13 September 2023
During a routine inspection
Nuffield Health Leicester Hospital provides a range of private treatments and services. They had specialists in orthopaedic, general surgery, ear nose and throat, cosmetic surgery, paediatric surgery, women’s health, physiotherapy and sport injuries. The hospital saw both private, insured and NHS patients. We inspected the surgery core service for adults only.
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 understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff managed medicines well. The service managed safety incidents well and mostly 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 7 days a week.
- Leaders ran services well using reliable information systems and supported staff to develop their skills. 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.
However:
- Not all staff were correctly assessing patients using the National Early Warning Score 2 (NEWS2) scoring system.
- Not all staff were trained on safeguarding adults and children, however, they were close to the target set by the provider.
- Whilst there was a robust audit programme, not all audits were completed, and action plans were not always in place or actioned.
- Leaders did not always feedback information to their teams during meetings. Staff were not always aware of incidents, learning, risks and audits. This meant leaders could not ensure improvements were made.
- The risk register was brief and did not contain all the risks within the service.
Areas for improvement
Action the service SHOULD take to improve:
- The service should ensure that all staff are trained on NEWS2. (Regulation 12: Safe Care and Treatment).
- The service should ensure that all staff are aware of the Control of Substances Hazardous to Health Regulations (COSHH) and all items are stored appropriately. (Regulation 15: Premises and equipment).
- The service should ensure that all audits are completed in line with the hospital audit programme, and they have an associated action plan to increase compliance. (Regulation 17: Good Governance).
- The service should ensure they have embedded methods of feedback for staff to ensure that all staff are aware of learning, incidents, audits, and areas where improvements are needed. (Regulation 17: Good Governance).
- The service should ensure that all theatre staff complete the debrief following surgery as per policy. (Regulation 12: Safe care and treatment).
- The service should consider putting further detail into their meeting minutes to ensure that staff who could not attend were aware of the content of the meeting. (Regulation 17: Good Governance).
- The service should ensure that staff are aware of the risks contained on the risk register and the measures in place to reduce the risks. (Regulation 17: Good Governance).