Practice Plus Group Hospital - Barlborough

Updated 1 July 2015

Barlborough NHS Treatment Centre (the treatment centre) opened in July 2005, and in 2009 was acquired by Care UK Clinical Services Ltd, the largest independent provider of NHS services in England. Independent NHS treatment centres are private-sector owned treatment centres contracted to treat NHS patients free at the point of use. The treatment centre is a dedicated orthopaedic centre and provides in-patient and day case orthopaedic elective surgery with associated outpatient and diagnostic clinics. It provides services to people living in Derbyshire, Lincolnshire, Nottinghamshire and South Yorkshire, and runs some satellite outpatient clinics in Lincolnshire.

The treatment centre has a 40 bed inpatient ward and a six bed day patient ward. There are three theatres that operate Monday to Saturday, and also Sunday on demand. Procedures include minor and intermediate orthopaedic surgery, major joint replacements and revisions, joint arthroscopy, ligament repair, shoulder decompression, repairs and stabilisations, foot and ankle procedures, and hand procedures such as carpal tunnel release. It also provides non-complex spinal surgery.

We carried out a comprehensive inspection of Barlborough NHS Treatment Centre on 17 to 19 and 28 March 2015 as part of our second wave of independent healthcare inspections. We used the new approach to inspections and inspected the following two core services:

• Surgery
• Outpatients and Diagnostic Imaging

Updated 1 July 2015

Barlborough NHS Treatment Centre (the treatment centre) opened in July 2005 and in 2009 was acquired by Care UK Clinical Services Ltd, the largest independent provider of NHS services in England. Independent NHS treatment centres are private-sector owned treatment centres contracted to treat NHS patients free at the point of use. The treatment centre is a dedicated orthopaedic centre and provides in-patient and day case orthopaedic elective surgery with associated outpatient and diagnostic clinics. It provides services to people living in Derbyshire, Lincolnshire, Nottinghamshire and South Yorkshire, and runs some satellite outpatient clinics in Lincolnshire.

The treatment centre has a 40 bed inpatient ward and a six bed day patient ward. There are three theatres that operate Monday to Saturday, and also Sunday on demand. Procedures include minor and intermediate orthopaedic surgery, major joint replacements and revisions, joint arthroscopy, ligament repair, shoulder decompression, repairs and stabilisations, foot and ankle procedures, and hand procedures such as carpal tunnel release. It also carries out non complex spinal surgery.

We carried out a comprehensive inspection of Barlborough NHS Treatment Centre on 17 to 19 and 28 March 2015 as part of our second wave of independent healthcare inspections. We used the new approach to inspections and inspected the following two core services:

• Surgery
• Outpatients and Diagnostic Imaging

Barlborough NHS Treatment Centre has been awarded a shadow rating of good. Shadow ratings apply to inspections which are undertaken during the development of our approach and before our final methods are confirmed and published.

Our key findings were as follows:

• Leadership

Members of the senior leadership team were relatively new in post and roles were being developed. However staff morale and motivation were high and staff enjoyed working at the treatment centre. There was supportive management at all levels, effective team-working and an open culture in which staff were able to raise concerns and make suggestions.

• Cleanliness

The treatment centre maintained high standards of cleanliness and hygiene. There had been no incidents of healthcare acquired infections in the last 18 months. There had been no surgical site infections since August 2014. There were sufficient supplies of personal protective equipment available such as gloves and aprons. We saw staff using these and changing them between patients. The cleaning of equipment was monitored effectively.

•  Safety

There had been four never events between October 2013 and September 2014 (never events are serious, largely preventable, patient safety incidents that should not occur). Other serious incidents resulting in harm to patients were not always reported to the Care Quality Commission as required by legislation. Operating staff used the a recognised surgical safety checklist, but this was not the most up to date version. There were systems in place to identify and record patient safety incidents;  thorough investigations were completed and findings were cascaded to staff.

• Nutrition and hydration

Patients were given clear guidance on pre-operative fasting and staff telephoned patients the day before surgery to ensure they were clear about this. Patients were screened for malnutrition and the risk of malnutrition on admission to the treatment centre using a recognised tool. After surgery there were accurate and complete records to monitor fluid intake and output. Where there were concerns nurses followed protocol and scanned patients’ bladders, seeking medical advice as needed, so as to prevent post-operative urinary and kidney dysfunction.

Patients found the choice and quality of meals to be very good. The range available was suitable for patients’ needs and preferences. It included foods suitable for coeliac, diabetic, vegetarian and other diets.

• Staffing levels

Staffing levels were adjusted according to patient numbers and to accommodate patients who needed additional support. There were more nursing staff than the recommended National Institute for health and Care Excellence (NICE) guidelines, and staff confirmed that these levels were consistently maintained. There were low rates of sickness and low staff turnover for all staff groups. Staff were well supported and were able to work flexibly. There was variable use of agency staff in theatres but overall there was a low rate of agency staff employed at the treatment centre. A resident medical officer was available on site 24 hours per day and a consultant anaesthetist and consultant surgeon were on call 24 hours per day. These were permanent staff who worked on a rotating shift basis.

• Mortality rates

There were three unexpected inpatient deaths in the reporting period October 2013 to September 2014. Two of these occurred in 2014. In one case the patient died as a result of an undiagnosed serious condition. Following the second death, as a result of kidney disease, an investigation recommended improved patient monitoring and assessment in certain cases. New procedures have been put in place to ensure swift identification and management of the condition.

We saw several areas of outstanding practice including:

• Staff were exceptionally caring and went the extra mile to provide high quality care.
• Staff were highly motivated to offer care that was respectful and promoted people’s dignity. They took the initiative in seeking solutions to meeting individual patients’ needs.
• There was an ethos of teamwork and supportive management, with effective communication throughout the treatment centre.
• Emergency equipment, including portable oxygen and suction, was kept in the lift used to transport patients between the ward and theatres. This meant that in an emergency patients could be treated without delay.

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

Importantly, the provider must:

• Ensure that all notifiable incidents resulting in harm to patients, including safeguarding incidents, are reported to the Care Quality Commission, so that action can be taken where needed.

In addition, the provider should:

• Update the World Health Organisation (WHO) surgical checklist.

• Continue to improve staff hand hygiene practices.

• Ensure sufficient, suitable storage space for theatre equipment

• Establish an effective formalised system to ensure sufficient out of hours nursing staff when patients have to return unexpectedly to theatre.

• Ensure all staff comply with the requirements of the Mental Capacity Act 2005, when caring for someone who lacks or may lack the capacity to make decisions about their care and treatment.

• Improve staff uptake of dementia awareness training.

• Establish a clear system to ensure ward staff are aware when patients have specific nutritional needs or need assistance with eating.

• Provide nursing staff with regular clinical supervision.

• Provide all staff, including administrative and clerical, with an annual performance appraisal.

• Advise people attending as outpatients in advance about the opportunity for a chaperone to accompany them during their appointment.

• Provide patients with information about how to travel to the treatment centre by public transport and about the availability of provided transport

• Make available patient information leaflets in large print and formats other than written English.

• Ensure patients in all areas have accessible information on how to raise concerns and complaints.

• Strengthen the risk register to include ownership of actions and their timely review.

• Report patient comments, concerns and complaints regularly through the hospital’s governance structure so that systematic and consistent learning can be shared.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Updated 1 July 2015

Overall we rated outpatients and diagnostic imaging services as good. There were reliable systems, processes and practices in place to protect patients from avoidable harm and abuse. Risks to patients were appropriately assessed, monitored and managed. Not all patient safety incidents were reported to CQC as they should have been. Patients’ needs were assessed and care, treatment and support were delivered following local and national standards and evidence based guidance.

Without exception patients told us they were treated with kindness, dignity, respect and compassion. Patients and those close to them were involved in planning their care and treatment and staff offered them appropriate emotional support.

Staff were appropriately qualified and skilled to deliver effective care and treatment. There were good examples of staff and teams working well together to deliver care. There was a culture of supportive management where staff felt respected and valued. They were proud of the service they offered and they focused on improving and promoting good quality care. There was openness and transparency and patients were actively encouraged to feed back about their experiences. There were effective systems to manage and respond to complaints but most patients did not have access to information on how to make a complaint.

Updated 1 July 2015

Overall we rated Surgery as good. However, there was limited assurance about safety. There had been four never events between October 2013 and September 2014, (never events are serious, largely preventable, patient safety incidents that should not occur). Other serious incidents resulting in harm to patients were not always reported to the Care Quality Commission as required by legislation. There were systems in place to identify and record patient safety incidents. Where serious incidents had occurred investigations were completed to identify learning and cascade this to staff. Not all incidents were reported to CQC as they should have been. There were sufficient suitably skilled staff available to care for patients. Patients received care and treatment which followed National Institute for Health and Clinical Excellence (NICE) guidelines. Surgical outcomes for patients were monitored and were either within or better than the national average.

Patients were overwhelmingly positive about the care they received with some patients choosing to travel significant distances to have their operations at the treatment centre. Patients were involved in their care and were treated with dignity and respect by staff. Staff were polite, kind and professional. Staff were not all familiar with procedures to follow when people did not have the capacity to make decisions about their care. Access to care and treatment was monitored and was in line with or better than the national average. There was effective multidisciplinary team working to ensure patients received appropriate care and treatment.

While members of the senior leadership team were relatively new in post and roles were being developed, staff morale and motivation were high and staff enjoyed working at the treatment centre. There was an open culture in which staff were able to raise concerns and make suggestions. Feedback from patients was gathered and used to improve practice. There were effective systems to manage and respond to complaints but most patients did not have access to information on how to make a complaint.