Archived: Peninsula NHS Treatment Centre

Updated 20 October 2016

The Peninsula NHS Treatment Centre is part of the Care UK group. The hospital opened in April 2005 and is located in a converted warehouse redesigned for healthcare purposes in Plymouth, 0.4 miles from the large NHS acute hospital serving the area.

The treatment centre treated only NHS patients which were referred via choose and book or may be seen on behalf of the local acute hospital. The referral criteria of the treatment centre excluded the following patients: under 18 years of age, patients with high suspicion of cancer, clinical emergencies, patients with poorly controlled morbidities, pregnancy, and patients with a body mass index of more than 42 for general surgery or more than 45 for local anaesthesia.

Patients were seen as outpatients at the start of their pathway to surgery either for initial consultations or for their pre-assessment clinic visit. Diagnostic imaging was performed on site. Patients underwent surgery as either inpatients or day care patients. During the period April 2015 to March 2016, 24.8% of patients stayed overnight following their surgery. There were 28 inpatient beds and 12 patient bays including four patient chairs. There were two operating theatres. There was one procedure room, and one pre and post anaesthetic care unit with five recovery bays.

Surgical procedures performed at the hospital included: cataract, hand, knee, hip, arthroscopy, hernia, cholecystectomy, foot, shoulder and tonsillectomy. The orthopaedic specialty accounted for 71% of outpatient attendances, followed by ophthalmology at 25% and general surgery at 4%. Several specialist services were outsourced to independent providers, such as: computed tomography, magnetic resonance imaging, ultrasound/doppler; or to the local acute trust, such as: bone scan, nerve conduction studies and pathology and microbiology. The ophthalmology service was outsourced to an independent provider but based on the hospital site. The resident medical officer provision was outsourced to an independent agency.

The hospital opened in April 2005. In October 2014 the New Devon clinical commissioning group made a decision to cease commissioning care at the treatment centre as capacity could be met at the local acute trust and another independent provider hospital. This decision was withdrawn two months later following significant protest from the local population

The registered manager and accountable officer for controlled drugs for Peninsula NHS Treatment Centre was the hospital director, Patricia Warwick, who had been in the post since April 2015.

During this inspection we looked at surgery and the outpatient and diagnostic imaging service.

We inspected the hospital as part of our routine comprehensive inspection programme for independent healthcare services. We carried out a comprehensive announced inspection on 13 and 14 July 2016

2016 and an unannounced inspection on 30 April 2016.

Updated 20 October 2016

Peninsula NHS Treatment Centre is an independent hospital and part of Care UK Limited. At the time of our inspection it provided care and treatment to NHS patients, with no privately funded work undertaken.

The hospital provided surgery, and outpatient and diagnostic services. There were no services provided to persons under the age of eighteen. Day case and inpatient surgery specialities included major and minor orthopaedics, ears nose and throat, and general surgery. Ophthalmology surgery was located on site but outsourced to an external provider (obtaining services by contract from an outside supplier). There were 28 inpatient beds and 12 patient bays including four patient treatment chairs. There were two operating theatres. There was one procedure room, and there was one pre and post anaesthetic care unit with five recovery bays.

The outpatient department provided a service for patients before and after surgery. No patients were seen in outpatients who were not on the surgery pathway. Diagnostic services included plain film x-ray only. There was a physiotherapy service for inpatients.

All treatment was consultant led. All consultants were employed on either substantive or bank contracts. The senior leadership team included the hospital director, the medical director, and the head of nursing and clinical services manager, and the regional finance manager.

We carried out a comprehensive announced inspection of Peninsula NHS Treatment centre on 13 and 14 July 2016, and an unannounced inspection on the evening of 20 July 2016. We inspected and reported on two core services: the surgery service and the outpatients and diagnostic imaging service.

The overall rating for the Peninsula NHS Treatment Centre was outstanding. We rated both core services as good for being safe, effective and responsive. We rated both services as outstanding for being caring and well-led. Our key findings were as follows:

Are services safe?

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

We rated safety overall as good:

• All staff we spoke with understood the importance of reporting incidents and were confident in the investigation and learning from incidents that extended across all the departments. All staff we spoke with understood the duty of candour principles. The governance management team monitored all incidents and clearly understood the requirements under this legislation.
• The ward manager was the safeguarding lead for adults and for children and this individual was trained to level 4. Staff demonstrated a clear understanding of their responsibilities to recognise and act upon safeguarding concerns.
• All areas of the hospital were visibly clean and there were clear systems in place to ensure high risk areas were regularly cleaned. There had been no incidences of hospital acquired infections during the reporting period of April 2015 to March 2016. Staff were observed to consistently use effective infection prevention and control techniques.
• All patients were admitted under the care of a named consultant who reviewed their cases daily. Out of hours patients were cared for by the resident medical officer (RMO) who contacted consultants when required. The RMOs were employed by an agency and their suitability was closely monitored by the anaesthetists and medical director.
• There were safe staffing levels on the ward, in theatres and in outpatient services. Staffing models were based on nationally recognised staffing tools.
• We saw that all members of the clinical teams were involved in clinical decision making and worked closely together to ensure thorough and timely handover of patients. Policies and procedures were in place for the safe transfer and escalation of patients to the local acute NHS hospital where necessary.

However:

• Out of date medicines were found in one consulting room and in the day surgery unit. Some medicines were pre-prepared and left unattended in the anaesthetic room, this was not included in the hospital’s risk assessment.
• The flooring in consulting rooms was non-compliant with guidelines for infection control and had not been risk assessed.
• The humidity levels of theatres were not maintained at an appropriate level which resulted in an increased risk of fire if flammable materials were used during surgery.

Are services effective?

By effective, we mean people’s care, treatment and support achieves good outcomes, promotes a good quality of life, and is based on the best-available evidence.

We rated services overall as good for effective:

• Services at this hospital were effective. Evidence based guidance was used to plan and provide care and treatment to help improve patient outcomes. The hospital participated in national Patient Reported Outcome Measures (PROMS) for knee and hip arthroplasty and groin hernias The PROM’s between April 2014 and March 2015 were within the expected range of the England average.
• There were ten unplanned readmissions to surgery within 29 days of discharge between April 2015 and March 2016. This was good compared to other independent healthcare providers who have provided data to the CQC. There were no cases of unplanned returns to the operating theatre in the same reporting period.
• There were nine unplanned transfers of inpatients to other hospitals between April 2015 and March 2016, this is higher than average compared to other independent healthcare providers who have provided data to the CQC.
• All consultants were employed on substantive or bank contracts. Revalidation and appraisal of consultants was completed by the Care UK group and the hospital was 100% compliant.
• All policies originated as corporate documents through the Care UK group and were then modified and agreed by the senior management team to meet local needs.
• Staff acted within the legal framework to obtain consent for patient treatment. Staff were rarely required to implement the mental capacity act and reported any concerns to senior staff when issues arose.

Are services caring?

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

We rated the service at this hospital as outstanding for caring:

• There was an embedded patient centred culture evident in all departments throughout the hospital, and all staff demonstrated genuine compassion for patients and their families.
• Relationships between staff, patients and those close to them were caring and supportive. Teams encouraged patients to be active partners in care and patients felt informed and involved in decisions about their care.
• Leaders empowered staff to promote caring and collaborative relationships with patients.
• Staff took the time to recognise and respect people’s cultural, social and religious needs, any preferences were reflected in how their care was delivered.
• Staff provided emotional support to patients, identifying anxieties and responding to ensure the patient was at ease.
• Feedback from patients was overwhelmingly positive about staff and the service they received which they described as exceeding their expectations. Response rates for the friends and families test were above average at 74% and scores during October 2015 to March 2016 indicated an average of 99% of patients would recommend the hospital.
• Twenty five patients reported feedback to their local Healthwatch regarding the care at the hospital. Twenty three of these responses were highly complimentary.

Are services responsive?

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

We rated responsiveness overall as good:

• Patients experienced a seamless flow throughout their patient journey with many patients not identifying a difference between their preassessment, surgery, and postoperative care.
• The service at the hospital was responsive. The service worked in partnership with the local acute NHS trust to reduce waiting lists and ensure that patients were treated in a timely fashion. Most patients were seen within six weeks of their referral.
• Complaints were handled promptly and sensitively and learning was shared across the organisation. Feedback received from patients was used to improve the quality of service delivery.
• The service aimed to meet the individual needs of patients by offering a choice of appointment times and dates and offering longer appointments where necessary for patients with additional needs such as learning disability, dementia or sensory loss. Carers were encouraged to be actively involved in care.
• The multidisciplinary team made exceptional effort to accommodate the cultural needs of patients, such as single sex room, all female staff teams for the duration of patients admission, specific dietary requirements.
• The hospital used exclusion criteria to ensure that patients accepted for treatment could be safely managed within their existing facilities.
• Consultants were available on call 24 hours daily to respond to emergencies.

Are services well-led?

By well-led, we mean the leadership, management and governance of the organisation, assure the delivery of high-quality person-centred care, supports learning and innovation, and promotes and open and fair culture.

We rated well-led overall as outstanding:

• There was a clear vision and strategy for the hospital which included challenging but achievable objectives. There was a strong collaborative relationship with the local acute trust which resulted in improved care outcomes for patients. All staff were engaged with the values and vision of the hospital.
• The focus on patient centred care was evident at all levels of the organisation and throughout the patients journey.
• Governance systems were robust. Senior staff understood the key risk management issues. Live risk registers were maintained and reviewed regularly. Performance against key performance indicators was discussed at the monthly governance meetings.  Current and future risks were actively managed using a thorough process.
• All staff throughout the hospital were actively encouraged to attend monthly ‘governance days' when no clinical work other than inpatient care was undertaken. This had embedded a strong understanding of the relevance of governance within hospital teams.
• There was a comprehensive system of audit in place to measure quality. These audits formed an integral part of a continuous learning process. Clear action plans were put in place if non-compliance was identified and learning was shared.
• There was no medical advisory committee. However, the purpose of a medical advisory committee was met by several forums at corporate and local level. The hospital did not grant practising privileges.
• Compliance with the ‘fit and proper persons’ requirements of Regulation 5 of the Health and Social Care Act were undertaken at corporate level by Care UK. This included an enhanced level of DBS check for the registered manager.
• There was a strong leadership team that were well known and respected by all staff. Staff at every level of the organisation including the night shift told us information was always cascaded to keep them well informed.
• Staff were empowered to raise concerns and make changes to improve services. All staff were proud to work for the organisation and described it as a ‘family’.

Our key findings were as follows:

• Safety was of a high standard. Staff were encouraged to report incidents and these were thoroughly investigated and learning shared across the organisation.
• Staff understood their responsibilities to identify and report safeguarding concerns and were trained to do this.
• The hospital was clean and staff adhered to good infection control practice.
• Comprehensive risk assessments were completed and audited to ensure harm free care for patients.
• Equipment was well maintained.
• Records were accurate and complete.
• There was adequate staffing and staff were well trained.
• The multidisciplinary team worked very well together for the benefit of patients.
• Patient’s needs for nutrition and hydration were met.
• Patient outcomes were within expected ranges and were monitored closely. The hospital submitted data for the National Joint Registry (NJR) and Patient Reported Outcome Measures (PROMs). Between April 2015 and March 2016 there were no inpatient deaths.
• Evidence based guidelines were used to provide care.
• All treatment was consultant led with consultant on-call cover 24 hours daily. Diagnostic imaging and physiotherapy was available to inpatients seven days per week.
• Patients were consistently positive in their feedback about their experiences of care.
• Patients described themselves as ‘partners in care’ and staff ensured patients understood their treatment at every stage.
• There was an embedded patient centred culture, and all staff demonstrated genuine compassion for patients and their families in all interactions we observed.
• Staff provided emotional support to patients, it was embedded in staff practice to value and identify emotional and social needs of patients.
• Teams made exceptional effort to meet the cultural needs of patients
• The hospital was meeting its referral targets.
• Patients were offered a choice of appointments to suit them; treatment was only cancelled or delayed when necessary.
• The service was responsive to the needs of patients with learning disabilities.
• A choice of food options was available to patients that accommodated cultural requirements.
• Feedback from people who used the service was actively sought and used to make improvements.
• Clear governance arrangements were in place and risks were identified and managed.
• The quality of the service was monitored through an extensive audit programme.
• Feedback from staff was overwhelmingly positive about the leadership from department and senior managers. Staff at all levels said information was always cascaded to keep them well informed.
• The senior management team were highly visible and supportive.
• Staff were extremely proud of the hospital as a place to work. Staff spoke highly of the open culture where they were encouraged and empowered to make improvements and develop their potential.

We saw several areas of outstanding practice including:

• Cleanliness of the outpatient, diagnostic imaging and physiotherapy departments was of a high standard, with facilities scoring 100% compliance against cleaning standards.
• The multidisciplinary team working was excellent across all departments and all staff roles. The strong collaboration and support provided was evident during our inspection.
• Patients consistently described feeling highly satisfied with the care they received and we observed this caring in practice. The multidisciplinary team ensured that the totality of patients’ needs was addressed.
• Teams made exceptional effort to accommodate the cultural needs of patients such as single sex accommodation, dietary requirements, all-female staff teams for the duration of patient stays.
• The senior management team were visible, approachable and supportive to staff. They encouraged and motivated staff, and embraced innovation.
• Comprehensive risk assessments were used to assess and respond to patient risks, these were recorded clearly on the electronic patient record.
• The extensive audit programme allowed early identification of areas for improvement, action plans were put in place as a result of any non-compliance.
• Staff were fulfilled by the culture in their working environment. They were extremely proud of the organisation and regardless of their role or level of patient contact had the patient care at the centre of everything they did.
• There were clear governance arrangements which allowed the hospital to work in line with best practice and deliver high quality care

However, there were also areas of where the provider needs to make improvements. The provider should:

• Ensure an effective system is in place to verify that all medicines are in date and checked regularly.
• Ensure that the health care risk assessment for pre prepared medication within the anaesthetic room also includes the risk for leaving drawn up medicines unattended in the anaesthetic room, in line with the Royal College of Anaesthetics guidance.
• Ensure that non-compliant flooring in the consulting rooms have been risk assessed.
• Ensure the humidity of the theatres is maintained at an appropriate level.

• Consider displaying the harm-free care NHS safety thermometer results on the ward in line with best practice.
• Consider the accuracy of the process in theatre for recording the completion of the World Health Organisation safe surgery checklist, specifically the potential for errors when inputting the information retrospectively following the check.
• Consider increasing the size of the signs to the ophthalmic clinic.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Updated 20 October 2016

Outpatient and diagnostic services at Peninsula NHS Treatment Centre were rated as outstanding overall. We found:

• There was a strong culture of incident reporting, with no serious incidents reported in the last year,
• The department was clean with good infection prevention controls in place.
• There was a good understanding of safeguarding by staff that were appropriately trained and could describe how to escalate any concerns.
• The use of best practice was evident throughout the outpatients and diagnostic imaging department. The hospital used national surveys to capture patient outcomes.
• Multidisciplinary team working was evident throughout the department and diagnostic imaging and physiotherapy was available to inpatients seven days per week.
• Staff demonstrated an understanding of consent and decision making requirements of legislation and guidance.
• Care was delivered with kindness and patience. The atmosphere was calm and professional without losing warmth and reassurance. There was an embedded patient centred culture, and staff demonstrated genuine compassion for patients and their families.
• The outpatients team identified the cultural needs of patients and their carers
• Consistent positive feedback was provided by patients, which demonstrated high levels of satisfaction of the outstanding care which was being provided. Staff provided emotional support to patients, identifying anxieties and responding to ensure the patient was at ease.
• The hospital was meeting its referral targets and most patients were seen within six weeks of their referral.
• Patients could access care and treatment with a choice of appointments offered to suit them, and care and treatment was only cancelled or delayed when necessary.
• Arrangements to support patients with learning difficulties were in place, such as extra time for appointments and visits to the ward prior to admission.
• There had been no formal complaints regarding outpatients or diagnostic imaging in April 2016 to March 2016.

• The leadership, management and governance of the hospital assured the delivery of high-quality person-centred care. There were clear governance arrangements in place which reflected best practice and were managed proactively.
• All staff were encouraged to attend the monthly quality governance meetings and were actively engaged in the hospital’s governance processes.
• Staff at all levels said information was always cascaded to keep them well informed.
• Feedback from staff was overwhelmingly positive about department and senior managers. The senior management team were visible, approachable and supportive.

• There was an excellent working culture within the department, which was patient focused and interactions with patients were positive. Staff were encouraged to identify ways to improve the service for patients and were empowered to make changes themselves.

However:

• Out of date medicines were found in one consulting room.
• Non-compliant flooring in the consulting rooms had not been risk assessed.

• Signage was not adapted to aid the vision of patients with impaired vision.

Updated 20 October 2016

Surgery services at Peninsula NHS Treatment Centre were rated to be outstanding overall. We found:

• There were clear processes in place to ensure the safety of patients. Incidents were reported and investigated and as a result action was taken and learning shared.
• All areas of the hospital were visibly clean to a high standard; staff demonstrated good infection control practice to reduce the risk of infection.
• Comprehensive risk assessments were completed for patients and their application was audited to ensure harm free care and the ability to assess and respond in a timely way to patient risk.
• Equipment was well maintained. Staff received training when new equipment arrived to ensure they were competent in its use.
• The electronic patient record allowed for clear, complete and accurate records to be maintained for the patient throughout their pathway.
• Staff had appropriate training and when spoken with had good knowledge.
• There was a resuscitation team and equipment was readily available to respond to an emergency situation. Processes were in place to transfer patients to the local acute trust.
• Nursing and surgical staffing was reviewed regularly in line with best practice guidance and safe staffing levels were observed.
• Evidence based guidance was used to plan and provide care and treatment to help improve patient outcomes. Patient outcomes were regularly monitored.
• Pain relief, nutritional and hydration needs were all assessed and effectively managed.
• Staff were competent and the multidisciplinary team working was excellent throughout the departments and professions.
• Staff obtained both written and verbal patient consent throughout the patient pathway.
• Consistent positive feedback was provided by patients who demonstrated high levels of satisfaction of the outstanding care which was being provided.
• Care was person-centred and staff were both compassionate and professional. Patients were kept involved with their care and staff ensured their full understanding.
• Exceptional effort was made by multidisciplinary teams to accommodate the specific cultural needs of patients during their inpatient stay.
• Emotional support was provided to patients. Staff were observed identifying anxious patients and putting them at ease.
• The service was responsive to and accommodated patients’ needs, and where possible enabled patients to access care at a time that suited them.
• The leadership, management and governance of the hospital assured the delivery of high-quality person-centred care.
• There were clear governance arrangements in place which reflected best practice and were managed proactively.
• All staff were encouraged to attend the monthly quality governance meetings and were actively engaged in the hospital’s governance processes.
• Risks were identified and managed. The quality of the service was monitored through an extensive audit programme.
• The senior management team were visible, approachable and supportive, encouraging an open and fair culture.
• There were high levels of staff satisfaction across all equality groups. Staff were extremely proud of the hospital as a place to work and spoke highly of the culture.
• Feedback from people who use the service was actively sought and used to make improvements.

However:

• Out of date medicines were found in the ophthalmology trolley in the day surgery unit.
• Medicines were pre-prepared and left unattended in the anaesthetic room, this was not included in the hospital’s risk assessment.
• The humidity levels of theatres were not maintained at an appropriate level.