All inspections: Rivers Hospital - Care Quality Commission

Rivers Hospital is operated by Ramsay Health Care UK Operations Limited. The hospital has 49 beds. Facilities include five operating theatres and X-ray, outpatient and diagnostic facilities.

The hospital provides surgery, medical care, services for children and young people (CYP), and outpatients and diagnostic imaging. We inspected all core services.

We inspected this service using our comprehensive inspection methodology. We carried out the short notice inspection on the 17,18 and 19 December 2018.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

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

The main service provided by this hospital was surgery. Where our findings on surgery – for example, management arrangements – also apply to other services, we do not repeat the information but cross-refer to the surgery service level.

Services we rate

Our rating of this hospital improved. We rated Medicine, Surgery, Outpatients and Diagnostic Imaging as good and children and young people’s services as outstanding. The hospital was rated as Good overall.

The hospital provided staff with appropriate training to enable them to complete their roles and responsibilities.
The hospital premises were visibly clean and well maintained. Surgical, outpatient, diagnostic and children and young people services managed infection control risks well.
Equipment was well maintained and replaced as necessary.
There were systems in place to support staff to assess patients’ risks to ensure the safe provision of care and treatment.
The service managed staffing effectively and services always had enough staff with the appropriate skills, experience and training to keep patients safe and to meet their care needs.
Medicines were stored, prescribed and managed safely.
Safety incidents were managed using an effective system. There were processes in place to ensure shared learning.
Staff were able to identify potential harm to patients and understood how to protect them from abuse. Services knew how to escalate concerns.
The hospital provided staff with policies, protocols and procedures which were based on national guidance.
Staff ensured that patients were provided with adequate food and hydration, offering varied diets to meet nutritional or religious preferences.
Staff competency was assured through monitoring and regular appraisals.
Staff worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
Patients were supported to make decisions and were kept informed of treatment options. Staff treated patients with dignity and respect.
Services were planned to meet the needs of the patients, with additional support available for patients who had additional needs.
Services provided by the hospital were flexible to meet the needs of patients, enabling additional clinics, appointments or out of-hour services as able. Waiting times from treatment and arrangements to admit, treat and discharge patients were in line with good practice.
Complaints were taken seriously, with concerns being investigated and responses made within agreed timescales. Staff shared learning from complaints and encouraged patients to identify areas for improvement.
The leadership, governance and culture were used to drive and improve the delivery of high-quality child-centred care.
Managers and leaders were appropriately skilled and knowledgeable to manage teams and services. Leaders were accessible and respected by staff.
Managers promoted a positive culture which supported and valued staff, creating a sense of common purpose based on shared values.
There was a hospital vision and strategy which was developed in collaboration with the clinical team and reflected a focus on patients and staff.
The service had processes in place to monitor performance and used these to encourage staff to provide high standards of clinical care and treatment.

We found areas of outstanding practice in children and young people services:

Parents’ and children were extremely positive about the care and treatment they received. Feedback on the care, compassion and quality of the children and young people’s services were unanimous in their praise for “for all aspects of the children’s service”. Six parents and two children who had experienced the day surgery pathway rated the service as ten out of ten and said, the service ‘could not have been any better’.
We were told nurses, consultants and support staff were always friendly and welcoming to children and their families and were skilled in communicating with children and young people which helped to minimise their distress. We saw examples where staff had gone the ‘extra mile’ to adapt the service in a safe but personalised way to better meet the needs of children and young people and their families.
Staff involved children and their families at pre-assessment clinics where they were shown the type of equipment that would be used during their admission to hospital. For example, syringes, cannulas and blood pressure cuffs. Younger children had the equipment demonstrated on toys and were able to familiarise themselves with the equipment through play.
Children and young people services were tailored to meet the needs of individual people and were delivered in a way to ensure flexibility, choice and continuity of care.
Feedback from children and parents rated children’s services as being between 95% and 100% for all aspects of care including, overall rating of care 100%, being looked after 100%, and the care by nurses, doctors and physiotherapists was rated between 94% and 100%.
Areas used were dedicated solely for the use of children and had been adapted where possible to make them more appropriate for any age of child. For example, beds for children and young people had special bed linen and activities were provided to entertain and distract children of all ages.
Children and young people had short waiting times prior to consultations or appointments.
Children and young people’s (CYP) services were overseen by a lead paediatric nurse (LPN) and a named consultant paediatrician. Staff told us the LPN had raised the profile of children’s services and was recognised as being the clinical expert in the care of children and young people. Staff told us they were approachable and could be contacted for advice and support.
Children’s services were incorporated into the hospital vision and strategic direction for the hospital which was recognised by staff and integrated across children’s services.
The children and young people service actively engaged with children and their parents and families in feedback and development of children’s services.

However, we also found the following issues that the service provider needs to improve:

The service did not monitor outcomes for oncology patients.
Some policies provided were not in date or reviewed in line with the recorded timeline.
Competencies within oncology were not always evidenced. For example, there was no evidence to support that pharmacists had completed oncology specific competencies and the head of department had self-assessed their skills.
There were not always accessible handwashing sinks available in-patient rooms on the inpatient ward so staff could maintain good hand hygiene practices.
Intravenous fluids were not always clearly prescribed or recorded.
Some pain management audits were not always completed.
A minority of patients did not always appear to have time between consent being completed and the date of operation.

Following this inspection, we told the provider that it should make improvements, even though a regulation had not been breached, to help the service improve. Details are at the end of the report.

Amanda Stanford

Deputy Chief Inspector of Hospitals (Central Region)

We carried out an announced, comprehensive inspection visit of Rivers Hospital on the 21 and 22 June 2016 and an unannounced inspection on the 1 July 2016. Overall, the hospital was rated as requires improvement.

Our key findings were as follows:

Are services safe at this hospital?

There was generally access to suitable equipment to provide safe care and treatment.
Generally, systems were in place to ensure all areas complied with the service’s infection control procedures.
Staff were encouraged to report incidents and were aware of the duty of candour regulation. There was some evidence of learning from incidents and complaints and effective processes were in place to reduce risk.
Most staff were up to date with mandatory training in the medical care and children’s and young people service in line with the hospital’s annual training plan
Staff were suitably qualified and skilled to carry out their roles effectively and in line with best practice.
The hospital carried out a range of medicines safety indicators to assess how they were performing, and to identify areas for improvement. However, not all medicines were stored appropriately at the time of the inspection.
Staffing levels were generally appropriate to the needs and flexed according to the demands of the service, ensuring patients’ needs were met at the time of the inspection.
There were clear escalation processes in place, which included the use of the resident medical officer (RMO) and escalation to consultants.
Systems to safeguard patients were in place and staff knew how to respond appropriately to safeguarding concerns.
There was a system in place to recognise the deteriorating patient. Appropriate triggers were in place to ensure patients, who had deteriorated were treated according to their clinical needs.
The risk register for medical care was not updated regularly and in a manner that reduced the risk of disruption to the service. The risk register did not identify risks to the delivery of safe care and treatment that we found during the inspection. These risks had not been recognised by the service.
There were some potential risks to health and safety due to the administration of chemotherapy in some carpeted areas in patient bedrooms, which the hospital had assessed. The hospital took immediate action to provide four non-carpeted bedrooms immediately after we raised this issue.
The rooms used for chemotherapy were often used for other services if needed. The hospital had well defined processes regarding the cleaning of these rooms before and after use and also checked patients were not immunocompromised before having treatment in these rooms.
Not all consultant entries on medical records were legible.

Are services effective at this hospital?

Policies were current, accessible to staff and reflected professional guidance.
Care and treatment was given in line with evidence-based guidance.
The hospital offered intrathecal chemotherapy in line with the latest available guidance from the Department of Health (2008).
Information about the outcomes of children and young people’s care and treatment was not routinely collected and monitored. The service did not have a robust system for monitoring the outcomes for patients. We were not assured the service could therefore drive improvements due to lack of monitoring and performance information.
The hospital had some audit programmes specific to children and young people’s service, including documentation, environmental and pain audits. Feedback from patients and learning from incidents was also reviewed.
Staff followed evidence-based practice, including guidance from the Royal College of Nursing, the Joint Advisory Group (JAG), and the National Chemotherapy Advisory Service
There was participation in national audits in surgery, which showed outcomes within an expected range
The medical advisory committee reviewed all new consultants before practising privileges were approved; this included their scope of practice. The hospital had an effective system in place to ensure that practising privileges were updated annually with the relevant information.
An induction programme was provided to all new staff.
There was a process in place for checking professional registration.
Consultants were on call for 24 hours a day and seven days a week for their inpatients and day case patients. There was a RMO providing medical cover for patients and clinical support to staff.
There were arrangement’s to ensure staff were able to access all necessary information to provide effective care.
Staff were aware of their role with to regards to the Mental Capacity Act and Deprivation of Liberty and had received training. However, patients' consent to chemotherapy was not clearly documented.

Are services caring at this hospital?

Patients were overwhelmingly complimentary about the service they received at the hospital.
The Friends and Family Test survey results for the period July to December 2015 had a varying response rate from 8 to 58%. The percentage of patients that would recommend the hospital was 100% for inpatients and 99 for outpatients. Results from Rivers patient satisfaction scores showed that from January to March 2016 above 93% of patients were satisfied with aspects of the care they received including cleanliness of the hospital, staff, admission procedures, physiotherapy, discharge procedures and care since discharge.

Are services responsive at this hospital?

Services were generally planned and delivered in a way that met the needs of the local population.
There was a lack of recognition of the children and young people’s service as a separate, distinct service in the hospital.
Information on complaints or how to raise a concern was available for patients. Complaints and concerns were always taken seriously and responded to in a timely manner. There was evidence of actions taken to address issues raised in complaints and staff were informed of changes required in response to complaints.
Staff had awareness of dementia and had received training in caring for patients living with dementia. There was a lead nurse for dementia in the hospital.
The chemotherapy service demonstrated a positive relationship with commissioners and stakeholders in relation to service development.
Access for disabled people was good throughout the departments.
Interpreters could be booked when required for patients whose first language was not English.
Staff made efforts to ask people for their views on the service and used these to make improvements where possible.

Are services well led at this hospital?

There was a hospital risk register in place. However, the register lacked sufficient detail to provide adequate assurance about the appropriate identification and management of corporate risks, the mitigating actions, and the level of improvement or latest progress updates.
Risks to children and young people using the service had not been recognised, assessed, or mitigated against before our inspection. However, the service took immediate action once we raised these concerns.
There was limited assurance that improvements were being driven in the children and young people’s service due to a lack of effective performance and outcomes measurements.
There was good local leadership and an open culture where staff felt valued.
The hospital had a clear corporate set of values. Staff knew the provider’s vision and strategy, called ‘The Ramsey Way’.
The hospital had a clear governance structure and a clinical governance committee that met to discuss a range of hospital issues. However, some concerns found on inspection had not been recognised, assessed or mitigated against by the service.
There were clear routes for cascading information to hospital staff.
Senior management staff at the hospital were visible, supportive and approachable.
Staff were generally proud to work at the hospital.
Clinical leads had a shared purpose and motivated staff to deliver services and succeed
There were robust recruitment procedures in place including checks on professional registration and those for the disclosure and barring service (DBS).

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

The provider must:

Ensure effective quality assurance and performance measures are used to drive improvements in the children and young people’s service.
Ensure all risks in the medical care and children and young people services are recognised, assessed or mitigated against and that risk registers accurately reflect the level of risks and actions taken to minimise them.
Ensure the legibility of medical records in the chemotherapy service.

The provider should:

Monitor how consent to care and treatment is recorded before any procedure takes place. This may include implied consent or consent using non-verbal communication.
Monitor assessments and observations of care and treatment are accurately and routinely documented and that all records are legible.
Monitor that effective systems are in place so all equipment in medical care is fit for use to meet needs of patients.
Consider the risks and sustainability surrounding the paediatric nursing service, where it currently relies on two registered nurses (child branch) to cover all eventualities in relation to children and young people in the hospital.
Consider having a dedicated paediatric nurse in the outpatients department.
Enhance the environment of the hospital to make it more child-friendly.
Review the requirement to make child friendly information available to children and young people.
The provider should consider improving the environment in the outpatient and radiology departments as it is not suitable for providing dignified care to people who use the service
Share results from infection control audits, including hand hygiene audits, consistently with staff using a method they can readily access.
Review signage relating to the safe operation of fire doors so that it is up to date.
Improve the security of patient records at all times when not being used by staff.
Review the on-call nurse cover available in the chemotherapy service to ensure staff working hours are balanced and services are available to patients in line with their published standards.
Review the arrangements in place so that staff at all levels are clear about patients’ consent for surgery.
Review the systems for ensuring all patients’ requiring hydration monitored have the appropriate record to do this in place.
Review the clinical hand washing facilities in the bedrooms in the wards.
Monitor staff mandatory training is in line with the annual plan and with regard to helping patients living with a dementia.
Monitor the process for documented patients’ handover.
Monitor the arrangements for medicines’ storage in the pharmacy.

Professor Sir Mike Richards

Chief Inspector of Hospitals

During our inspection on 14 November 2013 we spoke with four people and two relatives of people who used the service. They told us that before they had received treatment the doctors had explained what it involved with them. One person told us, "I see my doctor... [the doctor] tells me everything."

People told us that they were happy with the care and treatment that they had received. One person described the service as, "...lovely. I can't fault it." They told us that they were happy with the food and the choice of food available to them. One person told us, "The food is perfect...lovely. I cannot fault it."

On the day of our inspection we saw that the premises were clean and bright. We looked at a number of rooms and found that these were all clean and smelled fresh.

People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines. We looked at the prescription and medicines recording charts for ten of the 54 patients who used the service on the day of our inspection. We found these records were in good order, provided a good record of what medicines were prescribed and demonstrated that patients received their medicines as prescribed.

We looked at the recruitment files of three staff members and found robust procedures were in place to safeguard people who used the service.

We noted that there were leaflets that explained how people could make a complaint in the reception area.

When we inspected the Rivers Hospital on 07 March 2013 we spent time in all areas and spoke with four people. All of the people we spoke with were complimentary about their experience.

People told us that staff had explained their treatment and procedures and that information had been sent to them prior to admission. This included information about consent and any risks involved in their treatment.

People were assessed and care and treatment was planned in accordance with those needs. We found that documentation describing treatment for each stage of a person's treatment pathway was detailed, precise and supported what we were told by staff. One person said, "The staff have been wonderful. All my needs have been met." Another told us, 'My notes are always available, they follow me wherever I go.'

We found that people using the service were protected from the risk of abuse because the provider made information and training available to staff about safeguarding. However, some staff members were unclear about being able to identify abuse and so the effectiveness of the training was in doubt.

Staff at the hospital were supported to provide effective care and treatment through supervision and training.

We saw records that showed us that the staff at the hospital were continuously working to improve the quality of the services they provided through monitoring performance and implementing changes to deal with shortfalls that were identified.

We did not speak to people who used this service as part of this review. We looked at a sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

These older reports are from our old approaches to inspection, including those from before CQC was created.

Rivers Hospital

All Inspections

17, 18 and 19 December 2018.

During a routine inspection

21 and 22 June and 1 July 2016.

During a routine inspection

Professor Sir Mike Richards

Chief Inspector of Hospitals

14 November 2013

During a routine inspection

7 March 2013

During a routine inspection

21 March 2012

During a themed inspection looking at Termination of Pregnancy Services

21 March 2012

During an inspection in response to concerns

Reports under our old system of regulation