Nuffield Health Wolverhampton Hospital provides a range of clinical services including orthopaedics, ophthalmology, oncology, ear, nose and throat (ENT), gynaecology and general surgery. It has two operating theatres of which one has a laminar flow system, which is a system to control air and reduce infection during operations. There are 27 en-suite bedrooms and two chemotherapy rooms on the second floor and the hospital has a diagnostic suite offering mammography, fluoroscopy and general x-ray. It also offers 10 consulting rooms within the outpatient department.
We carried out an announced inspection visit on 14 September 2016 and an unannounced inspection on 19 September 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 into account what people told us and how the provider understood and complied with the Mental Capacity Act 2005.
We conducted a comprehensive inspection at Nuffield Health Wolverhampton Hospital as part of our independent healthcare inspections programme. The inspection was conducted using the CQC’s new methodology. The inspection team inspected the following core services:
• Surgery
• Outpatients and Diagnostic imaging (including chemotherapy treatment).
The hospital carried out minimal medical care service activity but had recently introduced chemotherapy treatment services. The service was small and in its infancy at the time of the inspection and did not warrant its own separate report. Therefore, chemotherapy services were inspected and reported as part of the outpatients and diagnostic imaging service.
Prior to our inspection visit, we considered a range of quality indicators captured through our monitoring processes. In addition, we sought the views of a range partners and stakeholders.
Key elements of this process were focus groups with healthcare professionals and feedback from the public.
We spoke with a range of staff in the hospital, including nurses, allied health professionals, support staff and consultants. During our inspection, we reviewed services provided by Nuffield Health Wolverhampton Hospital in the ward areas, operating theatres, outpatients, pharmacy and imaging departments.
We observed how people were cared for and reviewed patient records of 16 patients. We spoke with 12 patients and their relatives, 26 staff, including consultants.
We collected 69 completed comment cards by people attending the hospital. There were 68 (98.5%) positive comments recorded on the feedback. Only one negative comment was noted.
Our key findings were as follows:
Overall, we rated the hospital as Good
We saw several areas of good practice including:
- There was a good induction process for new and agency staff.
- We saw a positive incident reporting culture with good quality incident reports.
- The medicine management system and safety checklists were good.
- We saw supportive managers at all levels and staff told us they were visible and approachable.
- There was protected swipe card access in areas of the diagnostic imaging department.
However, there were areas where the provider needs to make improvements.
The provider should;
- The provider held records securely however; they had no tracking tools in place to prevent loss of patient notes when consultants took them offsite.
- Work towards recommended guidelines such as the Health Technical Memorandum 03-01: Specialised ventilation for healthcare premises when carrying out minor procedures outside of the main theatre areas.
- Ensure mandatory training for Immediate Life Support (ILS) is kept up to date.
- The hospital had no written procedure for covering consultants when on leave or unavailable. Consultants verbalised their availability to OPD and Diagnostic Imaging staff as an informal process. We saw this arrangement as not a robust system and needed to be strengthened.
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. We also issued the provider with a requirement notice that affected surgery and outpatients. Details are at the end of the report.
Professor Sir Mike Richards
Chief Inspector of Hospitals