Fitzwilliam Hospital

Fitzwilliam Hospital is operated by Ramsay Health Care UK. The hospital has 45 beds. Facilities include a two-bedded high care unit (HCU), three main theatres with laminar flow, a purpose built ambulatory care unit and a day case unit. The hospital provides surgery, outpatients and diagnostic imaging for adults.

We carried out a responsive inspection of surgery services in response to the number of serious incidents in gynaecological surgery reported by the provider between January 2017 and September 2017. We announced the inspection to the provider on the 6 September 2017 and carried out the inspection on the 13 September 2017and inspected the key question of safe in surgery only.

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

Services we rate

We rated surgery as good for safe and good for Well led.

We found good practice in relation to surgery:

• Staff understood their responsibility to raise incidents and concerns and the hospital had documented procedures for incident investigation and sharing of learning.

• Staff mandatory training and e-learning compliance was above hospital target (85%).

• The hospital was 100% compliant with intermediate life support (ILS) training.

• Staff knew their responsibility to safeguard vulnerable adults. Safeguarding training compliance was above the hospital target.

• The hospital had processes in place to manage risks to people. Risks were assessed, monitored and managed appropriately.

• Staffing levels and skill mix were appropriate and reflected patient acuity.

• The hospital had a clear governance structure in place with appropriate arrangements for communication. The hospital had committees such as clinical governance, senior management, and heads of department, which all fed into the medical advisory committee (MAC) and hospital management team.

• The theatre department and the ward had dedicated managers who reported to the hospital matron.

• Theatre and ward staff told us they felt valued and well supported by their manager. All the staff we spoke with told us that they were able to raise concerns openly and both managers had an open door policy.

• Staff knew the hospital vision was to be the number one provider of health care in the local area, and to offer high quality, safe, patient centred care.

• The hospital had a variety of mechanisms to gain feedback from patients by means of the friends and family test, monitoring social media comments, the online patient survey and through complaints and complements received.

We found areas of practice that require improvement in surgery:

• Two of the eight duty of candour letters the hospital had sent to patients who suffered serious incidents (SIs) were not accurate. One suggested “patient anatomy” to be the cause and the second did not detail why two procedures had been carried out when one would have sufficed.

• Theatre staff we spoke with said they were not as well informed around previous incidents and their investigation outcomes despite incidents being a standard agenda item at weekly meetings.

• In theatre three anaesthetic room nursing staff recorded the room temperature to be 27°C. We reviewed room temperature records for theatre three anaesthetic areas. Theatre staff had recorded the temperature above 26 degrees on seven days in July, 13 days in August and 15 days in September. This is above recommended limits for storing medications and may impact on medicine efficacy

• The hospital did not keep records of conversations between the hospital general manager, the medical director (MD) and the MD at the local NHS provider regarding concerns around behaviour and performance of consultants.

Following this inspection, we told the provider that it should make other improvements, even though a regulation had not been breached, to help the service improve.

Heidi Smoult

Deputy Chief Inspector of Hospitals