Cambridge Heart Clinic

We carried out an announced inspection visit on 25 August 2016 and an unannounced inspection on 07 September 2016.

Overall the service was rated as good. We rated safe, effective, caring and responsive as good in both core services reviewed. However, we found that well-led required improvement because robust governance arrangements were not in place. We have issued the service with a requirement notice in this respect and told them to make improvements to the systems and processes they have in place. We will follow this up to ensure improvements have been made in due course.

Our key findings were as follows:

Are services safe at this service

• The service had a good track record for safety. There were no clinical incidents, non-clinical incidents or never events reported between April 2015 and March 2016.
• Appropriate infection control procedures were in place and the environment was clean and utilised well.
• Staff recognised how to respond to patient risk and there were arrangements to identify and care for deteriorating patients.
• Staff were aware of their responsibility to safeguard vulnerable adults from abuse. There were clear internal processes to support staff to raise concerns.
• Staffing levels were appropriate and planned in line with capacity. There had been no agency or bank usage in the past year.
• Staff and leaders were aware of their responsibilities in relation to duty of candour. The duty of candour is a regulatory duty that relates to openness and transparency and requires providers of health and social care services to notify patients (or other relevant persons) of certain ‘notifiable safety incidents’ and provide reasonable support to that person.
• Patient records were well maintained, legible and up to date. We saw that there were stored securely and noted regular auditing took place.
• Appropriate medicine management procedures were in place. We found that medicines were stored and administered in line with legislation.
• We were informed that staff were up to date with their mandatory training, however we could not be provided with data which confirmed this.

Are services effective at this service

• The Cambridge Heart Clinichad a service level agreement (SLA) with Cambridge University Hospitals NHS Foundation Trust (‘the trust’)) which detailed arrangements for CHC sharing policies and procedures developed by the trust. We saw that CHC monitored these policies to ensure that these were in date and updated to reflect best practice.
• The CHC did not participate in national audits. This was due to the unique set up of the service and low patient volume which meant national benchmarking could not be achieved. However, the service did undertake some local audit and measure patients’ outcomes through patient feedback. There had been no negative outcomes recorded with all patients reporting an improvement in their condition following treatment with CHC.
• There had been no unplanned readmissions to the service within the past year.
• There were effective procedures in place to ensure medical staff were appraised, competent and revalidated. This was monitored through the Medical Advisory Committee (MAC) who on an annual basis ensured those consultants working under practicing privileges submitted evidence such as their annual appraisal and GMC registrations to demonstrate their fitness to practice. Full practicing privileges reviews were undertaken on a bi-annual basis.
• Consent was consistently well recorded and audited.
• Staff were aware of the requirements of the Mental Capacity Act and Deprivation of Liberty Safeguards.
• We were informed that staff were up to date with competency checks, however we could not be provided with data which confirmed this.
• There was also a limited amount of clinical audit taking place across the service and this could be improved upon to demonstrate effective practice.

Are services caring at this service

• The service received consistently positive feedback from patients. We reviewed feedback from the 2015 feedback and found that overall, out of six individually test areas, patients’ scored the service excellent.
• The satisfaction survey also demonstrated that 99.3% of patients would recommend the service.
• Patients we spoke with were complimentary about the service. One patient we spoke with stated it was “amazingly good” and another patient stated “I can’t fault any aspect of my care – I have been here three times and it’s always been fantastic.”
• Patient’s privacy and dignity was maintained and they were well respected at all times. We saw many positive interactions between staff and patients. For example, one patient had travel a long way to get to their outpatient appointment and was quite flustered when they arrived at the clinic. We saw staff comfort this patient, they made them a cup of tea and sat with them for a while in the waiting room.
• The use of chaperones was encouraged and additional requirements were discussed upon booking, prior to attendance at the clinic.

Are services responsive at this service

• Access to the service was seamless and without delay. Outpatient appointments were offered immediately upon referral and were usually attended within five weeks. We saw one case where a patient was referred, seen in the outpatient clinic and admitted for treatment in the same day.
• The clinic offered preferential access (as per the SLA agreement with the trust) to the catheterisation laboratory minimise waiting times.
• The clinic offered individual, patient focused care through the use of specialist nurses, chaperones and translation services where required.
• There was no cancellation of procedures due between April 2015 to March 2016.
• The individual needs of patients were being met with access to specialist dementia and learning difficulty nurses and chaperones. Specialist equipment was also available via the SLA agreement with the trust and the premises was accessible for those people living with physical disabilities.
• There was a robust complaints procedure in place. The CHC had one complaint for the reporting period of April 2015 to March 2016. We saw this was reviewed and discussed, with evidence of learning having taken place.

Are services well led at this service

• Governance systems required improving. We found the services governance framework made reference to out of date guidance and a reporting structure which was not accurate.
• In addition, the governance framework made reference to various reports and annual plans which should have been in place but were not.
• There was no agreed governance framework between CHC and the trust. Whilst processes were in place these were not documented and agreed by both parties which meant that intended outcomes could not be monitored.
• SLA monitoring was not robust. CHC did not receive or take appropriate assurance on the quality of staff training and competency.
• The policy ratification/approval process for CHC was not robust. For example, we found from the services governance framework that the clinical audit strategy should have been signed of by the MAC but instead it was signed off by the executive management team. In addition, there was no audit trail for the signing off of this document as it had not been presented to an executive management team meeting for approval.

• However, the service had a clear vision and staff were aware of this.
• The leadership team was proactive and approachable. Staff told us that they felt comfortable in raising concerns and that they had confidence these would be taken forward.
• Staff felt there was an open and honest culture within the service.
• The service was working to improve services and was in the processes of redefining its strategy following announcements that the environment it worked within (cardiology services) were being redesigned and improved on locally.

We saw an area of outstanding practice:

• A patient was referred to the service by their GP and offered an outpatient appointment the same day. A treatment plan was agreed which meant the patient was also admitted the day of their referral and received treatment the following day.

However, there were also areas where improvements are required. Importantly, the provider MUST:

• Consider reviewing its clinical audit plan to include a wider range of audits to demonstrate patient outcomes and identify areas where practice could be improved.
• Consider reviewing its governance framework to ensure this accurately reflects the governance arrangements in place.
• Consider ensuring these arrangements are approved and agreed with the trust.
• Consider how it takes appropriate assurance that all aspects of the SLA with the trust are working effectively.
• Consider implementing an effective policy approval process.

Professor Sir Mike Richards

Chief Inspector of Hospitals