Fitzwilliam Hospital

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

The service provided care and treatment based on national guidance and evidence-based practice. Staff assessed patient needs and provided good care and treatment. Managers monitored the effectiveness of the service using reliable information systems.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had processes in place to assess patient needs. The service’s pain management audit from January 2024 showed 93.7% compliance following the policy to record pain as part of the observation chart. Processes in place ensured staff assessed patient needs as part of the pre-operative assessment. For example, staff used the malnutrition universal screening tool (MUST) to assess nutritional needs prior to admission. The service used audits to assess compliance with nutrition and hydration. The audit from October 2023 showed 81.7% compliance. Leaders put an action plan in place to address areas for improvement and there were plans to check improvements were made.

We reviewed service user feedback after the inspection and found it to be positive. Patients were provided with booklets before admission which was tailored to their procedure and the journey from pre-admission to rehabilitation. Patients said they felt well-prepared for their procedure and their individualised care plans supported their recovery and met their needs.

Leaders of the service described how they kept up to date with the most recent evidence-based practice. When new policies or procedures were introduced, they shared this information with the relevant heads of the department, who shared updates through team meetings and huddles. Staff accessed evidence-based practice through the services policies and procedures on the staff intranet.

Changes to clinical practice, national guidance and policies were reviewed and developed centrally by the corporate provider and cascaded to the hospital and shared with staff. We saw evidence through minutes of the medical advisory committee (MAC), the clinical effectiveness group and departmental team meetings that changes in practice and guidance updates were routinely discussed. All staff could easily access policies and procedures through the provider’s intranet which reflected current guidance. Managers and staff conducted a comprehensive programme of repeated audits to check improvement over time. Audits were shared at the clinical effectiveness group and at the medical advisory committee and any learning was cascaded to staff.

We did not look at How staff, teams and services work together during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Monitoring and improving outcomes during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Consent to care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.