Archived: The Nottingham NHS Treatment Centre

Updated 8 December 2016

The Nottingham NHS treatment centre is operated by Circle Nottingham Ltd which belongs to a group of companies owned by Circle.

Independent NHS treatment centres provide services to NHS patients but are owned and operated by organisations outside of the NHS. They have a contract with the NHS to treat NHS patients. The Nottingham centre opened in 2008 and is the largest independent treatment centre in Europe. Circle Nottingham Ltd was awarded the contract to provide services from the centre in July 2013 for five years.

The hospital has a general manager who is also the registered manager with the Care Quality Commission. They registered in December 2014.

We undertook an inspection in January 2015 looking at all the services the centre provided. At that time we rated the Nottingham NHS Treatment Centre as good overall but the termination of pregnancy service required improvement.

The inspection on 27 May 2016 was focussed; the inspection team looked at specific issues in the effective, responsive and well-led domains within the core service of termination of pregnancy only. This was to determine whether the service had improved since January 2015. We did not inspect surgical or diagnostic and outpatient services on this occasion.

Updated 8 December 2016

The Nottingham NHS treatment centre is run by Circle Nottingham Ltd which belongs to a group of companies owned by Circle. Independent NHS treatment centres provide services to NHS patients but are owned and run by organisations outside of the NHS. They have a contract with the NHS to treat NHS patients. The Nottingham centre opened in 2008 and is the largest independent treatment centre in Europe. Circle Nottingham Ltd was awarded the contract to provide services from the centre in July 2013 for five years. Although it predominantly provides services for NHS patients, the centre does provide services to patients who wish to pay privately for their treatment. The treatment centre is currently registered to provide services to children, however the centre was in the process of altering its registration and did not provide services to children at the time of our inspection.

The centre offers a variety of services including outpatients, surgery, termination of pregnancy and diagnostic tests. There were 60 outpatient consultation rooms, five operating theatres, three skin surgery theatres, four endoscopy rooms and dedicated diagnostic facilities such as scans and x-rays. In addition, the centre has an 11 bedded short stay ward for patients who have undergone surgery and need an inpatient stay.

The Nottingham NHS Treatment Centre was selected for a comprehensive inspection as part of the second wave of independent healthcare inspection. The inspection was conducted using the Care Quality Commissions new methodology. The inspection team inspected the following core services:

• Surgery
• Outpatients and diagnostic imaging
• Termination of pregnancy

We rated the Nottingham NHS Treatment Centre as “Good” overall but the termination of pregnancy service required improvement. The safety, caring and leadership in the surgical service were rated as "Outstanding."

Our key findings were as follows:

Care and Compassion

• Without exception staff were caring and compassionate. Patients reported very high levels of satisfaction with the care they received.
• We saw people being treated as individuals and staff spoke about patients in a kind and sensitive manner.

Cleanliness and inspection control

• The treatment centre had reported no incidence of MRSA, clostridium difficile (C.difficile) or Meticillin- sensitive Staphylococcus Aureus (MSSA) in the reporting period April 2013 to September 2014. MRSA, MSSA and C.difficile are infections that can cause harm to patients. MRSA is a type of bacterial infection that is resistant to many antibiotics. MSSA is a type of bacteria in the same family as MRSA but it can be more easily treated. C.difficile is a bacterium that can affect the digestive system; it often affects people who have been given antibiotics.
• In all areas we observed staff to be complying with best practice with regard to infection prevention and control policies. Staff were observed to wash or apply gel to their hands between patients. There was access to hand washing facilities and a supply of personal protective equipment, which included gloves and aprons. The majority of staff were observed adhering to the dress code, which was to be bare below the elbow.
• Staff in operating theatres and endoscopy were observed to be following the correct technical procedures prior to undertaking sterile procedures in surgery.
• Most of the areas we visited were clean and well maintained. There were procedures for the management, storage and disposal of clinical waste, environmental cleanliness and the prevention of healthcare acquired infection guidance. However, in endoscopy we found storage within the decontamination areas made it difficult to ensure all areas were sufficiently clean. During our inspection we noticed the floor area under the sinks was stained and white powder was visible. We discussed this with the nurse in charge who told us the metal racking stored within this area had probably not been moved to allow for effective cleaning of this area. We saw this had already been identified in the environmental hygiene audit in November 2014. We also saw the plans that were in place to improve the endoscopy area so this issue could be rectified. The work was due for completion by August 2015.
• Patients were given wound management advice following surgery. Verbal instructions were supported through the use of an information leaflet given to the patient when they were discharged. The information included details of what the patient should do if there were any wound complications after their discharge from the treatment centre.
• The cleaning of endoscopes met national decontamination standards for flexible endoscopes and we saw only appropriately trained staff were responsible for the decontamination of equipment.

Complaints

• There were quality monitoring structures in place to monitor any complaints. We found information throughout the centre that told patients how they could raise a concern, complaints or compliment. Staff had a good understanding of the complaints process and received regular feedback following complaints. The treatment centre analysed feedback and monitored themes. We saw evidence of changes to practice being undertaken in response to complaints and patient feedback. The treatment centre actively promoted the “Four Cs” process (complaints, concerns, comments and compliments). We saw these were reported quarterly as part of the treatment centre’s ‘quality quartet’ scorecard.
• We found areas in the complaints process that could be improved further because they were not consistently following their internal complaints policy. We found the treatment centre was not providing advice on how to obtain advocacy. The complaints leaflet that was being sent with the complaint acknowledgement letter was out of date and referred to an independent complaints advocacy service that was not longer in existence. We looked at a final response letter that contained no information about the Parliamentary and Health Service Ombudsman We also found not all complaints were being acknowledged within the required two day standard. We looked at one complaint where the final response deadline was not met and a letter sent to apologise for this and to extend the deadline was not sent until two weeks after the deadline had initially passed.

Staffing Levels

• Throughout our inspection both patients and staff told us they thought the treatment centre had sufficient staff. There were some concerns about the numbers of consultant dermatologists but this was being managed with the use of long term locums.
• Nurse staffing levels were in accordance with national guidance issued by the National Institute of Health and Clinical Excellence (NICE). There were escalations arrangements in place so that additional staff could be brought into an area should there be either a gap in the planned staffing or the level of dependency of the patients had increased.
• Where locum medical staff or bank or agency nursing staff were used a named individual would be requested from an agency approved by the treatment centre. This meant temporary staff were already familiar with the area in which they were working. The treatment centre had a robust system in place to ensure agency staff were appropriately inducted to the service. This included a dedicated induction programme and competency framework documentation for each gateway of the treatment centre.
• There was a Resident Medical Officer (RMO) based on the short stay unit who reported any changes in the patient’s condition to the consultants, and together with the nursing team provided 24 hour medical support to patients.

Mortality rates and outcomes for patients

• The treatment centre had reported no incidence of either day case or overnight inpatient mortality in the reporting period April 2013 to September 2014.
• There had been no unexpected patient deaths from April 2013 to December 2014. One had been reported to the CQC in January 2015. We were told a full investigation had been undertaken by the senior management team at the treatment centre and they were currently awaiting the outcome of a post mortem.
• Transfers of care to a nearby trust had reduced since the opening of the short stay unit in April 2014. Information received prior to our inspection showed there had been two unplanned transfers of inpatients to other hospitals between April 2013 to December 2014. A senior manager told us this had been due to having no facilities for the provision of emergency care at the treatment centre. The transfer of these two patients was appropriate.
• There had been no unplanned readmissions within 29 days of discharge in the reporting period April 2013 to September 2014.
• Patient reported outcome measures (PROMS) for the period April 2013 to March 2014 indicated patient outcomes for groin hernia were worse than the England average. However for the reporting period April to June 2014 patient outcomes for groin hernia had improved and were in line with the England average. Outcomes for varicose veins surgery were similar to the England average.
• The treatment centre had started performing joint replacement procedures on knees in the six weeks preceding our inspection. Hip replacement surgery was due to commence at the end of February 2014. It was too early for any patient reported outcome data to be assessed at the time of the inspection.

Leadership

• There was good leadership throughout the treatment centre. Morale amongst individuals and in teams was extremely high. Staff felt very engaged and numerous staff told us how they felt listened too. There was a culture in the hospital where everyone was valued regardless of their position or grade.
• The treatment centre had a “Credo.” This was displayed in the treatment centre and staff knew about it. The credo set out three main principles that underpinned their work. It puts patients at the centre of their care, empowers staff to do their best and pursues excellence. From our conversations with staff and patients we could see how the credo was put into practice.

We saw several areas of outstanding practice including:

• The treatment centre was piloting the implementation of a care certificate for healthcare assistants (HCA’s) achieved through a HCA training programme which offered specialty training and skills development.
• The centre had an initiative called ‘Stop the Line.’ Any member of staff could stop activity if they felt patient safety may have been compromised. When “Stop the line” was triggered, there was immediate escalation of the issue and a resolution was developed immediately. All the staff we spoke with were enthusiastic about this initiative and were able to give examples of where they had used ‘Stop the line.’ The examples they gave demonstrated staff felt confident to use the process and most importantly that action was taken to respond to concerns. The treatment centre used a process called Swarm. Staff at different levels attended the swarm which was a meeting following a stop the line which was designed to assess the risk and put immediate control measures in place to reduce those risks. We saw evidence of this being used in practice.
• The treatment centre undertook a 28 day post-operative call to patients to monitor clinical outcome data that included surgical site infections. This patient self-reported data was shared with the commissioners of the service. Information received following our inspection indicated a decline in surgical site infections, with 13 reported in November 2014; nine reported in December 2014 and; three reported in January 2015.

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

Importantly, the provider must:

• Ensure medication administration records within the termination of pregnancy service are clearly legible and written in accordance with GMC guidance, “Good practice in prescribing and managing medicines and devices.”
• Ensure the prescribing of Anti-D immunoglobulin medication within the termination of pregnancy service only takes place when it has been established that it is a clinically suitable treatment for the patient.

In addition the provider should:

• Ensure complaints are managed in accordance with the treatment centre policy so that patients have up to date information about how they can access the support of complaints advocacy services.
• Ensure there is timely access to termination of pregnancy procedures, which should meet Department of Health required standard operating procedures (RSOP11 – access to timely abortions).
• Ensure the governance and leadership in the termination of pregnancy service is strengthened to ensure there is effective monitoring and response to the findings of audits.
• Ensure there is a system for checking the accuracy of HAS4 forms used in the termination of pregnancy service to ensure that accurate information is provided to the Department of Health.
• Ensure systems are developed so that sessional staff working in the termination of pregnancy service receive feedback and learning from incidents.
• Ensure a review of the risks associated with the use of the lifting and handling equipment within the imaging department takes place so that patients who have mobility difficulties can be safely assisted onto the imaging beds.
• Consider introducing team development initiatives within the termination of pregnancy service to enable cohesive working practices.
• Consider working with partner providers and commissioners of termination of pregnancy services to ensure the patients care pathway is one which meets required standards.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Updated 12 May 2015

Overall we found that outpatients and diagnostic imaging departments were good.

We found that safety was good, incidents were reported and risks to patients were assessed. Infection control and cleanliness of the environment and equipment was of a good standard. There were no concerns around staffing levels across the outpatient services. Where there were challenges in medical and nursing staffing the treatment centre were able to plan and respond accordingly.

Appropriate systems were in place in diagnostic and imaging to measure quality and provide a safe and effective service but there was little evidence as to how effective the services were because the service was still new and had only been in place for six months at the time of our inspection.

The physical environment of the centre was modern and comfortable for patients. Waiting times for the majority of patients were better than both national and the internally set targets with patients waiting between eight and 11 weeks from referral to treatment. In diagnostics and imaging the wait for diagnostic tests was 18 days; which was better than the national guidelines.

Staff were caring and we saw many positive interactions between staff and patients. Patients were happy about their care and treatment.

Outpatients and diagnostic departments were well led. Staff were positive about working at the treatment centre and their leaders. Staff felt supported and involved in many aspects of the treatment centre and spoke of a positive culture which encouraged innovation and collaboration.

Updated 12 May 2015

The treatment centre had systems and processes in place to keep patients safe. Staff demonstrated a good awareness of the process for identifying and recording patient safety incidents. Where serious patient safety incidents had occurred we found the process of investigation to be robust with actions identified and implemented as a result.

We saw arrangements were in place to minimise risks to patients with measures to prevent falls and pressure ulcers and, the early identification of patient risk during surgery. We saw elements of good infection prevention and control practice and clean clinical areas.

Staffing within surgery was managed effectively at a local level to ensure there was no disruption to care delivery. We saw there was good access to senior clinicians when required. Staff were competent and suitably trained to deliver care in line with the Trust policies and procedures, national guidance and, NICE (National Institute for Health and Care Excellence) quality standards.

Medicines were stored safely and we observed good practice where staff followed a safe medicines administration procedure. Patients’ individual care records, including medication charts, were accurate, complete, legible and up to date. We saw where records and patient identifiable information was stored securely.

Access to care and treatment and surgical outcomes for patients were mostly within, or exceeding, the national average.

A multi-disciplinary team approach was evident across all of surgery the surgical services. We observed good multi-disciplinary working in all the areas we inspected and saw where there was a shared responsibility for care and treatment throughout the teams. All the patients we spoke with were extremely positive about the quality of the care and treatment they were receiving and with the approach of the staff.

There were arrangements in place to monitor and improve quality and the morale of staff was extremely high.

Updated 12 May 2015

Overall, we found termination of pregnancy services required improvement.

The termination of pregnancy service was fragmented and lacked cohesive leadership, team identity and systematic working practices. There were very limited opportunities for staff to meet and whilst there was some governance and monitoring of the service in place no one took responsibility for ensuring findings were used to improve the service.

There was a shared care pathway with other providers. Work was being put in place to meet with other providers and improve communications and systems. Sometimes care and treatment wasn’t delivered effectively, particularly the taking of blood samples to establish if Anti-D treatment was required. As a result patients did not always receive the right treatment.

Although we found the staff were very caring and patients were positive about their experience, not all patients were offered counselling prior to their procedure. We also found not all staff involved in counselling of patients were trained to the level required in the required standard operating procedures.

Procedures did not always take place within the Department of Health required standard operating requirement of 10 working days. This was attributed to appointments being made by other providers. Referral to treatment times showed that 21% of procedures exceeded 10 working days. The reason for the delays was not recorded. Where patients were near to 14 weeks gestation there were systems to fast track procedures to limit the future risk to their health.