in January 2017.

• The last staff survey showed a decline in staff satisfaction and staff commitment. The rate of ward and theatre staff turnover was above the average of other similar hospitals (July 2015 to June 2016).

• There was a resident on-call theatre team available out-of-hours for primarily obstetric patients. The same team also covered gynaecology emergencies. The absence of a second theatre team on-call was on the hospital’s risk register and most surgical patients were day cases with low pre-operative risk profiles.

• In the outpatients department, we found that changes in working practices arising from incident learning were not embedded into written policies or procedures in a timely manner.

• Mandatory training rates for staff in the outpatient department did not meet the hospital target of 90% compliance. Not all maternity staff were trained in the appropriate level of safeguarding.

Services we do not rate

We do not currently have a legal duty to rate termination of pregnancy, or the regulated activities they provide but we highlight good practice and issues that service providers need to improve and take regulatory action as necessary.

We found the following areas of good practice:

• Infection prevention and control (IPC) measures ensured that both the wards and theatres were clean and suitable for purpose.

• Medicines were managed and stored appropriately. Pain relief and antibiotic medications were given to women post-procedure to manage their symptoms.

• Documentation was concise and clear. We saw evidence that legislation relating to the termination of pregnancy (TOP) was followed in all the cases we examined.

• Staff we spoke with were knowledgeable about safeguarding and knew how to recognise if a woman was at risk or had been exposed to abuse, and how to escalate concerns. They were up-to-date with appropriate levels of training.

• There were enough nurses in the wards and theatres for staff to perform their roles safely. There was 24 hour, seven-days a week, resident medical officer (RMO) cover for the wards.

• Hospital policies were current and appropriately referenced relevant national guidance. The TOPS policy had recently been reviewed and updated.

• Consultants gave women verbal and written information on what to expect during and following a TOP procedure. Nurses on the ward also provided information about what women may experience. Women were able to contact the ward 24/7 after discharge for support or advice. Counselling was available to all women before, during and after they had received treatment, as required. This was from an external provider.

• Nurses shared responsibility for completing audits to monitor compliance and improvement. Records of all TOP procedures were maintained on a spreadsheet to monitor that all Department of Health (DH) Required Standard Operating Procedures (RSOPs) were met.

• Consent and capacity were considered by nurses when a women was admitted for a TOP procedure. All staff demonstrated a working knowledge of the Mental Capacity Act (MCA) and its implications.

• Patient’s privacy was maintained throughout their stay, as they were admitted to single occupancy rooms. Feedback from women about the gynaecology wards was consistently positive, although it was not possible to identify women undergoing TOP from returns.

• All women referred to the service received timely treatment, often beginning the same day they had their initial appointment.

• Women were given enough information to make an informed choice about the sensitive disposal of pregnancy remains and time to consider this. Appropriate storage arrangements were in place.

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

• Not all women having surgical terminations had a pre-operative assessment. The hospital had recruited a nurse into a post to perform these, but this was not yet in place.

• The hospital could not be assured that consultants were all returning the HSA4 forms to the Department of Health within 14 days because consultants did not always copy the form to the ward.

Following this inspection, we told the provider that they should make some improvements, even though a regulation had not been breached, to help the service improve. Details are at the end of the report.

Professor Sir Mike Richards

Chief Inspector of Hospitals