Archived: The Foscote Private Hospital

Updated 17 May 2016

The Foscote Private Hospital is a charitable trust providing services to patients in Banbury, Oxfordshire and the surrounding areas of Northamptonshire, Warwickshire, Gloucestershire and Buckinghamshire. The hospital provides surgical and medical treatments for patients. The on-site facilities include consultation rooms, an imaging department offering X-ray and ultrasound, an endoscopy suite and an operating theatre with laminar air-flow. There are 12 patient bedrooms with en-suite facilities.

The Foscote Hospital opened in Banbury, Oxfordshire, in 1981. The hospital came out of a 10 year management contract with a large healthcare company in 2014 and returned to being independently managed. We undertook a comprehensive inspection of The Foscote Private Hospital in July 2015. At that inspection, we rated the hospital overall as inadequate. Surgery was rated as inadequate and outpatients and diagnostic imaging as requires improvement. We rated safety, effective and well-led as inadequate for the surgical service. This was because the staffing levels, skill mix, staff training and working practices in the operating department were not safe. Also, medicines were not always safely managed.

There was an inconsistent approach to the use of national guidance to ensure patients received effective care and treatment. In the operating department, staff were undertaking roles, which they were either not qualified for or not assessed as competent to perform

Governance practices to monitor risk and quality were not embedded across the whole hospital, including in the endoscopy department and theatres. The quality of the service was not monitored effectively through audit and some working practices were out of line with hospital policies and national guidance. Senior management did not adequately identify, assess or manage risks.

After this inspection in July 2015, we served three warning notices against the hospital under “staffing’’ and “safe care and treatment’’ for the regulated activity surgical procedures. The third notice was served under “governance’’ for the regulated activities surgical procedures and treatment of disease, disorder or injury. The warning notices required the hospital to take 

immediate action to improve the safety of patient care and address the staffing levels and training needs of staff in the operating department. Changes were required to governance processes to identify, assess and manage issues around quality and risk at the hospital.

We undertook an unannounced comprehensive focused inspection of the surgery service at The Foscote Private Hospital in August 2015 to follow-up on the warning notices served. At this inspection, we found improvements in some areas, however there remained concerns around the governance processes. A further warning notice was issued under “governance’’ for the regulated activities surgical procedures and treatment of disease, disorder or injury. After the inspection, there was not sufficient evidence to change the rating applied at the comprehensive inspection, therefore the overall rating for the hospital remained inadequate.

Governance procedures and processes were not effective in the operating department or across the hospital as whole. We found staff in the operating theatre had made improvements, with the support of senior management, but we still had concerns about patient safety. Theatre staffing did not always meet national guidance. Instrument counts were completed, but the Five Steps to Safer Surgery was not yet part of normal practice. Medicines management had improved and staff had received training to safely use equipment.

Policies referenced relevant national guidance, but staff did not fully appreciate the benefit of this guidance in respect of the treatment outcomes for the patient. However, staff acting as surgical first assistant (SFA) were following a national training programme. Competency assessments were in place for the staff in the operating department.

We undertook this unannounced comprehensive inspection of the surgery and outpatients and diagnostic imaging services at The Foscote Private Hospital, in January 2016, to follow-up on the warning notice served.

The registered manager is Karen Ruth Thompson (Ruth) who has been in post since October 2014.

Updated 17 May 2016

The Foscote Hospital opened in Banbury, Oxfordshire, in 1981. In October 2014, the hospital came out of a ten-year management contract with a large healthcare company and returned to being independently managed. The Foscote Private Hospital is a charitable trust providing services to patients in Banbury, Oxfordshire and the surrounding areas of, Northamptonshire, Warwickshire, Gloucestershire and Buckinghamshire.

The hospital provides surgical and medical treatments for patients using private medical insurance. Some procedures are offered under the NHS Any Qualified Provider Contract as well as a self-pay option for those patients who prefer to fund themselves.

The on-site facilities include an endoscopy suite, an operating theatre with laminar air-flow and consulting rooms supported by an imaging department offering X-ray and ultrasound. Physiotherapy treatment is offered as an inpatient and outpatient service in its own dedicated and fully-equipped physiotherapy suite. There are 12 patient bedrooms, all with a nurse-call system, en-suite bathrooms, free Wi-Fi access, a television and a telephone.

Services offered include cardiology, cosmetic surgery, dermatology, general medicine, general surgery, gynaecology, ophthalmology, oral & maxillofacial surgery, orthopaedics, rheumatology, respiratory medicine, urology, radiology and physiotherapy. There are no emergency facilities at this hospital.

We undertook a comprehensive inspection of The Foscote Private Hospital in July 2015. At that inspection, we rated the hospital overall as inadequate. Surgery was rated as inadequate and outpatients and diagnostic imaging as requires improvement. We rated safety, effective and well-led as inadequate for the surgical service. This was because the staffing levels, the skills and training levels, working practices in the operating department and medicines were not always safely managed. There was not a consistent approach to the use of national guidance to ensure patients received effective care and treatment. In the operating department, staff were undertaking roles which they were either not qualified for or not assessed as competent to perform.

Governance practices to monitor risk and quality were not embedded across the whole hospital, including in the endoscopy department and theatres. The quality of the service was not being monitored effectively through audit and some working practices were out of line with hospital policies and national guidance. Risks were not adequately identified, assessed or managed.

We undertook an unannounced focused inspection of the surgery service at The Foscote Private Hospital in August 2015. At that inspection, we concentrated on specific areas of noncompliance identified during the comprehensive inspection around surgery. Some improvements had been made, but there had been insufficient changes in the six week period since the comprehensive inspection for these changes to be fully embedded. There was not sufficient evidence to change the ratings applied at the comprehensive inspection and the overall rating of inadequate remained.

We undertook a further unannounced comprehensive inspection of the surgery and outpatients and diagnostic imaging services on 19 January 2016. The inspection team of five included an inspection manager, two CQC inspectors and two specialist advisers, an operating department manager and an infection control lead nurse with outpatients experience.

Our overall rating for this hospital was “good”.

Are services safe at this hospital?

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

We rated safety as “good” in both surgery and outpatients and diagnostic imaging.

• There were sufficient staff in all areas. Staff followed relevant infection control practices and all clinical areas were clean and tidy. All theatre staff participated in the Five Steps to Safer Surgery. Staff had access to the equipment they needed and medical equipment was in date for servicing.
• Staff reported incidents in line with hospital policy and the learning was shared to improve services. Staff understood the principles of openness and transparency that are encompassed within duty of candour.
• Risk assessments for patients were completed and there were processes in place to support patients who became unwell. Staff were able to describe the different types of abuse and understood the importance of raising a safeguarding concern.

Are services effective at this hospital?

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.

We rated effectiveness “good” in surgery. We inspected but did not rate effectiveness in outpatients and diagnostic imaging.

• Staff received an annual appraisal and were able to access relevant training to update their clinical skills specific to their roles, such as the surgical first assistant programme. Medical staff were only granted practising privileges to work at the hospital if all pre-employment checks demonstrated they were competent. There was good multidisciplinary working across all teams in the hospital so patients received co-ordinated care and treatment. Patients’ care and treatment was planned and delivered using evidence based guidance, standards and best practice. Staff worked effectively within their teams and across the hospital as a whole to support patient care.

Are services caring at this hospital?

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

We rated caring as “good” in both surgery and outpatients and diagnostic imaging.

• Staff were caring, compassionate, and treated patients with dignity and respect. Patient feedback was universally positive, with patients reporting that staff took the time to talk with them and treated them holistically.

Are services responsive at this hospital?

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

We rated responsive as “good” in both surgery and outpatients and diagnostic imaging.

• There was prompt access to outpatient appointments after referral, both in the daytime and the evening. Patients told us the processes relating to their surgery including booking, admission and discharge had been efficient, and they felt fully informed at each step in the process. Waiting times for surgery from referral were in general four weeks or less. The hospital had strict selection criteria for patients to be accepted for admission, this meant the patient type was carefully managed to ensure that the hospital could meet their needs. he hospital had systems in place to support patients with additional needs, including those living with dementia or with a mobility need. There was an established complaints system. Complaints were investigated and learning shared, with changes implemented as required.

Are services well-led at this hospital?

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.

We rated well-led “good” in surgery and in outpatients and diagnostic imaging.

• Staff were informed about the vision and values for the hospital and were aware of possible development plans for the hospital. Governance processes were overall well developed to manage risks and quality. Although patient outcome data was collected and submitted to a number of national databases, it was not used locally to keep staff informed about how effective care and treatment had been.
• Staff spoke positively about the leadership at a local level and the visibility and support of the senior team. There was an open culture and staff felt they could make suggestions to improve services for patients. Staff acknowledged the last few months had been challenging with all the changes but the culture had changed positively and the hospital was a different place to work at.

Our key findings were as follows:

• Staffing levels on the ward were maintained at a safe level and those in the operating department were in line with national guidance.
• The principles of the Five Steps to Safer Surgery, designed to reduce harm by consistent use of best practice, were being adhered to.
• A full review of hospital polices was being conducted, including a review against national guidance. Systems were in place to monitor practice such as adherence to the Five Steps to Safer Surgery and instrument counts.
• Staff were being supported to develop in their role. For example, staff in the operating department were under taking training to act as a surgical first assistant.
• Most staff were up to date with their mandatory training.
• There was an established system for the servicing and maintenance of equipment. Staff had received training in the use of equipment.
• There was limited storage space in theatres, which meant sterile and non-sterile items were stored together in the same area. Staff had managed the risk by segregation. There was no fume cabinet in theatres to protect staff when using formalin. This risk had been assessed and additional measures were in place to protect staff, while the hospital reviewed the purchasing of a cabinet.
• Medicines were being stored and managed safely.
• Staff followed relevant infection control practices and all clinical areas were clean and tidy.
• Staff were clear about their role and responsibilities under the principles of the duty of candour.
• The hospital had safeguarding procedures, staff had received training and there was a named safeguarding lead.
• Staff were able to define abuse and how to identify adults at risk. They were also clear about the procedures to follow.
• Staff completed Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) training. Staff we spoke with had an understanding of how this applied to patient consent but told us they implement the training infrequently as the majority of patients had capacity.
• The hospital submitted patient outcome data to a number of national audits and had subscribed to a national database to enable it to benchmark against other similar services providing private healthcare.
• Staff in different disciplines worked well together. The hospital worked flexibly, including the opening times, according to the needs of their current patient group.
• Staff were caring and compassionate and treated patients with dignity and respect. Patients told us they felt informed about their treatment plan and had been actively involved in decisions about their care. Patients were encouraged to consider their overall wellbeing as part of their treatment plan.
• Patients had prompt access to appointments after referral, with patients able to choose daytime and evening appointments. However, there was not always timely access to test results at follow-up appointments in the outpatients and diagnostic imaging department. This was due to delays in reporting by the provider for this service.
• Patient’s pain and the effectiveness of pain management was assessed and monitored.
• The hospital was responsive to patient needs. A professional interpreter service was available to enable staff to communicate with patients for whom English was not their first language. Patients were provided with written information about their diagnosis or planned procedure. This information was available in languages other than English on request.
• Staff spoke positively about the leadership at a local level and the visibility and support of the senior team. There was an open culture and staff felt they could make suggestions to improve services for patients.
• There was a system for the recording of events, which included incidents. Incidents were investigated and learning shared.
• A review of the committee structure and governance process had resulted in a streamlined reporting system and refreshed committee structure.
• Risks were captured on a risk register, which included action taken to mitigate the risk and was reflective of the risk identified during the inspection.

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

The provider should:

• Introduce a clinical audit programme to monitor the standard of care, treatment and outcomes and take action in response to areas of poor performance.
• Ensure plans for safe handling of specimens in the operating theatre are implemented and ensure the hospital is compliant with any guidance.
• Ensure all staff are up to date with their mandatory training.
• Review the level of training provided for staff in the endoscopy unit and consider the provision of additional training.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Updated 17 May 2016

• Staff reported incidents in line with hospital policy and the learning was shared to improve services. Staff understood the principles of openness and transparency that are encompassed by the duty of candour. Staff followed infection control processes. We identified infection control risks in endoscopy, due to the positioning of the decontamination unit. The hospital was aware of this risk and had taken actions to minimise any infection risks. The environment was visibly clean and well maintained, with all clinical areas providing hand-washing facilities and hand sanitiser gels for patients and staff. There were sufficient numbers of staff, but nursing staff in endoscopy raised concerns around the skill mix of staff, in the absence of the lead nurse. Equipment was well maintained and patient records were available for appointments.
• Departments followed national guidelines relating to their service. Patient Reported Outcomes (PROMs) were reported in the physiotherapy department. The endoscopy unit had started reporting quality indicators as part of the Global Rating Scale (GRS), to assess how well they provide a patient-centred service. Staff had received an annual appraisal and were able to access relevant training to update their clinical skills, specific to their roles. Staff worked effectively within their teams and across the hospital as a whole to support patient care.
• Staff were caring and compassionate and treated patients with dignity and respect. Patients told us they felt informed about their treatment plan and had been actively involved in decisions about their care. Patients were encouraged to consider their overall wellbeing as part of their treatment plan.
• There was an interpretation service for people for whom English was not their first language and the hospital was accessible to those with a disability. There was prompt access to appointments after referral, both in the daytime and the evening. Friends and Family Test scores were positive.
• Staff were informed about the vision or values for the hospital and were aware of possible development plans for the hospital. Governance processes in the outpatients department, endoscopy and diagnostic imaging were overall well developed to manage risks and quality. Staff spoke positively about the leadership at a local level and the visibility and support of the senior team. There was an open culture and staff felt they could make suggestions to improve services for patients.

Updated 17 May 2016

• Theatre staff had made significant changes to improve practices in theatre to ensure they were safe and followed current guidance. This included completing and auditing compliance with the Five Steps to Safer Surgery and ensuring theatre staffing was appropriate for the type of surgery being performed. Areas of concern such as engagement from all staff during the Five Steps to Safer Surgery had been addressed. Staff followed relevant infection control practices and all clinical areas were clean and tidy. Staff had access to the equipment they needed and medical equipment was in date for servicing.
• Staff were up to date with their mandatory training and appraisal. Staff could access training to maintain their core skills or complete additional training to develop their role, such as the surgical first assistant programme. Medical staff were only granted practising privileges to work at the hospital if all pre-employment checks demonstrated they were competent.
• There was good multidisciplinary working across all teams in the hospital so patients received co-ordinated care and treatment. Patients’ care and treatment was planned and delivered using evidence based guidance, standards and best practice. Nursing staff completed risk assessments for patients on admission and reviewed these as necessary during their stay. In the event that a patient became unwell, there were systems in place for staff to escalate these concerns to medical staff and refer the patient to another hospital if necessary. Care was provided to inpatients seven days a week, with access to diagnostic imaging and theatres via an on-call system.
• Patient feedback was positive. Patients described the excellent quality care they received and how they were treated with dignity and respect. Patients told us they and those close to them, had been involved in making decisions about their care. Discussions with staff were clear and in sufficient depth so they could make an informed decision to have surgery. Staff took the time to speak with them and treated them holistically, rather than focusing on just their medical needs.
• Patients told us the booking, admission and discharge process had all been efficient, and they felt fully informed at each step in the process. Waiting times for surgery from referral were in general four weeks or less.
• The hospital had systems in place to support patients with additional needs, including those living with dementia or with a mobility need. There was access to translation services for patients who were non-English speaking.
• Staff were informed about the vision or values for the hospital and were aware of possible development plans for the hospital. Governance processes in the surgery service were overall well developed to manage risks and quality. Staff spoke positively about the leadership at a local level and the visibility and support of the senior team. There was an open culture and staff felt they could make suggestions to improve the service for patients. Staff acknowledged the last few months had been challenging with all the changes but the culture had changed positively and the hospital was a different place to work at.
• There was limited storage space in theatres, which meant sterile and non-sterile items were stored together. The hospital had plans to purchase new racking to address this risk. There was also no fume cabinet in theatres to protect staff when using formalin; the hospital had included this on their risk register and business plan.
• The hospital collected patient outcome data and submitted this to a number of national databases but this data was not used locally to keep staff informed about how effective care and treatment had been, using clinical audit. Staff involved in the surgery service did not meet as a whole team to discuss outcome data.