Archived: West Valley Hospital

Updated 6 September 2021

West Valley Hospital is operated by Ramsay Health Care UK and offers day-case services to private and NHS patients living in South East London. The hospital is registered with the CQC to provide the following regulated activities for people over the age of 18:

• Treatment of disease, disorder or injury
• Surgical procedures
• Diagnostic and screening procedures
• Family Planning Services

West Valley Hospital has a manager registered with CQC and opened in August 2017. Hospital facilities include two operating theatres, endoscopy and imaging suites as well as outpatient and physiotherapy consulting rooms. These enable the hospital to provide day-case surgery, radiology and ultrasound imaging, outpatient services and physiotherapy.

NHS funded admissions accounted for 93% of activity with the remaining 7% from private, predominately insured patients. Clinical specialties offered include dentistry, gastroenterology, general surgery, orthopaedics, gynaecology, ophthalmology, plastic surgery, urology and pain management. Diagnostic imaging services included mobile and static radiology and ultrasound facilities. Family planning services included the insertion and removal of intrauterine devices for contraception or medical purposes.

Physiotherapy at the hospital was provided by another company and was not part of this inspection.

The main services provided by this hospital were surgery and outpatients. Where our findings on surgery (for example, management arrangements) also applied to other services, we did not repeat the information but cross-referred to the surgery section.

Updated 6 September 2021

We have not previously rated this service. We rated it as good because:

• The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
• Staff provided good care to patients. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients and had access to good information. Services were available five days a week.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
• The service took account of patients’ individual needs and made it easy for people to give feedback. People could access the service when they needed it.
• Leaders ran services well using reliable information systems and supported staff to develop their skills.
• Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were generally clear about their roles and accountabilities.
• The service engaged well with patients received overwhelmingly good feedback.

However:

• In the theatre suite, we found logs used in the ordering of controlled drugs that contained gaps in the record. We acknowledge that as soon as we identified this, an action plan was developed and implemented to prevent recurrence.
• The signing in and out sheets for the theatre complex were not always completed and there were gaps in checklists that were not accounted for.
• Some members of staff we spoke with weren’t sure how their development needs would be addressed.
• Leaders were still working to involve staff in auditing and governance processes.
• In outpatients staff were not always clear about their responsibilities.
• Policies were not always reviewed with specified time frames, meaning staff were sometimes working from policies that were out of date.
• In outpatients, we found some equipment servicing that was not always completed annually where this was indicated.
• We observed an incident in the X-ray room when a patient moved and the ‘stop and check’ protocol failed.

Updated 6 September 2021

Medical services were a small proportion of the hospital activity. The main activities of the hospital were surgery and outpatients. The endoscopy service was the main medical service and was integrated into operating theatres, which is included in the surgery core service report.

Where arrangements were the same we have reported findings in the surgery report.

There was no activity on the day of our unannounced inspection, however we were able to inspect the environment; equipment management and stores along with decontamination facilities and records.

We have not previously rated the service. We rated this service as good because it was safe, responsive and well-led.

Updated 6 September 2021

Diagnostic imaging is a small proportion of hospital activity. The main service was surgery. Where arrangements were the same, we have reported findings in the surgery section. This is the first time we rated this service. We rated this service as good because:

• The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
• Staff provided good care to patients. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients and had access to good information. Services were available five days a week.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions.
• The service took account of patients’ individual needs and made it easy for people to give feedback. People could access the service when they needed it.
• Leaders ran services well using reliable information systems and supported staff to develop their skills.
• Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients.

However:

• We observed an incident in the X-ray room when a patient moved and the ‘stop and check’ protocol failed.

Updated 6 September 2021

This service includes a part-time GP practice. This is the first time we rated this service. We rated the service as good because:

• The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They mostly managed medicines well. The service managed safety incidents well and learned lessons from them.
• Staff provided good care and treatment and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
• The service took account of patients’ individual needs and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care.

However:

• Staff were not always clear about their responsibilities.
• Policies were not always reviewed in their time frames, meaning staff were sometimes working from policies that were out of date.
• Equipment servicing was not always completed annually, where this was indicated.

Outpatients is a large proportion of hospital activity, but we also inspected the GP service provided by the hospital. The service arrangements and governance for the GP service and the outpatient appointments were generally the same, where this was not the case, and something only referred to the GP service we have clearly reported this as different.

We rated this service as good because it was safe, effective, caring, responsive and well led.

Updated 6 September 2021

This is the first time we rated this service. We rated it as good because:

• The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. The service managed safety incidents well and learned lessons from the provider wide organisation. Staff collected safety information and used it to improve the service.
• Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good patient information.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
• Leaders ran services well using reliable information systems. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. Staff and managers were focused on the needs of patients receiving care. Staff were clear about their clinical roles. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

• We found that logs for accountability in the ordering of controlled drugs where not used appropriately and allowed gaps that decreased the accountability during the ordering process. However, after raising this during inspection an action plan was developed to address and rectify this in the next two months
• The signing check in and check out sheets for the surgery suite were not always completed and there were gaps in check lists that were not accounted for.
• The service had a new team and despite focusing on embedding a culture of safety, new members of staff we spoke with identified they weren’t sure how their development needs would be addressed.
• Leaders were still working to involve staff in auditing and governance processes.