Practice Plus Group Hospital - Emersons Green

Updated 22 July 2016

Emersons Green NHS Treatment Centre is an independent hospital situated in Bristol. It opened in 2009 and provides services to people living in Bristol, North Somerset, South Gloucestershire, Wiltshire, Gloucestershire, Bath, North East Somerset, Swindon and South Wales.

Independent NHS treatment centres are private-sector owned treatment centres contracted to treat NHS patients free at the point of use. Emersons Green NHS Treatment Centre is run by Care UK, the largest independent provider of NHS services in England.

The treatment centre provides routine surgery, outpatient and diagnostic imaging services in a modern purpose-built hospital. Specialities for which treatment is available include: ophthalmology, oral surgery, ear, nose and throat, general surgery, orthopaedics, gynaecology, urology and endoscopy.

Admission to the treatment centre for surgery follows strict referral criteria for people aged 16 years and over who required routine surgery.

There is an outpatient department in the treatment centre for routine pre- and post-operative appointments.

The treatment centre has an inpatient ward with 33 bed spaces. There are four operating theatres, one minor procedure room and two anaesthetic induction rooms, operating Monday to Saturday.

We carried out a comprehensive announced inspection of Emersons Green NHS Treatment Centre on 30 and 31 March 2016, and an unannounced inspection on11 April 2016.

We inspected the following two core services:

• surgery

• outpatients and diagnostic imaging.

Updated 22 July 2016

Emersons Green NHS Treatment Centre is an independent hospital, owned by Care UK, contracted to provide treatment for NHS patients free at the point of use.

The treatment centre provides surgery, outpatient and diagnostic imaging services for the following specialities: ophthalmology, oral surgery, ear, nose and throat, general surgery, orthopaedics, gynaecology, urology and endoscopy.

Admission to the treatment centre for surgery follows strict referral criteria for people aged 16 years and over who require routine surgery.

There is an outpatient department within the treatment centre for routine pre- and post-operative appointments.

The treatment centre has an inpatient ward with 33 bed spaces. There are four operating theatres, one minor procedure room and two anaesthetic induction rooms, operating Monday to Saturday.

We carried out a comprehensive announced inspection of Emersons Green NHS Treatment Centre on 30 and 31 March 2016, and an unannounced inspection on 11 April 2016.

We inspected the following two core services:

• surgery

• outpatients and diagnostic imaging.

The overall rating for this service was good.

Our key findings were as follows:

Are services safe?

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

• There was a good incident reporting culture amongst staff, which was reflected in the consistent numbers of incidents reported in the hospital between October 2014 and September 2015. Learning from serious incidents and root cause analyses was shared with the whole Care UK organisation.

• Staff were aware of the principles of the duty of candour and were open, transparent and apologetic to patients when things went wrong.

• The treatment centre was visibly clean and staff followed infection prevention and control protocols.

• Staff were aware of their roles and responsibilities in reporting a safeguarding concern and knew how to go about this process. Safeguarding policies and procedures were readily available and up to date.

• There were good numbers of staff employed, with relevant skills, that kept people safe from avoidable harm. These levels were regularly reviewed to ensure changes in demand were adequately staffed.

• The design of the treatment centre kept people safe at all times, with waiting areas free from obstructions and providing staff with good visibility of patients.

• There was a good process for monitoring controlled drugs and breakages, including unannounced inspections of controlled drugs log books.

• Patients who deteriorated were well supported by staff. Clear processes existed to ensure rapid and safe transfers to a local NHS acute hospital if needed.

• We found out of date equipment stored on the ward.

• Incident reporting data had identified a trend in poor reporting of patient allergies prior to October 2015. However, actions had been put in place and allergy reporting had improved.

• The hospital identified a need for better communication between consultants and a clear system to flag urgent referrals.

• The diagnostic imaging department only had one X-ray cassette reader, which would mean there would not be an on-site X-ray service if it broke down.

• The hospital target of 90% compliance with mandatory training in January 2016 had not been met in outpatients or physiotherapy. In diagnostic imaging only 80% of staff had completed basic or intermediate life saving training.

• We saw sediment on a patient water dispenser, and staff did not know if flushing of the dispenser took place, and could not produce any records of this.

Are services effective?

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.

• An evidence-based enhanced recovery programme was used for patients undergoing hip or knee replacements.

• The treatment centre scored better than the England average in its hip replacement and varicose vein surgery for the reporting period October 2014 to September 2015.

• Staff were qualified and had the skills to carry out their roles effectively, with a variety of internal training provided by speciality consultants.

• There was good multidisciplinary team working across all departments to ensure effective patient care.

• Discharge planning was started early at the pre-operation stage, including follow-up appointments and organisation of continuing care packages.

• The use of best practice was evident throughout the treatment centre.

• Staff felt their training was good and provided them with the necessary skills and knowledge to perform their role.

• Diagnostic imaging was available seven days a week to inpatients within the hospital.

• The outpatient department provided evening and weekend clinics in all specialities.

• The hospital used approved national surveys to capture patients’ outcomes, including the use of a dedicated survey for patients with learning difficulties.

• Diagnostic imaging staff did not always follow up urgent results with GPs.

• Computer systems used to store images and reports were different throughout the Care UK diagnostic imaging centres and other NHS trusts. This meant images had to be sent over to the computer and transferred by a staff member to the patients’ electronic folder. We were told images were not always readily available because this was not always done.
• The electronic patient record system was prone to slow down, and the hospital had identified a risk should it stop working completely.

Are services caring?

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

• All the feedback we received from patients about the service was continually positive. Patients felt they were treated with dignity and respect and valued their interactions with staff.

• All staff demonstrated genuine compassion for the people in their care, which was embedded into the culture of the departments.

• Patients told us their family were involved as partners in their care. Patients felt able to raise questions and concerns and felt they were always responded to in a positive way and received information in a way they could understand.

• Patients were seen as individuals and care was tailored to them, and explained clearly at each step of the way.

• All patients were given a 24 hour contact number based in the hospital to call at any time if they were concerned about any aspect of their care or condition.

• When care fell short of a patient’s expectations, senior managers were quick to engage with the patient to find a solution.

Are services responsive?

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

• The treatment centre worked with local Clinical Commissioning Groups, GPs and the patient forum group to plan and develop services for the local population.

• Services were flexible to meet the needs of the population and planned to ensure continuity of care from department to department.

• The hospital took all complaints seriously and investigated them. Where possible, managers offered face to face meetings with patients to discuss their concerns.

• The hospital was meeting all of its referral to treatment standards. All waiting times for a first appointment were six weeks or less.

• The hospital was improving relationships with GPs in the community to understand reasons why referral rates had declined towards the end of 2015.

• The hospital used a pager system to alert patients when they were ready to go through to the clinic, and identified patients this was not appropriate for.

• Staff monitored and audited the length of time patients spent in each department during their journey through the clinics using a traffic light computer system.

• Staff volunteered to put on extra lists to help treat a group of patients from Wales. The treatment centre provided a coach to bring all the patients to the hospital and provided food for all patients.

• Where treatment or care had to be delayed or cancelled, the hospital supported patients and fully explained the reasons why and what would happen next.

• Patients who had additional needs, such as those with learning difficulties, were offered extra support such as longer clinic appointments, and pre-procedure experience visits along with their relatives or carers.

• The hospital did not have sufficient parking for all of its patients, and a patient told us their partner had missed their consultation because they could not park.

• Not all staff were aware of the electronic flagging system for patients with additional needs.

Are services well-led?

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.

• The treatment centre had a challenging, yet achievable, vision and strategy that staff were aware of and involved with achieving.

• Work was actively ongoing with external stakeholders to help deliver the vision and strategy, and to provide the best service for patients.

• The senior management team were an enthusiastic, committed team delivering safe, patient centred care. Staff and patient engagement was embedded in the culture at the treatment centre.

• There were strong governance processes at all levels in the treatment centre, with a monthly quality assurance meeting attended by all clinical and non-clinical staff, as well as the patient forum.

• Staff told us they felt very well supported by their immediate line managers, the divisional management team and the executive team.

• The diagnostic imaging department was working towards achieving accreditation with the Imaging Service Accreditation Scheme.

• There was a strong culture of openness and transparency.

• The vast majority of staff spoke highly of the working culture. Senior management were visible, approachable and engaged with staff.

• Some staff felt senior management styles could be overpowering at times, although this was not reflected by the majority of staff we spoke with.

• We did not see evidence of a strong emphasis on promoting the safety and wellbeing of staff, and a number of incidents reported showed staff were sometimes working through breaks.

We saw several areas of outstanding practice including:

• The treatment centre had a policy that allowed any member of staff at any time to call a multidisciplinary team meeting if they had any concerns about any aspect of a patient’s care.

• The safeguarding policies and procedures were well established and well understood by staff who gave us many examples of where the safeguarding process had been followed to help protect vulnerable adults receiving care in the hospital.

• Pharmacy staff were involved in projects to help simplify information given to patients about their medicines. This included easy-read medicines sheets and a colour-coded system for the administration of eye drops post-surgery.

• The senior managers were very visible and welcomed engagement with staff and patients in both a positive and constructive manner, and frequently served as first point of contact in situations where patients were unhappy with services.

• A patient forum was set up to engage with patients and be involved with a lot of internal processes and meetings. In particular, patient forum members attended and participated in the monthly clinical governance meetings.

• Staff were very quick to offer patients apologies and the opportunity for a conversation following an incident where something had not gone as well as it should. Learning from these conversations and subsequent investigations was shared throughout the Care UK organisation.

• The hospital welcomed and was responsive to patient feedback, including feedback about patient toilets and adding specialty food items to the canteen menu.

• The physiotherapy enhanced recovery programme allowed detailed monitoring of the effectiveness of patient treatment at six weeks, with the option to refer back to the consultant if any concerns about the patient’s progress arose.

• Free telephone calls were available for all patients to landlines and mobile phones to enable them to remain in contact with their family during their stay.

There were some areas where the provider needs to make improvements.

The provider should:

• Ensure effective communication takes place between consultants at all times and implement a clear system to flag urgent referrals.

• Consider having a contingency plan in case the diagnostic imaging computed radiography reader breaks down.

• Ensure mandatory training is completed in accordance with Care UK targets.

• Maintain records of regular tap flushing.

• Ensure effective stock management is in place and that out of date items are removed from circulation.

• Implement a system to ensure diagnostic imaging staff follow up urgent referrals with GPs in all cases.

• Consider alternative parking arrangements for patients and relatives.

• Ensure the pharmacy recording, tracking and monitoring systems are fit for purpose.

• Consider enhanced training for prescribers to make sure all referral information is taken into consideration at the time of prescribing ‘to take out’ medication.

• Ensure the number of patients booked into a clinic is appropriate to the length and staffing of that clinic.

• Ensure staff are allowed time to take allocated meal breaks.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Updated 22 July 2016

The outpatient and diagnostic services at Emersons Green NHS Treatment Centre were rated as good overall, with caring rated as outstanding. We found:

• There were good systems in place for incident reporting and learning when things did not go as planned.

• Systems were in place for the safe administration of medicines and for the prevention of infection.

• Staff were knowledgeable about safeguarding and their responsibilities to vulnerable adults.

• Staff were knowledgeable about their duty of candour towards patients.

• Staff were very competent in the roles they were being asked to perform.

• There was good multidisciplinary working within the hospital.

• Staff captured data about patient outcomes, and used it to make changes to the way they worked.

• Staff communicated in a professional but friendly manner with patients and their families.

• Comments from patients and relatives were extremely positive about the staff and how they provided their care and treatment.

• Patients were involved in their care and treatment and their needs were always put first. The hospital put patients at the core of the services they delivered.

• The departments provided a good service to make sure people were not waiting long periods of time for either outpatients or diagnostic services.

• We saw the hospital was achieving all of its referral to treatment standards across all specialties.

• We saw evidence that complaints were discussed at departmental and higher level meetings and changes were made where necessary to help improve services and prevent further complaints.

• The hospital welcomed all feedback from patients, and made changes to services if necessary.

• Staff were supported at all levels, from their immediate manager through to the hospital executive team, including the hospital director.

• Good governance systems were in place across outpatients and diagnostics.

• The majority of staff we spoke with felt the culture was open and that staff strived to make sure the experience for patients was outstanding in line with the hospital’s values and vision.

• The hospital engaged with the patient forum and used them to help develop services.

However:

• The hospital target of 90% compliance with mandatory training in January 2016 had not been met in outpatients or physiotherapy.

• Some staff described the style of management of some senior managers as overpowering, although we did not find this view shared by the majority of staff.

• Diagnostic imaging staff did not always follow up urgent results with GPs.

• The electronic patient record system was prone to slow down, and the hospital had identified a risk should it stop working completely.

Updated 22 July 2016

The surgery services at Emersons Green NHS Treatment Centre were rated as good overall, with leadership rated as outstanding.  We found:

• Staff were open and honest when things didn’t go as planned and were encouraged to report incidents by the senior management team.

• All staff knew how to use the incident reporting system and we saw evidence of changes to practice that had been made as a result.

• We saw evidence of learning to support improvement which was communicated to all departments and not those just directly affected.

• An open culture was encouraged and staff understood the duty of candour and the principals of openness, honesty, integrity and providing an apology.

• The ward, theatre and endoscopy departments were all visibly clean, organised and well maintained. Staff followed infection, prevention and control policies.

• We observed good use of the WHO five steps to safer surgery checklist and minutes of theatre brief and debrief checklists.

• There were sufficient numbers of staff to safely meet the needs of patients and medicines were managed safely.

• Care and treatment was planned in line with evidence-based guidance, standards and legislation.

• Consent to treatment was sought and documented in line with legislation.

• Staff had the skills required, and were qualified, to carry out their roles effectively in line with best practice and were also provided with specialist training to cope with any eventuality on the ward.

• The multidisciplinary team shared responsibility for delivering care and treatment and worked together to co-ordinate this.

• Staff communicated and responded compassionately with patients and explained things in a way patients could understand.

• Patients were involved and encouraged to be partners in their care and decision making.

• Staff gave patients the time to ask questions about their care and treatment and also involved other family members throughout the process to ensure the patient was supported.

• Staff provided patient-centred care which was reassuring, caring, compassionate and supportive.

• Staff ensured privacy and dignity of the patient was maintained and independence was encouraged during their stay at the treatment centre.

• All feedback we received about the staff was very positive.

• The needs of different people were accounted for when planning and delivering services.

• Staff were responsive to individual patients’ needs.

• Staff demonstrated how they supported patients with learning difficulties, their families and carers, to reduce anxiety before the day of the procedure.

• Staff also demonstrated how they made allowances for patients to ensure care and treatment delivery met their needs.

• Complaints and concerns were always taken seriously and responded to in a timely way.

• The treatment centre took a proactive approach to make changes on the basis of patient feedback.

• The treatment centre had a challenging, yet achievable, vision and strategy that staff were aware of and involved with achieving.

• Work was actively ongoing with external stakeholders to help deliver the vision and strategy, and to provide the best service for patients.

• The senior management team were an enthusiastic, committed team delivering safe, patient centred care. Staff and patient engagement was embedded in the culture at the treatment centre.

• There were strong governance processes at all levels in the treatment centre, with a monthly quality assurance meeting attended by all clinical and non-clinical staff, as well as the patient forum.

• There was a strong focus on improving quality of care and patient experience.

• The vast majority of staff spoke highly of the working culture. Senior management were visible, approachable and engaged with staff.

However:

• There were occasions when staff felt overwhelmed by the senior management team and felt their work and decision-making was not trusted.