The Care Quality Commission
  • Hospital
  • Independent hospital

Rowley Hall Hospital

Overall: Good read more about inspection ratings

Rowley Park, Stafford, Staffordshire, ST17 9AQ (01785) 332898

Provided and run by:
Ramsay Health Care UK Operations Limited

All Inspections

21 February 2023

During a routine inspection

We carried out an unannounced comprehensive inspection of the services on 3 August, we completed a further follow up inspection on 21 February 2023.

We last inspected in October 2016 and inspected surgery and outpatients and diagnostics core services. We rated the hospital as good overall. Two breaches of the Health and Social Act Regulations were identified at this last inspection (for Regulation 12: safe care and treatment and Regulation 18: staffing), both were related to surgery.

Our rating of this location stayed the same. 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. They managed medicines well. The service managed safety incidents well and learned lessons from them.
  • 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 information. Key services were available seven 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 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 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 and the community to plan and manage services and all staff were committed to improving services continually.

12 October 2016

During a routine inspection

Rowley Hall Hospital is located in a Georgian listed building in five acres of Rowley Park, Stafford. The hospital opened in 1987 and currently has 13 ensuite bedrooms and 10-day case pods. The hospital is managed by Ramsay Healthcare UK Operations Ltd and is part of a network of over 36 hospitals, day surgery facilities and two neurological rehabilitation homes across England. In addition, they run hospitals in Australia, Indonesia and France.

We inspected the core services of surgical services and outpatients and diagnostic services as these incorporated the activity undertaken by the provider at this location.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 12 October 2016, along with unannounced visits to the hospital on 20 and 27 October 2016.

We rated both core services, and the hospital as good overall. However, we found that safety in surgical services required improvement because we had concerns that that safety checks in theatres were not consistently completed and infection rates for spinal and breast procedures were higher than the national average.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

The main service provided by this hospital was surgery. Where our findings on surgery, for example management arrangements, also apply to other services, we do not repeat the information but cross-refer to the core service.

We rated this hospital as good overall because:

  • Governance arrangements ensured that surgery was planned and co-ordinated effectively. Incidents were reported and investigated; staff felt incidents were dealt with appropriately and feedback was given. Staff told us they felt valued and listened to.
  • Staff were caring and supported patients to make informed decisions based on sound clinical options. Staff had a genuine interest in the health and wellbeing of their patients. Patients were complimentary about the care they received pre and post-operatively.
  • Patients with complex needs were supported and their carers encouraged to attend the hospital with them.
  • The hospital had systems in place, which ensured that patients were protected from the risk of avoidable harm.
  • Services were effective, practice was audited and learning shared to improve patient outcomes. Recognised pathways of care, and national guidance were understood and followed.
  • Services were responsive to patients’ individual needs. The patient journey from one department to another was easy and waiting times were minimal.

We found areas of practice that require improvement in both surgery and in outpatients and diagnostic imaging services.

  • Surgical safety processes were not embedded in theatres.
  • Staffing in theatres was not in line with surgical first assist perioperative care collaborative guidelines. Staff undertaking the role had not completed the recognised training requirements and undertook dual roles for procedures greater than a minor operation.
  • Not all staff who worked in recovery were trained in Advanced Life Support (ALS) which meant good practice guidelines were not being followed. Not all staff were clear about how to respond in emergency situations and update training had not been received.
  • Staff were not up to date with mandatory training.
  • The audit process in theatre had not been effective; the newly employed theatre manager was in the process of building a robust team of appropriately trained staff
  • Only 34% of nurses working in outpatients had currently received an annual appraisal.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with two requirement notices that affected surgery. Details are at the end of the report.

Ellen Armistead

Deputy Chief Inspector of Hospitals

During a check to make sure that the improvements required had been made

We completed a desk top review of Rowley Hall Hospital non compliance of Regulation 13. This was to ensure that compliance had now been met in the management of medicines.

When we inspected the hospital in November 2013 we were unable to see any system of stock control of stored drugs. We saw that not all drugs stored in this cabinet had been recorded in the register. We saw that some medication had been removed from their original packaging. We saw that some used hypodermic needles had been re-sheathed after use.

The registered manager sent us an action plan following this inspection to demonstrate how they would become compliant. We discussed the action plan with a CQC pharmacy inspector. We felt that sufficient assurances were given and a desk top review was planned.

The management had taken prompt action to address the non compliance.

5 November 2013

During a routine inspection

We inspected Rowley Hall Hospital on 5 November 2013 as part of our scheduled inspection plan. The visit was unannounced; this meant that the provider did not know we were visiting.

We met and spoke with the matron, two department managers, trained staff, ancillary staff and one day patient and two in-patients.

During the inspection we looked at two in-patient care plans. We saw clear evidence of consent being gained and the necessary checks being completed prior to surgery. We talked with them about the care they had received. Both were very satisfied with their care. One patient told us: "I would highly recommend this hospital; they're excellent".

We looked at the medication systems in place and found some areas which required improvement, for example stock control.

We discussed how the hospital recruited staff and we found the two staff files we looked at were in order. We reviewed the service's complaints procedure and discussed a current complaint with the matron.

19 February 2013

During a routine inspection

People who used the service told us that the staff were very respectful and treated them very well. One person told us they had been fully involved with discussing their particular treatment and felt at ease when speaking with staff.

People were positive about the care and treatment they received. We looked at the care planning documentation for two people who used the service to see how their care and treatment was provided and managed. We talked with staff who were aware of and able to discuss people's care and support needs.

Staff we spoke with told us about their understanding of safeguarding vulnerable adults and what they would do if they had any suspicions of abuse.

Staff told us that the staffing levels were sufficient to meet people's needs in a timely manner. People who used the service told us the staff did what they said they would do. People told us they had not experienced any delays when they required help and support from the staff.

The Matron showed us that they regularly audited the service people received to improve and maintain the high standards they expected.

17 November 2011

During a routine inspection

People were involved in discussions about their care and treatment and had been given the opportunity to ask questions and had been informed about how to consent to their treatment. The risks and benefits involved in their procedures had been explained to people prior to admission to the hospital. People had information about the treatment they had or were due to receive.

People spoke positively about the care and treatment they received. The staff respected people's privacy and dignity and asked people what they wanted. People told us that staff were friendly, polite, professional, considerate and respectful.

People liked the choice and quality of food and this was available to them when they needed it. There was a range of foods to meet people's cultural or dietary needs.

Staff were available in the clinics and on the ward in sufficient numbers that people did not have to wait to receive treatment or support. There was a call system, where people chose whether they needed staff in an emergency or for a more routine concern. People said staff acted swiftly to ensure they did not wait and care could be given.