benenden hospital newapproachcomprehensive report ... · ourjudgementsabouteachofthemainservices...

This report describes our judgement of the quality of care at this location. It is based on a combination of what wefound when we inspected and a review of all information available to CQC including information given to us frompatients, the public and other organisations

Ratings

Overall rating for this location Outstanding –

Are services safe? Good –––

Are services effective? Good –––

Are services caring? Outstanding –

Are services responsive? Outstanding –

Are services well-led? Outstanding –

BenendenBenenden HospitHospitalalQuality Report

Goddard's Green RoadBenendenKentTN17 4AXTel:01580 240333Website: www.benendenhospital.org.uk

Date of inspection visit: 16 January 2017 to 17January 2017Date of publication: 11/05/2017

1 Benenden Hospital Quality Report 11/05/2017

Letter from the Chief Inspector of Hospitals

Benenden Hospital is operated by The Benenden Hospital Trust. The hospital has 32 beds, three operating theatres, animaging department and outpatient and diagnostic facilities.

The services provided by the hospital are surgery, endoscopy, outpatients and diagnostic imaging. We inspected thesethree core services using our comprehensive inspection methodology. We carried out the announced part of theinspection on 16th and 17th of January 2017 along with an unannounced visit to the hospital on 24th January 2017.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are theysafe, 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 compliedwith the Mental Capacity Act 2005.

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

We rated this hospital as outstanding overall.

• The service planned and delivered care and treatment in line with current evidence-based guidance, standards,best practice and legislation. The service monitored this to ensure consistency of practice and staffing levels andskill mix were reviewed to ensure patients were safe.

• Staff were suitably qualified and had the skills they needed to carry out their roles effectively and in line with bestpractice.

• Staff from different disciplines worked together to meet the needs of patients who used the service and treatedpeople with dignity, respect and kindness. There was strong collaboration and support across all staff groups and acommon focus on improving the quality of care and the vision and values were well embedded amongst staff.

• The hospital had consistently high levels of constructive engagement with staff at all levels. Leaders listened to staffand valued their input. The hospital demonstrated a strong commitment to staff wellbeing.

• Hospital data showed 100% of staff had an up-to-date appraisal at the time of our visit. The service supportedrelevant staff through the process of revalidation, and 100% of relevant medical and nursing staff had up-to-daterevalidation.

• There were high levels of staff satisfaction across all staff groups and staff were proud of the organisation as a placeto work and spoke highly of the culture.

• Patients had comprehensive assessments of their needs including clinical needs, wellbeing, and nutrition andhydration needs.

• The hospital had the facilities to meet patient’s individual needs. This included patients living with dementia,patients with learning disabilities and bariatric patients and expected outcomes were identified with regularlyreviewed and updated care and treatment plans.

• Medical records were maintained accurately and securely in line with the Data Protection Act 1998 and medicineswere stored in locked cupboards and administration was in line with relevant legislation.

Summary of findings


• There were appropriate arrangements for unplanned returns to theatre, with 24 hours a day, seven day a weekon-call availability.

• The endoscopy services demonstrated compliance with British Society of Gastroenterology (BSG) guidelines. Theservice was working toward Joint Advisory Group (JAG) on gastrointestinal (GI) endoscopy accreditationincorporating the endoscopy global rating scale, which is the quality improvement and assessment tool for the GIendoscopy service.

• The hospital had a comprehensive audit programme in place to monitor services and identify areas forimprovement and outcomes for patients were similar to, or better than, other acute hospitals in England.

• The hospital had a good track record on safety. Openness and transparency about safety was encouraged and staffunderstood and fulfilled their responsibilities to raise concerns and report incidents and near misses.

• The hospital took appropriate action to detect, control and prevent the spread of infections and infectionprevention and control practices were in line with national guidelines. Areas we visited were visibly clean, tidy andfit for purpose.

• The service assessed monitored and managed risks to children and young people who used services on aday-to-day basis. These included signs of deteriorating health, medical emergencies and emotional wellbeing.

• The hospital responded to complaints by providing meaningful written responses to all complainants. The serviceshared learning from complaints with relevant staff to help drive improvement. The hospital tried to respondimmediately to verbal feedback to avoid the need for escalation to a formal complaint. As a result, the number ofcomplaints had reduced significantly.

• Patients and their loved ones were included to be partners in their care and the overall feedback from people whoused the service and those who are close to them was positive about the way staff treated people.

We found areas of outstanding practice:

• The hospital’s commitment to staff wellbeing and their “Investors in People Silver Award”.

• The hospital’s work in enhanced recovery pathways to reduce the length of hospital stay for orthopaedic patients.

• The hospital was a finalist in the national award for innovations in anaesthetics in 2016. Innovations in this areaincluded use of a multi-purpose anaesthetic breathing system which recycled anaesthetic gases and reducedpollution in theatres.

• We identified the infection prevention and control leadership of the hospital and staffs commitment was an area ofoutstanding practice, with staff inspired to provide a good service to patients.

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

• There were intermittent problems with the controlled access mechanisms on the doors into the theatredepartment. This created a risk of inappropriate access into theatres.

• The hospital did not stagger admission times for surgery. This meant patients at the end of an operating list waiteda long time between admission and surgery when they could have been at home.

• The scheduling of operating lists according to consultant availability meant some day surgery patients were not fitfor discharge on the day of surgery. As a result, the hospital frequently converted day case patients to overnightstays.

• Privacy and dignity could not be guaranteed in the mixed sex waiting area outside of the changing area for patientsawaiting procedures.

Summary of findings


Following this inspection, we told the provider that it should make other improvements, even though a regulation hadnot been breached, to help the service improve. Details are at the end of the report.

Professor Sir Mike RichardsChief Inspector of Hospitals

Summary of findings


Our judgements about each of the main services

Service Rating Summary of each main service

Medical care

Outstanding –

Medical care services were a small proportion ofhospital activity. The main service was Surgery. Wherearrangements were the same, we have reportedfindings in the Surgery section.We rated this service as outstanding because it wasgood for safe, effective and responsive, andoutstanding for caring and well led.

Surgery

Outstanding –

Surgery was the main activity of the hospital. Whereour findings on surgery also apply to other services, wedo not repeat the information but cross-refer to thesurgery section.Staffing was managed jointly with medical care.We rated this service as outstanding because it wasgood for safe, effective and responsive, andoutstanding for caring and well-led.

Outpatientsanddiagnosticimaging Outstanding –

Surgery was the main activity of the hospital. Whereour findings on surgery also apply to other services, wedo not repeat the information but cross-refer to thesurgery section.We rated outpatient and diagnostic imaging asoutstanding because it was good for safe and caring,and outstanding for responsive and well led.

Summary of findings


Contents

PageSummary of this inspectionBackground to Benenden Hospital 8

Our inspection team 8

Information about Benenden Hospital 8

The five questions we ask about services and what we found 11

Detailed findings from this inspectionOverview of ratings 17

Outstanding practice 79

Areas for improvement 79

Summary of findings


Benenden Hospital

Services we looked atMedical care; Surgery; Outpatients and diagnostic imaging.

BenendenHospital

Outstanding –


Background to Benenden Hospital

Benenden Hospital is operated by The BenendenHospital Trust. The hospital opened in 1907 as asanatorium providing treatment for Tuberculosissufferers, the hospital adapted through time to becomean independent hospital. It is a private hospital inBenenden, Kent. The hospital primarily serves thecommunities of the Kent and Medway areas. It alsoaccepts patient referrals from outside this area.

Jane Abbott has been the registered manager since 21stDecember 2010.

The hospital has one ambulatory care unit, an eye unit,theatres and an outpatient and diagnostic imagingdepartment and is registered to provide the followingregulated activities:

• Diagnostic and screening procedures.

• Nursing Care.

• Surgical procedures.

• Treatment of disease, disorder or injury.

There were no special reviews or investigations of thehospital ongoing by the CQC at any time during the 12months before this inspection. The hospital has beeninspected three times, and the most recent inspectiontook place in March 2014, which found that the hospitalwas meeting all standards of quality and safety it wasinspected against.

We carried out the announced part of the inspection on16th and 17th of January 2017 along with anunannounced visit to the hospital on 24th January 2017.

Our inspection team

The inspection team was led by, Elaine Biddle, InspectionManager, Care Quality Commission. The team includedother CQC inspectors, and specialist advisors withexpertise in surgery, medicine, paediatrics and radiology.

Information about Benenden Hospital

Surgical services at Benenden Hospital cover a range ofspecialties including orthopaedics, gynaecology,ophthalmology (eye surgery) and general surgery. Thehospital only provides surgery for adults aged 18 and overand does not operate on children.

In October 2015 – September 2016, there were 8,169 visitsto theatre. The most common operation in this periodwas cataract removal. There were 1,934 cataractprocedures, which represented 23.7% of surgical activity.The second most common procedure was varicose veinremoval (884 operations), followed by knee arthroscopy(549 procedures). Arthroscopy is a type of keyhole surgeryused to diagnose and treat problems with joints.

The hospital provides surgery to members of BenendenHealthcare Society, self-funding patients, private insured

patients and NHS-funded patients. Benenden HealthcareSociety members pay £9.10 each month for membership,which allows them to receive treatment at the hospital ona discretionary basis. The NHS funded 67% of inpatientprocedures in October 2015 – September 2016.

As part of the first phase of the hospital’s redevelopment,a new theatre suite, ward (Bensan Ward) and ambulatorycare unit (ACU) opened in 2016. The theatre suite hasthree operating theatres, eight recovery bays and threeanaesthetic rooms. Two of the operating theatres havelaminar flow (a system that circulates filtered air toreduce the risk of airborne contamination).

There were 1,611 inpatients and 7,326 day case patientsrecorded at the hospital between October 2015 andSeptember 2016. Both overnight and day case patients

Summaryofthisinspection

Summary of this inspection


recover from surgery on Bensan Ward. The ward has aninpatient area, with 14 single ensuite bedrooms forpatients staying overnight. Two of the rooms havefacilities for bariatric patients. There is a day case area atthe opposite end of the ward. This contains six singleensuite rooms and six twin rooms each containing twotrolleys. Patients recovering from day case surgery stay inthis part of the ward. Patients staying in the twin roomshave access to single-sex, communal bathrooms.

The ACU has eight recovery beds and six reclining chairs.Ambulatory care is surgery on an outpatient basiswithout admission onto a ward. The service carries outminor procedures such as varicose vein treatment andspinal injections to treat back pain. Ambulatory carepatients spend a short time in a single-sex recovery areaafter their procedure before discharge home.

The eye unit has a treatment room with a treatment chairfor eye surgery under local anaesthetic. There is a privateroom containing chairs for patients to sit with theirrelatives and recover after their procedure before goinghome. The eye department does not perform anyrefractive eye surgery (laser vision correction).

Outpatient services at Benenden Hospital cover a widerange of specialities, including cardiology, dermatology,ear, nose and throat, gastroenterology, general medicine,general surgery, gynaecology, neurology, orthopaedics,rheumatology, spinal services, varicose vein services andophthalmology.

The diagnostic and imaging department carried outx-rays and ultrasound scans. An external providerprovided more complex tests such as MRI and CT scanson certain days of the week at The Benenden Hospitalsite. These services were not included in this inspection.

From October 2015 to September 2016, there were 46,129outpatient total attendances, of these 24% (10,910) wereNHS funded and 76% (35,219) were other funded.

The outpatient department runs clinics from 8.30am to7pm, Monday to Friday. Saturday clinics were providedbetween 8.30am and 5pm. The diagnostic imagingdepartment run clinics between 8am and 7pm, Mondayto Friday, and Saturday between 8am and 2pm. Providesa 24-hour a day, seven day a week service for urgentrequests.

There are 24 consulting rooms, including seven specialistrooms, such as for gynaecology procedures, in theoutpatient department.

The imaging department consisted of one x-ray rooms, anultra sound room, and an ultrasound scan room. Thephysiotherapy department had with two rooms withcouches, and a small gym area.

During the inspection, we visited all clinical areasincluding outpatient department, diagnostic imagingdepartment, physiotherapy, and pharmacy, theatres,ward areas and the eye unit during our inspection. Duringour inspection, we spoke with 42 members of staffincluding consultants, medical staff, operatingdepartment practitioners, nurses, allied healthprofessionals, radiographers, physiotherapists, clinicalsupport workers, administrators and managers and theexecutive team. We spoke with 15 patients and sixpatients’ relatives. We reviewed nine sets of patientrecords and a variety of hospital data including meetingminutes, policies and procedures, staff training records,audits and performance data. We also received 40comment cards with feedback from patients.

As of 1 October 2016, the service employed 16.7whole-time equivalent (WTE) theatre nurses. There werefour WTE theatre nurses vacancies. This meant thenursing vacancy rate for theatres was 19%.The servicefilled vacant shifts using bank and agency staff.

There were 12.7 WTE operating department practitioners(ODPs) and healthcare assistants (HCAs) in theatres.There were 5.2 WTE posts vacant for OPDs and HCAs intheatres. This gave a vacancy rate of 29%.

The ward had 31.1 WTE staff in post, which met thebudgeted compliment of staff.

The eye unit had two WTE nursing vacancies. The hospitalused specialist ophthalmic bank nurses to fill vacantshifts while they recruited new staff.

There was 8.4 whole time equivalent (WTE) outpatientregistered nursing staff and 10.9 WTE clinical supportworkers (CSW) for outpatients. The outpatientdepartment had a ratio of nurse to CSW of 1 to 1.3.

There were 1.8 WTE posts vacant for outpatient registerednurses given a vacancy rate of 18%. For CSWs, there were0.21 WTE posts vacant giving a vacancy rate of 2%.




116 doctors worked at the hospital under practisingprivileges. 2 regular resident medical officer (RMO)worked on a one week on, one week off working pattern.The accountable officer for controlled drugs (CDs) wasClaire Harley.

Track record on safety

• No Never Events in the reporting period (Oct 2015 toSep 2016).

• 771Clinical incidents of no harm, 0 low harm, 0moderate harm, 0 severe harm, 0 death

• No serious injuries

• No incidences of hospital acquiredMethicillin-resistant Staphylococcus aureus (MRSA),

• No incidences of hospital acquiredMethicillin-sensitive staphylococcus aureus (MSSA)

• No incidences of hospital acquired Clostridiumdifficile (C.diff)

• No incidences of hospital acquired E-coli

• CQC received no complaints in the reporting period(Oct 2015 to Sep 2016).

• The hospital received 19 complaints in the reportingperiod (Oct 2015 to Sep 2016). None of which havebeen referred to the Ombudsman or ISCAS(Independent Healthcare Sector ComplaintsAdjudication Service) 100% VTE screening rates inthe reporting period (Oct 2015 to Sep 2016).

• Seven incidents of hospital acquired VTE or PE in thereporting period (Oct 2015 to Sep 2016).

• There have been no safeguarding concerns reportedto CQC in the reporting period (Oct 2015 to Sep2016).

Services provided at the hospital under service levelagreement:

• Angiography

• Electroencephalogram (EEG)

• Nuclear medicine

• Pathology

• Clinical and or non-clinical waste removal

• Interpreting services

• Laser protection service

• Laundry

• Maintenance of medical equipment

• Pathology and histology

• RMO provision

• Occupational health

• MRI/CT scanner

• Transfer of patients for critical care support.




The five questions we ask about services and what we found

We always ask the following five questions of services.

Are services safe?We rated safe as good because:

• The service planned, implemented and reviewed staffing levelsand skill mix to keep patients safe.

• The service had a good track record on safety. Openness andtransparency about safety was encouraged. Staff understoodand fulfilled their responsibilities to raise concerns and reportincidents and near misses.

• The service took appropriate action to detect, control andprevent the spread of infections.

• There were effective systems in place to report incidents.Incidents were monitored and reviewed and staff gaveexamples of learning from incidents. Staff understood theprinciples of duty of candour regulations, were confident inapplying the practical elements of the legislation.

• Patients were cared for in a visibly clean environment that waswell maintained.

• There were adequate supplies of appropriate equipment thatwas properly maintained to deliver care and treatment andstaff were competent in its use.

• There was good medicines storage, management andadministration. There were systems that ensured patient’smedicines were given safely, on-time and according to theconsultant prescription. Medicines were stored securely as pernational guidelines.

• We found there were systems to identify patients whosecondition may be deteriorating to allow early intervention.

• There were sufficient numbers of medical, nursing anddiagnostic staff to deliver care safely. Patient risk was assessedand responded to. There was a major incident plan in place,and a recent exercise had been undertaken.

• Staff were aware of their responsibilities with regard to theprotection of people in vulnerable circumstances. All staff hadreceived appropriate training in adult safeguarding.

• Records were stored safely, up to date, legible, and wereavailable for staff. Emergency equipment was in place.Medicines were well managed within the department.

• The environments were visibly clean.

However:

Good –––




• Privacy and dignity could not be guaranteed in the mixed sexwaiting area in outpatients outside of the changing area forpatients awaiting procedures.

• Staff did not consistently print names with a legible signature inpatient records in line with guidance issued by the professionalregulatory bodies for doctors and nurses.

• There were inconsistencies in the suitable number of staffreceiving training at the appropriate level for safeguardingchildren and vulnerable adults.

• There were intermittent problems with the controlled accessmechanisms on the doors into the theatre department. Thiscreated a risk of inappropriate access into theatres.

Are services effective?We rated effective as good because:

• The service planned and delivered care and treatment in linewith current evidence-based guidance, standards, best practiceand legislation, including National Institute for Health and CareExcellent (NICE) guidance. The service monitored this to ensureconsistency of practice with formal systems in place forcollecting comparative data regarding patient outcomes.

• Outcomes for patients were similar to, or better than, otheracute hospitals in England.

• Patients had comprehensive assessments of their needs. Theseincluded consideration of clinical needs, wellbeing, andnutrition and hydration needs. The expected outcomes wereidentified and staff regularly reviewed and updated care andtreatment plans.

• Staff were suitably qualified and had the skills they needed tocarry out their roles effectively and in line with best practice.Patients were cared for by staff who had undergone specialisttraining for the role and who had their competency reviewed.

• The service supported staff with supervision and appraisal.Hospital data showed 100% of staff had an up-to-date appraisalat the time of our visit and the hospital supported themthrough the Nursing and Midwifery Council’s (NMC) revalidationprocess. All of relevant medical and nursing staff hadup-to-date revalidation.

• There was a good multidisciplinary team approach to care andtreatment. Staff had the right qualifications, skills andknowledge to do their job. Staff from different disciplinesworked together to meet the needs of patients who used theservice.

• The hospital had an on-going, comprehensive auditprogramme which monitored areas for improvement regularly.

Good –––




• Staff worked with other healthcare professionals in and out ofthe hospital to provide services for patients.

• Patients provided informed, written consent beforecommencing their treatment. Where patients lacked capacity tomake decisions, staff were able to explain what steps to take toensure relevant legal requirements were met.

• Patients had access to appropriate nutrition and hydration.• Patients and their relatives we spoke with were pleased with

the care they had received.

Are services caring?We rated caring as outstanding because:

• The hospital allocated the time necessary for nursing staff tobuild positive relationships with patients and their families.Thisenabled the nurses to provide reassurance, information andsupport to patients and families.

• Overall feedback from people who used the service and thosewho are close to them was positive about the way staff treatedpeople. Patient’s surveys and assessments reflected thefriendly, kind and caring patient centred ethos.

• Staff encouraged patients and their loved ones to be partners intheir care.

• Staff respected people’s privacy and confidentiality at all times.• Staff provided sensitive, caring and individualised personal care

to patients. Staff supported patients to cope emotionally withtheir care and treatment as needed.

• Patients commented positively about the care provided fromall staff they interacted with. Staff treated patients courteouslyand with respect.

• Patients felt well informed and involved in their procedures andcare, including their care after discharge.Patients understoodthe care and treatment choices available to them and weregiven appropriate information and support regarding their careor treatment.

• Interactions between staff and patients were welcoming, caringand supportive.

Outstanding –

Are services responsive?We rated responsive as outstanding because:

• Services were planned and delivered to meet the needs of thelocal population.

• The hospital responded appropriately and had the facilities tomeet patient’s individual needs. This included patients livingwith dementia, patients with learning disabilities and bariatricpatients.

Outstanding –




• The hospital completed the first phase of an extensiveredevelopment in 2016, which included new theatres, a newward and a new ambulatory care unit. Staff and patients wespoke with were very positive about the new building.

• The hospital responded to complaints by providing meaningfulwritten responses to all complainants. The hospital sharedlearning from complaints with relevant staff to help driveimprovement. The hospital tried to respond immediately toverbal feedback to avoid the need for escalation to a formalcomplaint. As a result, the number of complaints had reducedsignificantly.

• There were systems to ensure that patient complaints andother feedback was investigated, reviewed and appropriatechanges made to improve treatment of care and the experienceof patients and their supporters.

• There were appropriate arrangements for unplanned returns totheatre, with 24 hours a day, seven days a week on-callavailability.

• Services operated at times that allowed patients to access careand treatment when they needed it.

• There were a variety of mechanisms to provide psychologicalsupport to patients and their supporters. This range of servicemeant that each patient could access a service that wasrelevant to their particular needs. For example those whose firstlanguage was not English, or support for people living withdementia or learning disabilities.

• Patients could choose appointments that suited them.• Patients were kept informed of any disruption to their care or

treatment.• Patients did not experience long waiting times to see their

chosen consultant.

However:

• The hospital did not stagger admission times for surgery. Thismeant patients at the end of an operating list waited a longtime between admission and surgery when they could havebeen at home.

• The scheduling of operating lists according to consultantavailability meant some day surgery patients were not fit fordischarge on the day of surgery. As a result, the hospitalfrequently converted day case patients to overnight stays.

Are services well-led?We rated well-led as outstanding because:

• Leaders drove continuous improvement and organisationalgrowth.

Outstanding –




• There was clear and highly visible leadership provided by seniormanagement and within the departments. Staff spokepositively of their managers, who told us they were visible andapproachable, and told us the senior management team hadan ‘open door’ approach, and visited departments daily.

• The vision and values were well embedded amongst staff.• The hospital’s vision was embedded in the departments and

staff embraced the values in the work they undertook.• There were high levels of staff satisfaction across all staff

groups. Staff were proud of the organisation as a place to workand spoke highly of the culture.

• The hospital had consistently high levels of constructiveengagement with staff at all levels. Leaders listened to staff andvalued their input. The hospital demonstrated a strongcommitment to staff wellbeing.

• The hospital had robust governance arrangements.Governance and performance management arrangementswere proactively reviewed and reflected best practice.

• Governance processes were evident at departmental, hospitaland corporate level. This allowed for monitoring of the serviceand learning from incidents, complaints and results of audits

• The hospital had a risk register and was reviewed at thegovernance committee meetings.

• We saw strong collaboration and support across all staff groupsand a common focus on improving the quality of care.

• Staff asked patients to complete satisfaction surveys on thequality of care and service provided. Departments used theresults of the survey to improve services.

• Leaders actively encouraged staff to raise concerns. There was aculture of openness, and all staff we spoke to could describetheir responsibilities relating to Duty of Candour.

• The management structure at the hospital meant there wereclear lines of leadership and accountability. The seniormanagement team were highly visible and accessible acrossthe hospital. Staff described an open culture and saidmanagers were approachable at all times.

• Staff had a good understanding of the vision for thedevelopment of their services.

• We saw staff were focused on providing the best service for allpatients, and were proud to work at the hospital

• Staff spoke highly about their departmental managers and thesupport they provided to them and patients. All staff saidmanagers supported them to report concerns and theirmanagers would act on them. They told us their managersregularly updated them on issues that affected the separatedepartments and the whole hospital.




• Projects such as the productive outpatients were in place toprovide data on performance and improve teamwork.




Overview of ratings

Our ratings for this location are:

Safe Effective Caring Responsive Well-led Overall

Medical care Good Good Good

Surgery Good Good Good

Outpatients anddiagnostic imaging Good N/A Good

Overall Good Good

Notes

Detailed findings from this inspection


Safe Good –––

Effective Good –––

Caring Outstanding –

Responsive Good –––

Well-led Outstanding –

Are medical care services safe?

Good –––

We rated safe as good

Incidents

• No never events related to medical care services werereported by the hospital in the period October 2015 toSeptember 2016. Never events are serious patient safetyincidents that should not happen if healthcare providersfollow national guidance on how to prevent them. Eachnever event type has the potential to cause seriouspatient harm or death but neither need have happenedfor an incident to be a never event.

• The hospital reported no serious incidents or deaths inthe period October 2015 to September 2016.

• The hospital had an incident reporting policy whichencouraged openness, the reporting of all incidents anddescriptions of the levels of incidents. An electronicincident reporting system was used and staffdemonstrated a good understanding of how to use thesystem. Feedback from incidents was discussed atdepartmental meetings and minutes of meetingsconfirmed this. Staff told us the hospital encouragedthem to report incidents to help the whole organisationlearn.

• Staff were able to give us examples of incidents that hadbeen reported. For example, the allegation by a patientthat money was missing led to a full investigation byhospital staff and police involvement.Lessons learnedfrom the incident instigated a review of information

given before admission to the hospital and patientswere reminded about the safety of valuables and thiswas achieved with reviewing the content ofpreadmission leaflets.

• Two Hundred and thirty six incidents were reportedbetween January and December 2016 in medical careservices. Of these, staff reported 25 as a near miss, 47resulting in harm and 164 resulting in no harm. The highnumbers of no harm incidents reported suggested agood reporting culture.

• Incidents were investigated by the management team.The majority of incidents related to clinicalcomplications (124) and 96 to day case conversions.Conversions to inpatients were reported as incidentsand were due to social, geographical or clinical reasons.Other incidents reported included infection control (33)and slips, trips and falls (11). These were then reportedlocally to departmental teams, the hospital executive,the medical advisory committee (MAC), the local clinicalcommissioning group and other relevant organisationsas required.

• The dissemination of information regarding incidentsand lessons learned was through electroniccommunications and staff meetings. We also reviewed asample of hospital wide clinical incidents, patient’snotes and root cause analysis and saw evidence thatstaff had applied the duty of candour appropriately.

• Staff were able to describe the basis and process of dutyof candour, Regulation 20 of the Health and Social CareAct 2008. This relates to openness and transparency andrequires providers of health and social care services tonotify patients (or other relevant persons) of ‘certainnotifiable safety incidents’ and provide reasonable

Medicalcare

Medical care

Outstanding –


support to that person. Patients and their families weretold when they were affected by an event wheresomething unexpected or unintended had happened.The hospital apologised and informed people of theactions they had taken.

• We saw operational staff understood theirresponsibilities with regard to the duty of candourlegislation and we found the responsible managerensured that the duty was considered and met wheninvestigating safety incidents.

• Clinical Quality Dashboard or equivalent (how does theservice monitor safety and use results)

• The hospital monitored patient safety to enable them tomeasure, assess and analyse any incidents of harm. Thisdata formed one of the hospital’s key performanceindicators (KPI’s), a measurable value to demonstratehow the hospital achieved its safety objectives. The KPI’swere documented in the integrated performance report.These were regularly monitored and reported toindividual teams, consultant groups and keycommittees.

• The individual patient care pathways captured key datasuch as falls, urinary tract infections in patients with acatheter, venous thromboembolism (VTE) and pressureulcers. Data showed between October 2015 andSeptember 2016, no pressure ulcers were reported, sixfalls and three urinary tract infections were reported. Wesaw the hospital had achieved 100% VTE screening ratesduring the same reporting period.

• There was a policy in place describing the managementof sepsis which was compliant with National Institute forHealth and Care Excellence (NICE) guideline NG51(sepsis: recognition, diagnosis and early management).Staff had attended scenario based training. Staff wespoke with were able to describe the prompt action tobe taken in this event.

Cleanliness, infection control and hygiene

• There were no incidences of E-Coli, MRSA and MSSAbloodstream infections or cases of C.difficile relateddiarrhoea reported in the period October 2015 toSeptember 2016 at the hospital.

• All the areas we visited in the medical care services werevisibly clean and tidy and there were good infectioncontrol practices in place.

• We saw the infection prevention and control strategyand annual plan 2016-2018. The hospital had aninfection prevention and control (IPC) team who fed intothe integrated governance group and the MedicalAdvisory Committee (MAC) and met every three months.We saw the minutes of the meetings held in July andOctober 2016. Items discussed, but not limited to,included infections, needle stick injuries, audits,antibiotic usage and review of policies.

• The ambulatory care unit (ACU) and Bensan ward hadan infection control champion known as ‘linkpractitioners’. The link practitioner was central todisseminating infection control education, support totheir local multidisciplinary team and provided a directlink with the IPC team. The link practitioners met everythree months and we saw the minutes of the meetingsheld in April and July 2016. All areas of IPC werediscussed. We saw in the July meeting the introductionof infection control information pack had been initiatedfor all new staff. The link practitioners were able todescribe how they informed staff of updates through thedepartments email system and verbally.

• Cleaning audits were carried out in clinical areasmonthly using the NHS 49 point checklist and the targetwas 90%. The checklist provides a comparativeframework within which hospitals and trusts in Englandcan set out details for providing cleaning services andassessing ‘technical’ cleanliness. We saw betweenJanuary and April 2016, the day case ward scored anaverage 92%, inpatient ward 91%, and endoscopy 96%.The data for the audits performed between May andSeptember 2016 showed improvement after thecompletion of the first stage of refurbishment. Theinpatient ward scored 95%, day case ward 97%, andendoscopy 96%.

• Each head of department was provided with the resultsof the audits and the housekeeper allocated to that areawas informed of failures to be rectified. Any failure whichconstituted a risk would be rectified immediately and allother failures (for example black marks on floors or bins)would be completed within 24 hours. Any area that fellbelow the agreed benchmark was closely monitoredand spot check audits were completed to ensure allfailures were rectified and standards maintained.

• Staff rota’s showed at least one member ofhousekeeping staff was working on Bensan ward at all

Medicalcare

Medical care

Outstanding –


times during the day. We saw there were cleaningschedules for individual treatment rooms and toilets,which were fully completed. Housekeeping staff showedus their cleaning schedules which clearly set out thetasks to be performed and their frequency. They wererequired to sign when each task was completed andtheir supervisor checked their work.

• The endoscopy suite in the ACU had separate clean anddirty utility areas for the preparation and cleaning ofequipment which minimised the risks of infection topatients. Staff transported dirty endoscopes from thetreatment area to the dirty area in a covered, solidwalled, leak proof container. This was in line with theHealth and Safety Executive (HSE) Standards andRecommended Practices for Endoscope reprocessingUnits, QPSD-D-005-2.2.

• In the endoscopy department, we saw adequatesystems to ensure that endoscopes were safelydecontaminated. Documentary evidence showed thatthe use of scopes was tracked and the use of a specificendoscope was linked to each procedure. Staff wespoke with could explain the correct decontaminationprocess. Scopes were stored safely in a drying cabinetfor up to three days. There were processes in place toensure staff reprocessed scopes at the appropriate time.

• All staff received infection control training as part ofinduction and this was repeated yearly. We sawmandatory training records which showed us byDecember 2016, 98% inpatients staff and all staff in theACU had completed infection control training. The trusttarget was 95%.

• Hand hygiene audits were completed across thehospital for all staff on a monthly basis. A target of 100%was required. The audit included technique used,observations with patients at point of care and the useof World Health Organisation (WHO) guidelines for handhygiene standards. We saw the September 2016 auditshowed 86% medical staff, 96% registered staff and100% non-registered staff were compliant.Areas ofnon-compliance related to the hand hygiene dresscode. Two registered staff were wearing inappropriatejewellery and another was wearing a cardigan. We sawareas of non-compliance were raised immediately withthe relevant member of staff concerned and traininggiven.

• During the inspection we saw staff were bare below theelbow and demonstrated an appropriate hand washingtechnique in line with ‘five moments for hand hygiene’from the WHO guidelines on hand hygiene in healthcare.

• There were sufficient numbers of hand washing sinksavailable, in line with Health Building Note (HBN) 00-09:Infection control in the built environment. Soap anddisposable hand towels were available next to sinks. Wesaw information was displayed demonstrating the ‘fivemoments for hand hygiene’ near handwashing sinks.Sanitising hand gel was readily available throughout allareas.

• Personal protective equipment was available for all staffand we observed staff use it appropriately.

• Disinfectant wipes were available in clinical areas.Equipment which was shared between patients, forexample commodes and observation equipment, wascleaned with these between each patient use. We sawstaff apply ‘I’m clean’ labels on equipment. Thisindicated equipment was clean and ready for use. Allthe equipment we looked at was visibly clean.

• Disposable curtains were used in all ward areas, dateson them indicated they had been changed within sixmonths in accordance with industry standards andhospital policy.

• Waste in the wards and clinical areas were separatedand in different coloured bags to identify the differentcategories of waste. This was in accordance with theDepartment of Health (DH) Technical Memorandum(HTM) 07-01, control of substance hazardous to healthand Health and Safety at Work regulations.

• The hospital commissioned an outside company toaudit sharps safety in April 2016. This was to raise sharpsawareness, assess practice and provide advice oncompliance and current legislation. The target was 95%.We saw the results of the audit which showed the daycare ward was 100% compliant. Garland ward(inpatients) scored 94% as it had some sharps boxesincorrectly assembled and unlabelled.

• Sharps bins were available in treatment and clinicalareas where sharps were used. This demonstratedcompliance with health and safety sharps regulations2013, 5(1) d. This required staff to place secure

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containers and instructions for safe disposal of medicalsharps close to the work area. The labels on sharps binshad been fully completed which ensured traceability ofeach container.

• The environment and clinical practice infection controlaudits for August 2016, for the ACU and Bensan wardshowed overall compliant. The audit highlighted theACU did not have infection control patient informationleaflets displayed and Bensan ward had fabric chairswhich were not compliant with national standards. Theaudits had an action plan with a named personresponsible to rectify, target date for completion andaction completed date. We saw the outcome showedthe ACU had completed the required action and we sawthere were leaflets for patient use. The replacement ofthe fabric chairs on Bensan ward was ongoing.

• During the inspection we saw all seating used within thepatient areas was covered in a material that wasimpermeable, easy to clean and compatible withdetergents and disinfectants. This was in line with HBN00-09 section 3.133 for furnishings.

• The ACU and Bensan ward did not have carpets inclinical rooms. The flooring was seamless and smooth,slip resistant, easily cleaned and appropriatelywear-resistant. This was in line with HBN 00-09: Infectioncontrol in the built environment, 3.109.

Environment and equipment

• Emergency equipment was located on Bensan ward andACU. The resuscitation trolleys contained all therequired equipment including a defibrillator, to managea medical emergency such as a cardiac arrest. We sawthe trolleys were secure and fully stocked and ready forimmediate use. All equipment needed was available, asindicated by an equipment list. All consumables were indate. There was a system for checking these daily andwe saw the fully completed records of checks. Staffchecked the trolley in the ACU on the days thedepartment was open. The records clearly stated ‘not inuse’ on the days the unit was not open.

• Equipment service records indicated 100% of electricalequipment had been serviced in the last 12 months.Individual pieces of equipment had stickers to indicateequipment was serviced regularly and ready for use. Wesaw electrical testing stickers on equipment, whichindicated the equipment was safe to use.

• Managers assessed staff to ensure competency beforethey used any medical devices, for example We sawexamples of competency assessments in staff records,which were kept in ward areas.

• Equipment used for near-patient testing(aninvestigation taken at the time of the consultation withinstant availability of results) was stored in the cleanutility room on Bensan ward. Equipment included ablood gas analyser and testers for internationalnormalized ratio (INR), blood glucose, andhaemoglobin(red blood cells). All equipment wasoperational and we saw the records which showed theywere quality controlled.

• Staff reported no problems with equipment and feltthey had enough equipment to run the service. We weretold there were no issues around securing the necessaryequipment for individual patients, for example pressurerelieving mattresses and commodes. The mattressesused by the hospital were fit for purpose and providedprotection from infection and pressure damage.

• The endoscopy lead told us the number and size ofendoscopes met the needs of the service. We saw avariety of scopes available to perform a variety ofexaminations. Equipment was maintained by anexternal contractor and we saw the equipment waslabelled to show it had been maintained at the requiredfrequencies. We saw competency certificates inendoscopy which indicated staff were competent in avariety of procedures and in the decontamination ofequipment.

• Fire extinguishers were serviced appropriately and inprominent positions. Fire exits were clearly sign postedand exits were accessible and clear from obstructions.

Medicines

• The hospital had a medicines management policy. Thepurpose of the policy was to make suitablearrangements for the recording, safe-keeping, handlingand disposal of medicines.

• The hospital had a separate policy for the managementfor controlled drugs (CD’s) and intravenous (IV)administration. IV therapy is the infusion of liquid

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substances directly into a vein and CD’s are medicinesthat are liable for misuse and have additional legalrequirements regarding their storage, prescription andadministration.

• The hospital had a named controlled drugs (CD’s)accountable officer. CD’s were kept securely and storedin suitable cupboards with records maintained. The CDcupboards were locked, with restricted access and werebolted to the wall. Controlled drugs to be administeredwere checked by two members of staff. Spot checks onbalances during the inspection showed contents of thecupboards matched the registers.

• We saw the controlled drug audit performed betweenApril and June 2016 and between July and September2016 for endoscopy and Bensan ward. The endoscopydepartment had the correct balance of stock and alldocumentation was completed correctly. However, inBensan ward the audit highlighted there were gaps inthe correct documentation as cancellations andalterations were made by staff. The pharmacy teamprovided individualised training to ward staff to rectifythis.

• Medicine management was part of mandatory trainingfor all clinical staff. This was part of induction and thenupdated every three years by e-learning. Trainingrecords showed us by December 2016, all inpatient andACU staff were up-to-date with this training. The trusttarget was 95%.

• Staff had access to up to date copies of the BritishNational Formulary (BNF, a pharmaceutical referencebook).Additionally, the hospital had devised its ownmedicines formulary which indicated the medicinesheld at the hospital, where they were located and whatthey were approved for. This assisted access for urgentmedicines out of hours. The formulary was divided intodifferent subject headings and included, but not limitedto pain, respiratory, gynaecology, urology andunlicensed medicines.

• We saw the audit of prescription charts and misseddoses for March 2016 was on a selection of inpatientsprescription charts randomly reviewed over a course ofthe previous three months. The audit assessed thequality of record keeping and found all to be compliant.

We checked six prescription charts during theinspection. The prescriptions we looked at met legalrequirements and were legible, signed and containedinformation about people’s allergies.

• Medicines were stored securely to minimiseunauthorised access. We saw medicine cupboards,fridges and trolleys were locked. Doors to medicinerooms had a key pad lock and only authorised staff hadaccess. Doors were secure and locked. Bedsidemedicines storage containers for patients ownmedicines were also locked. Each authorised memberof staff was issued with their own key which waspersonalised to the individual. This meant staff couldonly access areas as dictated by their key. Additionallythe system allowed authorised staff access to medicinecupboards and enabled the organisation to reviewaccess to cupboards if required.

• Medicines trolleys and fridges were clean and tidy. Wefound all the items stored were within date and therewas a system of expiry date checks by pharmacy.

• Security and safety of medicines was audited everythree months. In March 2016, endoscopy was 100%compliant. Non-compliance was found in the day caseward regarding staff not regularly recording ambientand fridge temperatures and action taken whenirregularities found.Additionally, the inpatient ward hadliquid medicine which had been opened and usedwithout the opening date being documented on thecontainer (expiry is one month from opening due to riskof contamination). The audits in June and September2016, found all areas were 100% compliant.

• Staff monitored and recorded the minimum andmaximum temperatures of the medicine refrigeratorand room temperatures where medicines and productswere stored in Bensan ward and the ACU. We sawrecords which indicated this was done daily and clearlymarked. This meant medicines were kept in optimalconditions.The records in the ACU clearly stated ‘not inuse’ on the days the unit was not open.

• On Bensan ward there was suction and piped oxygen inevery patient room. We saw records showing staffchecked the oxygen and suction equipment daily.

• The pharmacy department visited Bensan ward areasdaily, Monday to Friday. They checked all medicinecharts to ensure safe and effective use of medicines.

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Additionally the department organised the medicinesgiven to patients on discharge from a hospital stay(TTA’s). These were kept in a separate locked cupboard,restocked twice a day by pharmacy and dispensed bynurses on discharge.

Records

• No patients were seen without their relevant medicalrecords in the three months before the inspection.

• We saw patient records were stored in locked trolleysand kept securely at the staff stations, which were inconstant sight of staff. This maintained security andprevented unauthorised access of patient records.

• Staff on the endoscopy unit kept full scope-tracking andtraceability records. These indicated each stage of thedecontamination process. We saw the audit scope logbook was completed and up to date. The serviceaudited these records and we saw results of theseaudits, which indicated all stages of the process werecompleted. This followed guidance from the BritishSociety of Gastroenterology on decontamination ofequipment for gastrointestinal endoscopy (2014).

• We saw the record keeping audit completed in October2016. This was to ensure staff complied with therequirements of the standards for clinical recordkeeping policy and protocol in relation to auditingpatient records. The audit consisted of 233 sets of noteswhich were selected at random from the health recordlibrary for the period July to December 2015. The auditshowed three areas of concern whichwere:accountability and identification, legibility andaccuracy of entries and patient detail capture and use ofabbreviations. For example, in the nursing carepathways there were documented signature lists withauthors identified in block capitals, initials and bydesignation. However in the medical section of thenotes this was not the case and signatures wereillegible, there was no designation or identificationthrough the use of block capitals. The action plan of theaudit showed by December 2016 consultant staff wereto be made aware of the identified failings in thestandards of clinical record keeping and staff training.This was part of clinical team meetings to remind staff oftheir responsibilities. The action plan stated there wasto be a monthly audit to start in January 2017.

• We looked at six sets of patient records which weremulti-disciplinary and we saw doctors, nurses andtherapists contributed to a single unified document. Therecords were well maintained and easy to navigate.They were generally compliant with guidance issued bythe General Medical Council and the Nursing andMidwifery Council, the professional regulatory bodies fordoctors and nurses. The records we viewed werecomprehensive, contemporaneous and reflected thecare and treatment patients received. All werecompleted with appropriate assessments, signatures,allergies noted and all observations were documentedand dated. The notes we saw had evidence of medicinereconciliation by the pharmacy team. However, in fourrecords we saw the signatures of clinical staff were oftennot legible and names had not been printed.

• Mandatory training records showed us by December2016, 98% inpatient staff and all staff in ACU hadcompleted information governance training. The trusttarget was 95

Safeguarding

• See the Surgery section for main findings.

• The hospital had a safeguarding policy, 2016 whichincorporated adults and children and these wereaccessible to staff. Safeguarding training was mandatoryfor all staff and achieved either face to face or bye-learning. Training for both adults and children was atinduction and then every three years. We sawmandatory training records which showed us byDecember 2016, 93% inpatients staff and 90% staff inthe ACU had completed level 2 safeguarding childrentraining. All inpatients staff and 90% ACU staff hadcompleted safeguarding vulnerable adults level 2training. The trust target was 95%.

• Staff had a good understanding of what a safeguardingconcern might be. They told us they would escalate anyconcerns to their manager. They knew who thesafeguarding lead was.

Mandatory training

• We saw the training records for staff (excluding medicalstaff) for mandatory training. We spoke with managerswho monitored the completion of mandatory training

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for their teams. We saw they had electronic systems,which recorded the training that was required, and itscompletion dates. Managers described how they usedthe system to ensure staff remained up to date.

• The training programme was comprehensive andcontained all the training subjects that would beexpected. For example, safeguarding adults andchildren, conflict resolution, informed consent, healthand safety. Much of the training was available as on-linelearning packages. No staff we spoke with describeddifficulties accessing these electronic training packages.

• The target for mandatory training set by the hospitalwas 95%. Overall 99% of inpatient staff and 94% of ACUstaff had completed mandatory training by December2016.

Assessing and responding to patient risk

• We looked at the records of medical inpatients and sawa range of risk assessments were used which usednationally recognised and validated tools. Theseincluded assessments for risk of pressure damage(Waterlow), falls and visual infusion phlebitis (VIP) scorefor monitoring infusion sites. We saw these assessmentswere reviewed as required by the hospitals carepathways.

• The hospital’s anticoagulation policy stated everypatient admitted must be assessed for venousthromboembolism (VTE) risk. We saw the risks of VTEwere assessed for each patient and appropriateprophylactic measures were in place as a result of this,for example the use of anti-coagulant medication whenrequired.

• Guidance from NICE CG50 Acutely Ill Patients in Hospital,recommends the use of an early warning scoring systemto identify patients whose condition may bedeteriorating. The hospital used the National EarlyWarning System (NEWS) and we saw this was routinelyused for inpatients where appropriate.

• We found patients physiological parameters such aspulse and temperature were monitored in line withNational Institute for Health and Care Excellence (NICE)guidance CG50 Acutely Ill Patients in Hospital. We

watched observations being taken and noted thetechnique used to monitor their condition. We checkedobservation charts and saw physiological parameterswere conducted at appropriate frequencies.

• There was adequate resuscitation equipment and it waseasily accessible. Staff knew where they were located.

• All staff received training in basic life support andanaphylaxis. Immediate life support training was for allregistered staff and non-registered staff completed basiclife support. This face to face training was part ofinduction and staff attended an update every year. Wesaw mandatory training records which showed us byDecember 2016, all appropriate staff had completedimmediate life support in the inpatients and ACU areas.Basic life support training had been completed by allinpatient staff and 67% of staff in ACU.

• Medical cover was provided by the resident medicalofficer (RMO) 24 hours a day seven days a week. TheRMO was selected on their experience to enable them tomanage and respond to risks relating to the wide mix ofpatients at the hospital.

• An official on call rota was available for support out ofhours. The rota was collected from reception every dayand consisted of contact details for the RMO and asenior manager.

• The inpatient rooms on Bensan ward had access to anurse call system which was directed straight to nurse’shandsets.When the system was activated an audiblealarm was not heard by all and this indicated otherpatients were not disturbed during the night and restperiods. The system was used to alert staff when apatient required assistance, an emergency call and acardiac arrest call. This meant all staff on the ward wereaware when a patient required assistance and were ableto respond in a timely manner. The handsets were alsoused as a mobile telephone to enable nurses tocommunicate with each other.

• The hospital had a service-level agreement (SLA) with alocal NHS hospital. This enabled them to transfer anypatients who became unwell and needed critical caresupport.

• Bensan ward had ‘sepsis six’ kits, the name given to abundle of medical therapies designed to reduce the

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mortality of patients withsepsis. The‘sepsis six’consistsof three diagnostic and three therapeutic steps, all to bedelivered within one hour of the initial diagnosis ofsepsis.

Nursing staffing

• There was sufficient staff with the qualifications, skillsand experience to meet the needs of patients. Staffingrotas showed there was always registered staff availablein each department.

• Clinical staff were supported by other members of staffincluding health care assistants, porters, housekeepersand administrative staff. Staff we spoke with told us theyconsidered there was sufficient nursing staff to meet theneeds of patients. Patients echoed this view and told usany requests for help or care were responded topromptly.

• The hospital employed 24.8 Whole Time Equivalent(WTE) registered nurses and 13.5 WTE health careassistants (HCA’s) in the day case and inpatientdepartment.

• The use of bank and agency nurses in the inpatientdepartments was lower than the average of otherindependent acute hospitals CQC hold data for betweenOctober 2015 and June 2016. There was no use of bankand agency health care assistants in the departments inthe same reporting period. Staff told us the usage ofagency nurses was higher at night and these wereregular agency nurses.

• The ACU employed 11.46 WTE nurses and had a vacancyfor 16 hours each week. We saw the unit used 2.4 WTEagency nurses each week who were regular agencynurses and all were familiar with the department.

Medical staffing

• The medical staffing arrangements are reported onunder the surgery service within this report.

Emergency awareness and training

• The medical staffing arrangements are reported onunder the surgery service within this report.

• We saw mandatory training records which showed us byDecember 2016, 98% inpatients staff and 100% ACU staffhad completed fire safety training. The trust target was95%.

Are medical care services effective?

Good –––

We rated effective as good.

Evidence-based care and treatment (medical carespecific only)

• Relevant and current evidence based guidance,standards, best practice and legislation were used todevelop how services, care and treatment weredelivered. Including; National Institute for Health andCare Excellence (NICE) guidance CG161: falls in olderpeople assessing risk and prevention, QS24: nutritionsupport in adults, QS3: venous thromboembolism (VTE)in adults reducing the risk in hospital, QS66: intravenous(IV) in adults in hospital therapy and QS90: urinary tractinfections (UTI) in adults and NG51: sepsis: recognition,diagnosis and early management. NICE guidance wasreviewed at clinical governance meetings and ifrelevant, discussed with clinicians to ensure bestpractice.

• We reviewed a range of clinical policies and found thatall expected topics related to relevant and currentevidence based practice and legislation. Staff were ableto access national and local guidelines through theinternal computer system. This was readily available toall staff. Staff demonstrated how they could access thesystem to look for current hospital guidelines. We notedthere were appropriate links in place to access nationalguidelines if needed.

• Patient records we reviewed showed the care patientsreceived was consistent with NICE guidelines andprotocols in use at the hospital.

• We saw an alert system that could be quickly cascadedthrough the hospital to ensure people were workingwithin the national framework for the Medicines andHealthcare Products Regulatory Agency (MHRA). This isresponsible for ensuring that medicines and medicaldevices work and are acceptably safe.

• Endoscopy procedures were completed in line withprofessional guidance, for example NICE safe sedationpractice and British Society of Gastroenterology.

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• The endoscopy unit did not have Joint Advisory Group(JAG) accreditation at the time of inspection. The servicehad registered with JAG and had completed anendoscopy global rating scale (GRS) self-assessment.GRS is a quality improvement system designed toprovide a framework for continuous improvement forendoscopy services to achieve and maintainaccreditation. We saw minutes of meetings which wereheld every other month to discuss the progress of theapplication and this was led by a gastroenterologist. Wesaw the department had met level B of their applicationby April 2016 (level ‘A’ item on the GRS is seen asaspirational and best practice measures).

• The hospital had an equality and diversity strategy andplan to ensure there was no discrimination againstpatients when making care and treatment decisions.The strategy encompassed the nine protectedcharacteristics of the Equality Act 2010, for example age,disability and sexual orientation.

Pain relief (medical care specific only)

• We saw effective pain control was an integral part of thedelivery of care. Pain scores were documented on theNEWS charts in patient’s records and managedaccordingly. Patients had regular assessments for painand appropriate medication was given frequently andas required.

• The hospital had implemented the Faculty of PainMedicine’s Core Standards for Pain Management (2015).There were guidelines for prescribing using NICEguidance, for example opioids (a strong pain killer).

• None of the patients we spoke with required pain reliefat the time of our inspection. Staff told us they wouldescalate any concerns around pain relief to the ResidentMedical Officer (RMO).

• We saw the results of the audit conducted in October2016 to collect information regarding the incidence ofpostoperative pain and nausea (POPV) and vomiting ofgynaecological patients in the first 24 hours when on theward. The pain results did not reach the suggestedtarget of no or mild pain in more than 95% of patients.However, the audit showed the incidence of POPVreached the target of less than 20%. Recommendationsfrom the audit included an increased sample size of theaudit, different surgical procedures and review of thetype and method of recording relevant questions.

Nutrition and hydration

• We saw risk assessments were completed by a qualifiednurse when patients were admitted to hospital. Thisincluded a nutritional screen assessment tool MUST(Malnutrition Universal Screening Tool) which identifiedpatients who were at risk of poor nutrition ordehydration. This was part of the pressure ulcerprevention policy to identify those patients who were atrisk.

• We found patients and those supporting them hadaccess to hot and cold drinks at all times. We saw drinksmachines were available in waiting areas and we notedinpatients always had a drink within reach.

• We saw fluid intake was monitored using fluid balancecharts. This included the administration of intravenousfluids if prescribed, when oral fluids were started andthe patient commenced their diet.

• The hospital had a dietician who provided nutritionalsupport and expertise to bariatric patients before andafter surgery. The dietician also provided additionalsupport and advice for other patients.

Patient outcomes (medical care specific only)

• The hospital had a robust audit programme and we sawthe audit schedule for 2016. Audits for the day case andinpatient wards included National Early Warning System(NEWS), admissions and discharge lounge function anduse, patient satisfaction and infection control andhygiene. Audits for the ambulatory care unit includedcomfort, consent, completion rates, JAG audit censusand patient satisfaction.

• The care pathway used ensured key data was capturedin relation to patient outcomes which assisted thedepartments to define audits to measure efficacy ofcare. We saw audits were completed and reported tothe departments, the clinical governance committeeand clinical effectiveness meetings. Trends wereidentified and action plans created to improve theservice to patients. This was communicated back to theclinical departments for their action.

• The hospital reviewed patient satisfaction feedback,incidents and complaints, activity data and staffsurveys. This enabled them to monitor patientoutcomes to enable them to benchmark against similarservices and improve people’s outcomes.

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Competent staff


• Staff in the medical care service had the relevantqualifications and memberships appropriate to theirposition. There were systems which alerted managerswhen staff’s professional registrations were due and toensure they were renewed. These were demonstrated tous.

• The hospital provided training courses for staff topromote career and personal development. Thisincluded diploma and degree modules, NationalVocational Qualification (NVQ) training andmanagement skills. Nursing staff told us they had accessto local and national training. This contributed tomaintaining their registration with the Nursing andMidwifery Council (NMC).

• The mandatory training programme included trainingfor essential professional development for clinical skillsand knowledge. Subjects covered included medicaldevices, intravenous administration and allergyprotocol. Data showed us the majority of registered staffacross the hospital had achieved the 95% target in allsubjects.

• Sepsis training was part of induction and staff attendedan update every year. Sepsis arises when the body’sresponse to an infection damages its own tissues andorgans. It can lead to shock, multiple organ failure anddeath, especially if not recognised early and treatedpromptly. We saw 98% of registered staff had attendedthe training by October 2016. Staff we spoke with wereable to describe the prompt action to be taken in thisevent.

• Scenario training was provided for staff every threemonths in different areas of the hospital with differentsubjects, for example sepsis training and this was lastcompleted in December 2016. We saw and staff told usabout the training schedule for the training day whichwas booked for two days after the inspection. Thesubject of the training was the use of the oxygenmachines to be used for bariatric (extremely obese)patients.

• We saw the hospital received assurances from theagency used for nursing staff. This included training,qualifications, disclosure and barring service (DBS)check, immigration status, professional registration anddetails of induction.

• Data showed all staff had received an appraisal in theyear January to December 2016. All staff we spoke withtold us they had received an annual appraisal. They toldus this process was effective in developing their skillsand knowledge further. It also contributed tomaintaining registration with the NMC.

• We observed nursing handovers on Bensan ward tookplace at 7.30am, 1pm and 7.30pm every day. Nursesused handover sheets to provide written information oneach patient including allergies, relevant safetyinformation such as pressure area care and anysignificant medical history. This ensured an effective,accurate and patient centred approach to care.

• Agency staff who worked in the ACU were regular staffthat were familiar with the department. Staff showed usdocumentary evidence of agency staff inductions andformal competencies assessments.

Multidisciplinary working


• Staff told us they worked well as a team in theirdepartments and all other areas of the hospital. We sawa strong multi-disciplinary approach across all the areaswe visited. We observed good collaborative working andcommunication amongst all staff in and outside thedepartments.

Access to information (medical care only)

• Clinical staff were able to access results of diagnostictests via a picture archiving and communication system.This is medical imaging technology which provideseconomical storage and convenient access to imagesfrom multiple machine types.

• Staff in medical care services could access a shareddrive on the computer where policies and hospital wideinformation was stored. Staff demonstrated this to us.

• Some medical staff were provided with an NHS emailaddresses for confidential transfer of patient datarelating to all NHS contracts.

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• We saw ward based handover sheets for staff toreference. Staff regularly updated these, whichcontained current and accurate information aboutpatients’ needs, treatment plans, risks and theirmanagement. We attended a handover meeting andfound there was adequate communication of patient’son-going needs and of any risks to their well-being.

• Staff sent discharge summaries to GPs on dischargefrom hospital which we observed.

• Endoscopy patients received a letter on discharge. Thisincluded the reason for the procedure, findings,medication and any changes, potential concerns andwhat to do and details of any follow up. A copy of thisletter was send to the patients GP and a copy was keptat the hospital in the patients’ medical records. Thismeant there was a continuity of service and all medicalteams were kept informed.

Consent, Mental Capacity Act and Deprivation ofLiberty Safeguards (medical care patients and staffonly)

• The hospital had a policy for consent to examination ortreatment. The policy demonstrated the process forobtaining consent, documentation, responsibilities forthe consent process and use of information leaflets todescribe the risks and benefits. We saw signed consentforms in six medical records which showed patients hadconsented to treatment in line with the hospital’s policy.We saw the forms outlined the expected benefits andrisks of treatment so patients could make an informeddecision.

• Informed consent was part of mandatory training for allclinical staff. We saw training records which showed usby December 2016, all inpatient staff and 90% staff inACU had completed informed consent training. The trusttarget was 95%.

• The hospital had policies for Mental Capacity Act (MCA)and Deprivation of Liberty Safeguards (DoLS). Thepolicies gave guidance on the local policies, practiceand procedures to be followed by hospital staff whenworking with individuals who may lack mental capacityor are or may become deprived of their liberty. Staff hadaccess to flowcharts to prompt them of the process.

• All clinical staff received training in MCA and DoLS aspart of their induction and then as identified on their

personal development record. Training records showedus by December 2016, 98% inpatient staff and 90% ACUstaff had completed the training. This was worse thanthe 95% target. However, we saw clear guidanceavailable to all staff as part of the hospital’s ‘Informedconsent policy’.

• We spoke with a range of clinical staff who could allclearly describe their responsibilities in ensuringpatients consented when they had capacity to do so orthat decisions were to be taken in their best interests.

Are medical care services caring?

Outstanding –

We rated caring as outstanding.

Compassionate care


• We saw staff treating patients in a kind and consideratemanner. Patients and their friends and family told usstaff always treated them with dignity and respect.

• Staff maintained patients’ privacy and dignity. We sawstaff knock and wait before entering patient’s rooms inall areas of the hospital. We observed staff were kindand patient in their approach.

• Patients told us, and we observed, call-bells were leftwithin reach of patients and were answered promptlyand staff responded promptly to requests for assistance.

• All patients were asked to complete a satisfactionquestionnaire that incorporated questions of all aspectsof their care and experience. The hospital measurednational survey information, for example the Friendsand Family Test (FTT), and used all patient feedback toguide investment plans, treatments offered and theoverall patient experience.

• Data was submitted to the FFT for NHS patients only.The hospital's FFT scores were variable between Apriland September 2016 with an average score of 97%.Response rates were better than the national average ofNHS patients across the same period with an average of51%.

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• We spoke with six patients and five of their family andfriends during our visit who were positive about thehospital and care received. One patient told us “I cannotfault the hospital” and “everybody is lovely”.

• During the inspection we asked patients to completefeedback forms to describe their experience at thehospital. We collected four completed cards relevant toBensan ward and the ambulatory care unit.The cardswere all positive about the hospital and includedcomments “the staff were brilliant, I couldn’t have askedfor more” and “a lovely hospital and lovely staff”.

Understanding and involvement of patients and thoseclose to them


• We observed staff discussed treatments with patients ina kind and considerate manner. The patients and theirrelatives we spoke with told us staff were caring andprofessional. They felt involved in their care and weregiven adequate information about their diagnosis andtreatment. They felt they had time to ask questions andthat their questions were answered in a way they couldunderstand.

• We observed staff introducing themselves to patientsand their relatives.

Emotional support


• Patients reported they felt able to discuss theiremotional state with staff if required.

• Staff showed us how they could access counsellingservices and other psychological support for a patient ifit was needed.

• We saw staff interacting with patients in a supportivemanner and provide sympathy and reassurance.

Are medical care services responsive?

Good –––

We rated responsive as good.

Service planning and delivery to meet the needs oflocal people

• The hospital had arrangements and collaboration withClinical Commissioning Groups (CCGs) and the localNHS acute trusts. This ensured people had choicesabout where they received treatment but also thatwaiting was kept to a minimum. This meant the localpopulation had choice as to where they could receivetheir care and treatment and the provider was focussedon their needs.

• Patients told us they had been offered a choice of timesand dates for their appointments.

• The endoscopy unit was open Monday to Friday. Thehospital provided endoscopy services to both NHS andprivately funded patients.

• Inpatient wards had single rooms with separate showerand toilet facilities. The hospital providedcomplimentary toiletries for each patient. There weretelevisions available and internet connections in eachroom for patients to use.

• Visitors of inpatients on Bensan ward were welcomebetween 11am and 1.30pm and between 3pm and 8pmevery day.Outside of these hours visiting was byagreement with the nursing staff.

• The restaurant was accessible to all. We saw cold andhot drinks were available in all waiting areas we visited.

• The hospital had lounges and gardens for patients andvisitors use.

• The hospital had a volunteer programme. We spokewith volunteers who offered a guiding service, receptionand general information for patients and visitors.

Access and flow

• See the Surgery section for main findings on referral totreatment times.

• The discharge process was nurse led and started at timeof admission. We saw the care pathways used directedstaff to consider all aspects of discharge planning forinpatients. We saw all sections had been completedwhich meant patients were protected from the risksassociated with poorly planned discharge from thehospital.

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Outstanding –


• Nurses on the wards would refer to the communityteams if a patient required additional assistance whenthey returned home. For example, medication andwound care. Inpatients were provided with a dischargesummary to pass to their GP.

• The GP’s of endoscopy patients were sent a copy of thedischarge letter on the same day as the procedure.

• Data showed 82% of patients were day cases in 2016.The average length of stay for inpatients was two nights.

• The hospital monitored incidents of day caseconversions. We saw the information was collectedmonthly as part of the governance process to monitoras part of key performance indicators (KPI’s). Thehospital reported 96 incidents between January andDecember 2016 of patients admitted as a day case andrequired an overnight stay due to clinical complications.These were reported on the incident reporting system.Each incident was described, categorised, result, actiontaken and investigation and lessons learned ifappropriate. All incidents were reported as no harmexcept for one incident which was rated as a near miss.The investigation of the near miss highlighted thecomplication caused should have been identified onadmission. The lessons learned showed all staff to lookcomprehensively at pre-admission records.

Meeting people’s individual needs

• All staff received equality and diversity training as part ofinduction and then every three years by e-learning.Wesaw mandatory training records which showed us byDecember 2016, all staff in inpatients and in theAmbulatory care Unit (ACU) had completed equality anddiversity training.

• The endoscopy suite in the ACU had separate male andfemale changing and recovery areas to maintainpatient’s dignity.

• The physiotherapy team saw patients on Bensan wardtwice a day, seven days a week. They did not seepatients between 1.30pm and 3pm as this wasprotected rest time for the patients.

• Hotel service assistants on the ward discussed themenu with patients and collected their choices. Patientshad the opportunity to order meals that were not on themenu. Cultural and therapeutic diets were available, forexample, gluten-free, Kosher or Hal-al.

• Literature was available to help patients understandtheir care, treatment and general health issues. We sawa variety of health-education literature and leaflets inthe reception area. Some of this information wasgeneral in nature while some was specific to certainconditions.

• We did not see any leaflets in any other languages apartfrom English. However, staff told us these were rarelyneeded and they could access leaflets in otherlanguages if required, from a central database.

• Staff could tell us how they would access translationservices for people who needed them. We wereprovided with two examples from 2016 when patientswere provided with face to face translators. The hospitalhad access to a telephone interpreter service for aconsultation and individual interpreters who wouldfollow the patient through the journey of admission,consent, accompany to surgery, and were available inthe recovery room and on ward.

• Patients who were living with a learning disability ordementia were identified by staff when the referral wasreceived. Staff told us if applicable, the appropriateindividualised care and support was provided, forexample appointments to accommodate individualneeds. Bensan ward had facilities for family and friendsto stay with the patient if required.

• All staff received dementia awareness training as part ofinduction and then every three years by e-learning. Wesaw mandatory training records which showed us byDecember 2016, 98% inpatients staff and all staff in theACU had completed dementia awareness training. Thetrust target was 95%.

• The hospital had started an initiative in December 2016to ensure the hospital was dementia friendly. This hadinvolved an awareness campaign and recruitingdementia champions for each department.

• The hospital had allocated disabled parking bays anddisabled toilets to accommodate patients living with amobility disability. The hospital had several wheelchairsavailable for patients to use if required.

Learning from complaints and concerns

• The hospital recognised there may be occasions whenthe service provided fell short of the standards to whichthey aspired and the expectations of the patient were

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not met. Patients who had concerns about any aspect ofthe service received were encouraged to contact thehospital in order that these could be addressed. All staffwere encouraged and empowered to identify andaddress any concerns or issues while the patient wasstill in the hospital.

• The responsibility for all complaints rested with thehospital director who would decide which head ofdepartment and/or consultants needed to be involvedin the investigation. Matrons, managers and serviceleads had delegated responsibility for the managementof complaints arising in their areas of responsibility andwere responsible for updating the clinical governancecommittee on issues raised.

• We saw complaints and compliments were formallydiscussed at the clinical governance meetings anddepartment meetings as appropriate. This reviewedpatient satisfaction data, complaint trends, onwardsaction as appropriate and areas for continuousimprovements for the patient experience.

• The hospital’s complaints policy set out the relevanttimeframes associated with the various parts of thecomplaint response process. The patient experienceand governance lead triaged all written complaintsreceived and directed for appropriate management. Aninitial acknowledgement was required within twoworking days and a full response within 20 workingdays. If a complaint was escalated to a further stage thecomplainant would be given the information of who totake the complaint to if they remained unhappy with theoutcome. Private patients were signposted to anindependent adjudicator and NHS patients treated atthe hospital, to the NHS Ombudsman.

• During the complaint investigation the process wasmonitored to ensure timescales were adhered to andresponses provided within 20 working days. If aresponse was not able to be provided within thistimeframe a holding letter was sent so they were keptfully informed of the progress of their complaint. Allcomplaints information was retained within a paper file,with copies retained electronically and also stored in thehospital information management system.

• We saw there were three formal complaints made bypatients for medical care services between April andSeptember 2016. One related to lack of information

received on discharge, another the mismanagement ofpost-surgical pain and the third related to poor nursingcare and the patient felt they were not treated withdignity or compassion. For all three complaints we sawthe hospital had responded within the required timeframe by letter and a representative from the hospitalhad met with the patient. All three complaints wereresolved and showed lessons learnt from the hospital.Individual members of staff affected were provided withextra training where appropriate. We saw thecomplaints were discussed at ward meetings.

Are medical care services well-led?

Outstanding –

We rated well-led as outstanding.

Leadership and culture of service

• Staff in ambulatory care unit (ACU) and Bensan wardreported to the matron for wards and ACU.The matronreported to the director of patient services who sat onthe hospital’s executive committee.

• There were clear lines of leadership and accountability.Staff had a good understanding of their responsibilitiesin all areas of medical care services. Staff told us theycould approach immediate managers and seniormanagers with any concerns or queries.

• Staff saw their managers every day and told us theexecutive team were visible and listened to them. Anychanges made were communicated through teammeetings, newsletters and emails. We saw examples ofnewsletters on notice boards.

• Staff told us the hospital was a good place to work,everyone was friendly, they had sufficient time to spendwith their patients and they were proud of the work theydid.

• The rate of sickness for inpatient nurses and health careassistants (HCA’s) was lower than the average of otherindependent acute hospitals CQC hold data for betweenOctober 2015 and September 2016. There were nounfilled shifts reported in the last three months of thereporting period.

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• The rate of inpatient nurse vacancies was 2.38 wholetime equivalent (WTE) giving a vacancy rate of 9%. Therewere no vacancies for HCA’s in the department.

• The turnover rate for inpatient nurses was 7% betweenOctober 2015 and September 2016. This was a decreaseof 4% from the previous reporting period. The turnoverrate for HCA’s was 7% in the previous and currentreporting period.

• In January 2016, the hospital introduced an employeeassistance programme. This was designed to improvethe wellbeing of staff offering them support, guidanceand advice. Staff had unlimited access to 24 hoursupport and advice line to talk in confidence on anyissue causing concern including anxiety, stress,depression, grievance and harassment. Staff we spoketold us they were aware of the service.

Vision and strategy for this this core service (for thiscore service)


• We were told the mission of the hospital was to be aleading provider of high quality healthcare serviceswhich improved patient’s health. The strategic aimswere to maintain a robust business that was capable ofgenerating a reasonable surplus in order to invest in theachievement of their purpose.

• We saw and were told the hospital aimed to invest instaff to provide appropriate training and developmentto support practice. Additionally, they aimed to engagewith stake holders and work together to provide anincrease in knowledge and an improved service topatients.

Governance, risk management and qualitymeasurement (medical care level only)

• The service governance processes were the samethroughout the hospital. We have reported about thegovernance processes under this section of the surgeryservice within this report.

• We saw the minutes of staff meetings for the inpatientwards. These were held every two months and we sawthe agenda for the next meeting 23 January 2017. Wesaw key staff attended and the agenda items covered allthe main areas of concerns, and actions were identified

to individuals. We saw the meetings followed a standardtemplate with standing items to be discussed at everymeeting, for example audit results, patient pathwaysand staff training.

• The managers of the inpatient ward and ACU wereproactive in their understanding of the risks that couldaffect medical care services. We saw a separate riskregister which included a list of 22 risks which wereclearly identified and mitigating actions were related.The risk register was linked to the incident reportingsystem. Risks listed included the security of medicalrecords, the use of the lift, sharps and access and use ofbalconies. Each of the 22 risk had separate riskassessments and further relevant information. Forexample, a patient or their adult family or friend whowished to access the balcony a separate form was to becompleted and the risks involved explained.

• The minutes and actions from the clinical governance,Medical Advisory Committee (MAC), health and safety,infection prevention meetings were reported to themedical care service managers. The information wascascaded to the wider team through departmentalmeetings and staff briefings.

• A structured audit programme supported the hospital toensure patient safety was at the forefront of serviceprovision. Actions were monitored locally and withinsub-committees and clinical governance meetings.These ensured lessons could be learnt and actions hadbeen completed.

Public and staff engagement

• We saw posters in patient areas asking if patients hadcomments, compliments or a concern they were speakto the matron, ward sister or staff nurse and thesepeople were identified on the posters. Additionally,information of how to give feedback was provided inleaflets and available on the hospital’s website.

• Feedback from patients enabled the hospital to run‘spotlight’ experience events which looked athighlighted issues of care. These typically ran for onemonth and recent topics included site development,nursing care and doctors.

• Patient feedback cards were obtained and specificallyasked about pain relief, patient needs and trust in staff

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and we saw feedback was consistently over 90%.Additionally we saw a survey was undertaken bycatering department on a regular basis to obtainpatients feedback regarding the menu offered.

• We saw information displaying the results of patientsurveys and what patients thought about the care theyreceived on the ward. The information was updatedeach month with patients’ comments about theirexperience in hospital which included what the hospitalwas doing well and where they could do better, underthe title ‘you said, we did’. This meant the hospital waslistening to patient feedback and act on suggestionsand concerns to improve services. For example, staff onBensan ward told us a patient had provided feedbackabout the position of the shaving plug and the mirror inthe shower rooms. This had resulted in specific shavingmirrors being fitted to assist patients with their personalcare.

• Staff told us they were engaged in the changes occurringat the hospital and senior managers consulted themabout the changes, asking their opinion.

• The results of the staff survey completed in December2015 showed a response rate was 49% which wascomparable with the response rates from previous staffsurveys. The results showed 85% of staff agreedBenenden was a fair employer and 91% felt part of ahappy and healthy workforce.

• The hospital encouraged social interaction for staffthrough a range of events organised specific to thehospital. This included charitable initiatives toencourage staff engagement in a social context, forexample the awareness campaign ‘sock it to sepsis’.

Innovation, improvement and sustainability

• Innovation, leadership and excellence were recognisedat the annual staff awards. The awards were called ‘Bestof Benenden’ and a HCA on Bensan ward received anaward for leading and inspiring others.

• The management structure of hospital meant individualmembers were familiar with all aspects of the business.Decisions taken at board level could immediately beimplemented as actions and were allocated to thosepresent and systematically followed up.

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Safe Good –––

Effective Good –––

Caring Outstanding –

Responsive Good –––


Are surgery services safe?

Good –––

We rated safe as good.

Incidents

• Between October 2015 and September 2016, thehospital reported no never events. Never Events are atype of serious incident that are wholly preventable,where guidance or safety recommendations thatprovide strong systemic protective barriers are availableat a national level, and should have been implementedby all healthcare providers.

• Between October 2015 and September 2016, there were503 clinical incidents and 84 non-clinical incidentsrelating to surgery or inpatients. In the same period,there were 771 clinical incidents across the hospital.Hospital data showed 99.1% of incidents were low harmor no harm. This demonstrated the positive incidentreporting culture we observed.

• The hospital used an electronic system for reportingincidents. Staff could describe the process for reportingincidents, and gave examples of times they had donethis. All staff we spoke to had confidence in the incidentreporting process.

• The hospital had effective systems to ensure stafflearned from incidents to improve patient safety. Headsof department, such as the theatre manager or wardmanager, investigated incidents. The clinicalgovernance committee (CGC) reviewed more significantincidents and any trends in incident reporting, such asreturns to theatre and readmissions. We saw evidence of

CGC meeting minutes, which reflected this. The servicealso escalated some incidents to the medical advisorycommittee (MAC) and the senior management teammeetings for review. Again, meeting minutes providedevidence of this.

• Staff told us they received feedback with any learningfrom incidents at ward or theatre meetings. We sawcopies of theatre and ward meeting minutes, whichreflected this. Staff were able to give us examples ofchanges to practice following incident learning. Thisincluded introducing bladder scans before discharge forday surgery patients following an incident where apatient had urinary retention.Urinary retention is thesudden inability to pass urine, and occasionallyhappens after surgery. It is usually painful and requiresurgent treatment with a catheter.

• Staff we spoke with were aware of the duty of candour(DoC) under the Health and Social Care Act (RegulatedActivities Regulations) 2014. The DoC is a regulatoryduty that relates to openness and transparency andrequires providers of health and social care services tonotify patients (or other relevant persons) of “certainnotifiable safety incidents” and provide them withreasonable support. Staff knew what DoC meant andgave us examples of incidents which triggered DoC,such as drug errors. Staff could describe theirresponsibilities relating to DoC.

• The hospital did not carry out mortality and morbidityreview meetings as a matter of course. This was in partdue to the acuity level of patients treated and theconsequent low numbers of patients that would fall intothese categories. For example, the hospital had nopatient deaths between October 2015 and September

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2016; therefore, mortality meetings were not applicable.However, the hospital could review mortality andmorbidity through their multidisciplinary clinicalgovernance committee should the need arise.

Clinical Quality Dashboard or equivalent (how doesthe service monitor safety and use results)

• Hospital data showed no surgical inpatients acquired apressure ulcer between October 2015 and September2016. In the same period, three patients had acatheter-associated urinary tract infection (CAUTI) andsix patients had a fall. Data showed the harm-free carerates were 100% for pressure ulcers, 99.97% forcatheter-associated UTIs and 99.94% for falls.

• The service reported seven cases of acquired venousthromboembolism (VTE) or pulmonary embolism(blood clots in veins) in October 2015 to September2016. The hospital fully investigated each case usingroot cause analysis (RCA). We saw copies of RCAs for thelast four cases of VTE. All RCAs showed staff calculatedthe risk of VTE correctly and gave appropriateprophylaxis, such as anti-embolism stockings, inaccordance with the hospital’s “anticoagulation policy”.All RCAs showed the VTEs could not have beenprevented. However, one RCA identified the need forstaff to recognise and escalate early signs of VTE morequickly. Nursing staff received feedback around this at award meeting. The hospital’s clinical skills facilitator alsoadded learning from this incident into immediate lifesupport training.


• All clinical areas were visibly clean and tidy. We saw “Iam clean stickers” on equipment to provide staff withassurance that equipment was cleaned and ready touse. The hospital had an external infection controlenvironmental audit in August 2016. The externalauditor found an “excellent” standard of domesticcleaning throughout the ward and other departments,including theatres. The report also stated, “The cleaningof equipment undertaken by nursing staff was of a highstandard, reflecting good compliance with the Healthand Social Care Act 2008: code of practice on theprevention and control of infections and relatedguidance”.

• We saw copies of daily, weekly and monthly cleaningschedules in theatres. The hospital carried out monthly

cleaning audits. Audit results for 2016 showed theatres,ward areas and other clinical areas consistentlyexceeded the 90% hospital target every month inJanuary to December 2016. The average cleaning scoresfor 2016 were 95% for ward areas, 93% for theatres and93% for other clinical areas. This demonstrated thehospital had assurance around cleanliness.

• The hospital carried out quarterly mattress, pillow andduvet audits. These confirmed the hospital condemnedany stained or damaged mattresses, pillows or duvets.The hospital’s policy was to discard any duvet in use formore than one year, or earlier if there was any damageor staining. We saw that mattresses on the ward hadcovers that could be wiped to allow effective cleaning.We randomly checked the mattress, pillows and duveton an inpatient bed on Bensan Ward and saw that theywere visibly clean.

• The hospital’s annual IPC report for 2016 detailedactivities to ensure the hospital met the requirements ofthe Department of Health: Code of Practice on theprevention and control of infections and relatedguidance. This programme of work was mapped to thecompliance criteria within the code of practice andincluded systems to manage and monitor theprevention and control of infection, maintain a cleanand appropriate environment, ensure appropriate useof antimicrobials and ensure all staff were fully involvedin the process of preventing and controlling infection.

• All staff we met were bare below the elbows to alloweffective handwashing. Alcohol hand sanitiser andclinical wash hand basins were available in all clinicalareas. All clinical wash hand basins, including those inpatient bedrooms on Bensan Ward, were compliantwith the Department of Health’s Health Building Note00-09. We saw staff wash their hands and use hand gelappropriately, for example before and after patientcontact. This was in line with the world healthorganisation’s (WHO) “Five moments for hand hygiene”.

• Monthly hand hygiene audits showed the theatredepartment consistently achieved 100% compliancewith hand hygiene policy in January to September 2016.This meant all theatre staff cleaned their handsappropriately in line with the WHO’s “Five moments forhand hygiene”. Hand hygiene audits also assessed hand

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washing technique and dress code such as “bare belowthe elbows”. This meant the audits measured theeffectiveness, as well as the frequency, of hand washingand cleaning.

• In the same period, the eye department scored between93% and 100% on hand hygiene audits. Ward staffscored between 84% and 100%. However,ophthalmology achieved 100% compliance in five out ofnine months during this period. Ward staff achieved100% compliance in four out of nine months. Theinfection prevention and control (IPC) link nurse for eacharea fed back to departmental managers with any areasof non-compliance for action.This meant the hospitalcould be confident staff cleaned their hands in line withhospital policy, and that staff challenged non-compliantbehaviour.

• All theatre staff dressed appropriately in scrub suits anddesignated theatre shoes. Staff were not permitted intoany clinical areas within the theatre department inoutdoor clothing. We saw a sign on the internal doorswithin theatres reminding staff of the need to weartheatre clothes in these areas. Staff either changedclothes or wore a clean gown over their theatre clothesif they needed to visit other areas within the hospital.We saw that all staff followed this policy.

• We saw appropriate personal protective equipment(PPE), such as gloves and aprons, available in all clinicalareas. We saw staff using PPE appropriately, forexample, when cleaning patient rooms.

• The hospital had an onsite sterile services department(SSD) for the sterilisation of instruments. The serviceoffered a four-hour turnaround time on instruments,and a fast-track service if theatres needed particularitems more urgently. The SSD used an electronictraceability system to enable the tracking and tracing ofinstruments for quality assurances purposes. Staff toldus they had used the tracking system to carry out “lookback exercises”, for example, following an infection. Thisallowed the service to establish which individualinstruments were used on which patients, and when.The SSD was working towards achieving externalaccreditation in 2018.

• The SSD had a “two door system” to ensure dirtyinstruments did not contaminate clean areas. Dirtyinstruments went into washers through one door and

came out of a second door into the “clean” room. Therewere no personnel doors between “clean” and “dirty”areas. This meant staff could not move inappropriatelybetween these areas. We saw that all staff in SSD woreappropriate theatre clothing including sterile gowns;and PPE such as eye protection.

• In all clinical areas we visited, we saw the correctsegregation of clinical and non-clinical waste intodifferent coloured bags. We saw that staff had correctlyassembled, dated and labelled sharps bins and that nosharps bins were overfull. This was important to preventinjury to staff and patients from sharp objects such asneedle sticks. These practices were in line with HealthTechnical Memorandum (HTM) 07-01: Safe managementof healthcare waste

• The hospital reported no infections of MRSA ormethicillin-sensitive Staphylococcus aureus (MSSA) inOctober 2015 – September 2016. There were noreported cases of Escherichia coli or Clostridium difficile(C. diff) in the same period.

• At the pre-operative assessment stage, staff screenedhigh-risk patients for Meticillin-resistant Staphylococcusaureus (MRSA), such as orthopaedic surgery, those whohad been in hospital previously and patients who hadpreviously tested positive for the bacteria. This was inline with Department of Health: Implementation ofmodified admission MRSA screening guidance for theNHS (2014).

• We saw evidence of MRSA screening in five patientrecords we reviewed. However, one patient’s negativeMRSA result was more than one year old. The patientwas unable to attend for re-screening before theiroperation. However, we saw evidence in the notes thatthis patient’s operation took place at the end of theoperating list. This gave theatre staff sufficient time tocarry out a deep clean of the operating theatre beforethe next day’s list. After surgery, the patient had a singleensuite room on Bensan Ward. This would minimise therisk of potential transfer of MRSA to other patients.

• The hospital took part in the Public Health England(PHE) surgical site infection surveillance service (SSISS).This allowed the hospital to benchmark its infection

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rates against other hospitals and identify areas forimprovement. The hospital supplied surgical siteinfection (SSI) data to PHE on hip replacements andknee replacements.

• As part of the SSISS, the hospital sent out post-operativequestionnaires to patients. This helped them identifymore patients who developed an SSI after discharge. Forexample, patients who contacted their GP rather thanthe hospital for diagnosis and treatment of an SSI.

• The hospital’s PHE SSI report for October 2015 to June2016 showed 0.5% of patients developed an SSIfollowing hip replacement during this period. This wasbetter than the average infection rate of 1.2% for otherhospitals that sent patient questionnaires during thesame period.

• In October 2015 to June 2016, 1.8% of patientsdeveloped an SSI following knee replacement. This wasabout the same as the average infection rate of 1.9% forother hospitals that sent patient questionnaires duringthis period.

• In total, the hospital reported 46 surgical site infectionsin October 2015 to September 2016. The rates ofinfections following primary knee arthroplasty,gynaecology, upper gastro-intestinal and colorectal,urological and vascular procedures were worse than therates for other independent acute hospitals we holddata for.

• However, we saw that the hospital reported allsuspected wound infections, even if microbiology testsconfirmed there was no microbial growth. The reportingof all unconfirmed SSIs allowed the hospital tofollow-up all cases and monitor any trends. Thisreflected the positive incident reporting culture we sawduring our inspection. We reviewed SSI incidentinvestigations and saw that there were no deepinfections. All infections were superficial and resolvedfollowing antibiotic treatment.


• We checked two resuscitation trolleys, one in theatresand one on Bensan Ward. On both trolleys, allequipment and drugs were within their use-by dates.

We also saw checklists for both trolleys showingevidence staff checked the trolleys daily. This providedassurances emergency equipment was safe and fit forpurpose.

• We checked the anaesthetic machine in AnaestheticRoom Two and saw a logbook showing evidence of dailychecking with no gaps. This was in line with theAssociation of Anaesthetists of Great Britain and Ireland(AAGBI) guidelines. Records showed staff changed themachine’s tubing weekly to maintain its function.

• We checked the difficult airway trolley in theatres andsaw a logbook showing evidence of daily checking. Wesaw theatres stocked the trolley in line with equipmentreferenced in the 2015 “Difficult Airway Societyguidelines for unanticipated difficult intubation inadults”. Staff maintained a list of equipment expirydates, and we saw evidence staff replaced consumablesbefore they expired. We saw that all equipment on thetrolley was within its manufacturer-recommendedexpiry date. We observed that staff confirmed thelocation of the difficult airway trolley during a teambrief. This was important to ensure any new or agencystaff knew where to find the trolley quickly in anemergency.

• The hospital maintained an asset register with details ofequipment servicing. The estates department checkedthe register every Monday morning and allocatedservicing jobs to the team. We checked the register andsaw the hospital serviced all equipment within therecommended periods. We also saw completedworksheets, which provided evidence estates staff hadserviced equipment. We checked three items on BensanWard and three in theatres and saw evidence of recentservicing and electrical safety testing. These processesmeant the hospital had assurances around the functionand safety of hospital equipment.

• We saw the theatre implant register. This containedbatch numbers for all orthopaedic implants such asprosthetic hip and knee joints. We saw that the registerwas up-to-date and complete with all implants usedsince July 2016. This allowed traceability of orthopaedicimplants should any problems arise with a particularbatch.

• On Bensan Ward, we saw sufficient equipment tomaximise patients’ independence while they recovered

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from orthopaedic surgery. This included walking frames,crutches, wheelchairs and raised toilet seats. We alsosaw the ward had one hoist. We spoke with a nurse, whofelt one hoist was sufficient to meet patients’ needs.This was because very few patients stayed on the wardthat needed to use a hoist

• The hospital had appropriate equipment for bariatricpatients, including beds, shower chairs and wheelchairs.Staff knew the maximum weights for different pieces ofbariatric equipment to enable patients to useequipment safely. The hospital maintained bariatricequipment as part of the estates department’s servicingschedule.

• There was uncontrolled access into the theatredepartment at the time of our visit. This was becausethe swipe-card access system had broken, allowing thedoors to open freely. The theatre manager told us therehad been intermittent problems with the access sincethe new theatres opened in May 2016. This affected thedoors into the theatre department, the pharmacy doorwithin theatres and the doors between theatres andBensan Ward. However, the estates department wereworking to fix the problem. We saw that the doorsbetween Bensan Ward and theatres self-locked whenwe returned for our unannounced visit. The pharmacydoor also self-locked. However, there were stillintermittent problems with the doors from receptioninto the theatre department. We saw that these doorsopened freely during our unannounced visit, althoughthe theatre manager told us the locking mechanismworked earlier that week.

Medicines

• We checked controlled drugs (CDs) in the theatrerecovery area, Anaesthetic Room Two, and on BensanWard. Controlled drugs are medicines liable for misusethat require special management. We saw the CDcupboards were locked in all three areas. Onlyauthorised staff could access CDs using individualelectronic keys. The electronic key system logged whichstaff had accessed the CD cupboard to allowtraceability. We checked the CD registers in all threeareas and found two members of staff had signed for allcontrolled drugs. This was in line with national

standards for medicines management. We randomlychecked the stock level of two CDs on Bensan Ward andin recovery. We saw the correct quantities in stockaccording to the stock list, and that all were in-date.

• The theatre department reported a CD discrepancy inNovember 2016. Staff discovered there was no record ofreceipt of a CD in Theatre Three. The theatre managerand a matron fully investigated the incident and thepharmacy department carried out an audit. Theatressubsequently changed their practices, and recovery staffordered all CDs for theatres. Previously, different areasof the theatre department ordered their own CDs. Wesaw the “Theatre CD Record Book”, which provided aregister of all stock items. We saw that staff completedthe book in line with pharmacy policies. We also sawrecords of medicines destroyed, supplied andadministered. We also saw records showing staffchecked stock levels at each shift change. Theseprocesses had prevented any further CD discrepanciesand provided the hospital with assurances around themanagement of CDs.

• We checked the drugs fridges in Anaesthetic Room Twoand Bensan Ward. We saw that fridge temperatures inboth areas were within the expected ranges. We sawrecords in both areas, which showed staff had checkedthe fridge temperatures daily. All temperatures recordedwere within the expected ranges, and there were nogaps on the checklist. This provided assurances thehospital stored refrigerated medicines within therecommended temperature range to maintain theirfunction and safety.

• Medical gases were secured to the wall and stored safelyin theatres. On Bensan Ward, there was suction andpiped oxygen in every patient room. We saw recordingsshowing staff checked the oxygen and suction daily.

• The RMO prescribed medicines for patients to take-out(TTO). TTO medicines are medicines given to patient ondischarge from hospital stay. The pharmacy teamreviewed TTO prescriptions daily to provide oversight.We saw that nurses counselled patients on TTO drugs atdischarge.

• Drug allergies were clearly documented in five sets ofpatient records we reviewed, and also on their drugcharts. Patients with drug allergies wore an additionalred wristband to alert staff of their allergy status.

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• The hospital prescribed and administered antibioticprophylaxis in line with its “Antibiotic policy”. Amicrobiologist from a nearby NHS trust attended IPCmeetings to give advice on antibiotic prescribing. Thehospital had an antimicrobial stewardship programme,with each antibiotic prescribed on the ward recordedand monitored for indication, appropriateness andfrequency. This meant the hospital used antibioticsappropriately in line with relevant national guidance.This included the National Institute for Health and CareExcellence (NICE) NG15 Antimicrobial stewardship:systems and processes for effective antimicrobialmedicine use.

• We saw that there were no specific blue medicinesdisposal bins in theatres. Instead, staff discardedunused medicines into sharps disposal bins. However,the sharps bins contained solidifying agents. Thesesolidified liquid drugs, making them unusable andpreventing unauthorised use. Following our visit, theservice purchased designated bins for the disposal ofnon-hazardous healthcare medicines for incineration. Atour unannounced inspection we saw the bins in thetheatre department. The theatre manager was awaitingdelivery of appropriate brackets to secure the binsbefore the department started using them.

Records

• We reviewed five patient records and saw evidence ofclear documentation, with no loose records. Staff hadsigned and dated all entries. This was in-line withguidance from the General Medical Council. All fivepatients had care plans that identified all their careneeds. We saw staff had fully completed all five careplans.

• On Bensan Ward, staff stored notes securely in lockablecupboards at the nurses’ stations. This preventedunauthorised access to confidential patient data. Afterdischarge, the hospital held patient records in its securehealth records office. This allowed hospital staff to easilyaccess patient records, for example followingreadmission, to assist with clinical decision-making. Wesaw that operation notes were integrated into patients’hospital records in line with best practice guidance.

• Secretaries told us consultants with practicing privilegesdid not take any records off-site. This was in-line withthe hospital’s “Management of Health Records and

Clinical Information” policy. The policy stated staff couldonly transfer photocopies of patient records if a patientsubsequently received treatment at a different hospital.In these cases, staff kept the original set of recordson-site. This ensured the hospital retained a completeset of records for all patients.

• All patients attended for a pre-operative assessment inadvance of surgery. Staff completed a comprehensivepre-assessment record on a standard form. We sawcompleted pre-assessment records in all five sets ofnotes we reviewed.

Safeguarding

• Hospital data showed 98% of nursing and midwiferyregistered staff, 95% of allied health professionals, 98%of non-registered clinical staff and 100% of non-clinicalstaff had up-to-date safeguarding vulnerable adultslevel two training at the time of our visit. This was aboutthe same as the hospital target of 95%. This meant thehospital had assurances staff had the correct level oftraining to identify adult safeguarding concerns.

• Hospital data showed the following levels ofsafeguarding children level two children at the time ofour visit: Nursing and midwifery registered staff-95%;Allied health professionals- 94%, and non-registeredclinical staff- 93%. This was an appropriate level oftraining in line with the national intercollegiateguidance, “Working Together to Safeguard Children”(2014) because the hospital did not provide surgery forchildren under the age of 18.

• Staff could identify the safeguarding lead and describedhow to report safeguarding concerns. We saw a posteron Bensan Ward describing safeguarding reportingprocesses. This served to remind staff of the correctreporting processes.

• Hospital data showed the safeguarding lead for adultshad safeguarding vulnerable adults level three training.The safeguarding children’s lead had safeguardingchildren level three training. This was appropriate in linewith national guidance.

• The safeguarding lead told us they felt staff knew theprocess for raising potential safeguarding concerns inthe hospital, and gave us an example times they haddone this. The hospital did not report any safeguarding

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concerns to the local safeguarding authority betweenOctober 2015 and September 2016. The safeguardinglead told us they felt very confident staff knew how toidentify and report safeguarding concerns.

• The safeguarding lead attended regional safeguardingmeetings every three months with other localhealthcare providers. This allowed them to sharelearning from other organisations. The safeguardinglead shared any relevant learning from these meetingsat matrons meetings.

• Female genital mutilation (FGM) identification andreporting was incorporated into safeguarding adultslevel two training in autumn 2016. We saw evidence ofthe online mandatory training course, which showedFGM was included.

Mandatory training (if this is the main core servicereport all information on the ward(s) here.

• Hospital data showed the following rates of mandatorytraining at the time of our inspection: SSD- 99.1%;Ambulatory Care Unit- 92.3%; Bensan Ward- 91.5% andTheatres- 85.9%. With the exception of SSD, mandatorytraining rates were slightly worse than the hospitaltarget of 95%.

• There was a combination of online and face-to-facetraining. The hospital’s mandatory training programmeincluded the following modules: conflict resolution,equality and diversity, fire safety, health and safety,manual handling and infection control.

Assessing and responding to patient risk (theatres,ward care and post-operative care)

• We reviewed five sets of patient notes on Bensan Ward,and saw evidence of thorough pre-assessment forsurgery in all five files. This included risk assessments forfalls, pressure ulcers, IPC and general anaesthetic. Theseassessments were vital to assess a patient’s suitabilityfor surgery and to enable staff to make any necessaryadjustments to ensure safe care. For example, staff toldus they allocated patients at increased risk of falls tobedrooms closest to the nurses’ station where possible.

• The hospital’s “Anaesthetic department guidelines forelective surgery at Benenden Hospital” (reviewed July2016) set out clear exclusion criteria. This included

patients with haemophilia and patients withbiventricular pacemakers. This was to ensure the safetyof patients having surgery because the hospital did nothave facilities for planned critical care post-surgery.

• The hospital did not have any level two or three criticalcare beds. To mitigate this risk, the hospital operated onpatients pre-assessed as grade one or two under TheAmerican Society of Anaesthesiologists (ASA) gradingsystem. Grade one patients were normal healthypatients, and grade two patients had mild disease, forexample well controlled mild asthma. The hospitaloccasionally accepted grade three patients (patientswith severe systemic disease that is not incapacitating).However, the hospital assessed patients on anindividual basis and only accepted individual gradethree patients following further pre-assessment with aconsultant anaesthetist and consultant surgeon.

• Any patients highlighted to be at increased anaestheticrisk during pre-assessment had a further anaestheticassessment with a consultant anaesthetist. Staffdocumented all assessments in the patient’s records.We saw that the theatre team discussed a patient withincreased anaesthetic risk during a team brief. Theanaesthetist told staff what they were doing to mitigatethe risk, and all staff confirmed awareness of thelocation of the difficult airway trolley.

• We saw evidence in patients’ notes that the serviceroutinely checked the pregnancy status of all femalepatients of childbearing age before elective surgery.Staff checked pregnancy status using a urine pregnancytest with the patient’s consent. Theatre staff were awareof the hospital’s policy to test all women aged up to 60.They told us they would not proceed with surgerywithout documentation of a negative urine pregnancytest. This was in line with NICE guideline NG45: "Routinepreoperative tests for elective surgery”.

• Data showed the hospital risk-assessed 100% ofpatients for VTE in October 2015 – September 2016.However, we reviewed five patient records and saw staffhad recorded the risk of VTE, but not completed allsteps of the VTE assessment, in two out of the fiverecords. This meant the hospital might not have hadassurances staff always assessed the risk of VTEcorrectly.

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• We observed theatre staff carrying out the World HealthOrganisation (WHO) Surgical Safety Checklist for twopatients. The WHO checklist is a national core set ofsafety checks for use in any operating theatreenvironment. The checklist consists of five steps to safersurgery. These are team briefing, sign in (beforeanaesthesia), time out (before surgery starts), sign out(before any member of staff left the theatre) and debrief.We saw that staff fully completed and electronicallydocumented all the required checks.

• We saw that the service used a specific WHO checklistfor cataract surgery. This ensured staff checked the mostimportant safety factors relating to this procedure.

• The service audited staff compliance with the WHOchecklist and calculated the percentage complianceeach month. We saw the results for October – December2016. Theatres scored 100% compliance with all areasassessed in October 2016. The department scored 80%in both November and December 2016. The theatremanager explained that the service introducedobservational audits in November 2016. Previously, theservice audited compliance against the WHO checklistby checking patient notes retrospectively rather thanphysically observing staff carrying out the checklist. Thetheatre manager felt the observational audits weremore reliable at identifying non-compliance. Auditresults detailed the reasons for non-compliance. Thetheatre manager or another senior manager of thetheatre team addressed any areas of non-compliancewith staff to help improve performance.

• The service used the National Early Warning System(NEWS) track and trigger flow charts. NEWS is a simplescoring system of physiological measurements (forexample, blood pressure and pulse) for patientmonitoring. This allowed staff to identify deterioratingpatients and provide them with additional support. Wereviewed five patients’ NEWS charts. We saw staff hadcompleted all five charts fully and calculated NEWSscores correctly. We saw evidence of escalation whenclinically indicated in line with the NEWS guidance.However, NEWS chart audits for January – December2016 showed variable compliance with NEWS chartcompletions. Audit results showed staff completedbetween 10% and 40% of charts incorrectly during thisperiod. We saw that staff received feedback on NEWScharts at ward meetings to help improve performance.

• The hospital had a service-level agreement (SLA) with alocal NHS hospital. This enabled them to transfer anypatients who became unwell after surgery and neededcritical care support. Staff told us a patient transferredto the local NHS hospital by ambulance two weeksbefore our visit following a heart attack before surgery.The theatre manager told us staff worked well as a teamto care for the patient before transfer. Hospital datashowed there were six further cases of unplannedtransfer of an inpatient to another hospital betweenOctober 2015 and September 2016. Incidentinvestigations showed all patients made a goodrecovery following transfer and one patient transferredback to Benenden Hospital when they were wellenough.

• The hospital did not have a high-dependency unit.However, staff told us they cared for any deterioratingpatients in the two larger patient rooms on BensanWard. The ward routinely used these rooms for bariatricpatients but could use them for patients who neededadditional support before transfer. This was becausethese rooms had more space, as well as mobilemonitoring equipment that could transfer with thepatient in an ambulance.

• Bensan Ward had “Sepsis Six” kits containing all thecomponents needed for the diagnosis and treatment ofsepsis. We saw sepsis guidance available to staff in allthree anaesthetic rooms. Bensan Ward had a patientwho developed sepsis in 2016. Staff recognised sepsisand responded promptly, administering intravenousantibiotics within 15 minutes.

• The hospital had an SLA for the supply of blood fortransfusion. During our visit, we saw staff regularlyreviewed the haemoglobin levels of a patient withanaemia and had cross-matched blood available incase the patient’s condition deteriorated.

• Staff told us any patients who developed complicationsfollowing discharge could contact the nurses on BensanWard any time, day or night. We saw a copy of thedischarge pack given to patients, and this included a24-hour contact number direct to the ward. We also sawa nurse give this information to a patient shedischarged.

Nursing and support staffing

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• The theatre department staffed operating lists inaccordance with The Association for PerioperativePractice (AfPP) guidelines. Hospital data showed therewere no unfilled shifts in theatres between July toSeptember 2016. During our visit, we reviewed plannedstaffing rotas, as well as records showing the actualnumber of staff on each shift in December 2016. Theseshowed staffing levels met AfPP guidelines on all shifts.

• As of 1 October 2016, the service employed 16.7whole-time equivalent (WTE) theatre nurses. There werefour WTE theatre nurses vacancies. This meant thenursing vacancy rate for theatres was 19%.

• The service filled vacant shifts using bank and agencystaff. The use of bank and agency nurses in theatredepartments ranged from 4% to 8% from October 2015to June 2016. This was better than the average rate forother independent acute hospitals we hold this type ofdata during the same period.

• There were 12.7 WTE operating departmentpractitioners (ODPs) and healthcare assistants (HCAs) intheatres. There were 5.2 WTE posts vacant for OPDs andHCAs in theatres. This gave a vacancy rate of 29%.

• The use of bank and agency ODPs and health careassistants in theatre departments ranged from 0% -3.5% in October 2015 – June 2016. This was better thanthe average rate for other independent acute hospitalswe hold this type of data for during this period.

• Bensan Ward used staffing ratios of one trained nurse toseven patients, and one HCA to five patients. Staff andpatients we spoke with felt the staffing levels wereappropriate to meet patients’ needs. The ward reviewedthe ratios if they had higher acuity patients on the ward,or patients with additional needs. We saw that theactual staffing numbers met the planned levels on allshifts during our visit.

• Bensan Ward had an external staffing review inSeptember 2016. At this time, the ward had 31.1 WTEstaff in post, which met the establishment. Followingthe review, the hospital increased the proposedestablishment by 2.8 WTE registered nurses and 1.9 WTEHCAs. This meant there were 4.7 WTE vacancies. Theservice filled one of the nursing vacancies before ourinspection. The week before our visit, the service

interviewed and successfully recruited two full-timeHCAs. Once the HCAs were in post following recruitmentchecks, this would bring the vacancy rate on the warddown to one WTE registered nurse.

• At the time of our visit, the eye unit had two WTE nursingvacancies. The hospital used specialist ophthalmic banknurses to fill vacant shifts while they recruited new staff.

• We observed nursing handovers on Bensan Ward. Eachpatient had a named nurse, who handed over patientsin their care to the new nurse coming on shift.Handovers took place at every shift change. Handoverswere effective and nurses handed over important safetyinformation such as pressure area risks. This allowed forcontinuity of safe care. Nurses used handover sheets toprovide written information on each patient includingallergies and any significant medical history. Thisensured staff handed over all relevant information.

Medical staffing

• The hospital’s resident medical officers (RMOs) providedmedical cover 24 hours a day, seven days a week. Thisensured nurses could always quickly escalate any issuesconcerning a deteriorating patient. The RMO alsoinformed the patient’s consultant in an emergency sothat they could provide consultant-level care.

• As part of their practicing privileges agreement,consultants had to be available on-call 24 hours a daywhenever they had an inpatient under their care in thehospital. Staff told us consultants attended promptly toreview patients where there were clinical concerns.

• The hospital had an anaesthetist on-call rota outside ofcore theatre hours. This ensured 24 hour availability ofanaesthetic cover should a return to surgery becomenecessary.

• The RMO conducted twice-daily ward rounds at 9amand 10pm to ensure patients were safe. The RMO alsotold us they visited Bensan Ward in between those timesto review patients, usually between four and six timesdaily.

• As part of their practicing privileges agreement,consultants were required to review surgical inpatientsat least once daily during their hospital stay. Staff on theward confirmed consultants reviewed patients undertheir care at least once daily.

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• The RMOs carried out a formal handover. However, wedid not see this as there was no change over during ourvisit


• We saw the hospital’s business continuity plan, whichcovered emergencies and disasters. The businesscontinuity plan set out clear roles for key personnel,including the incident advisor and incident coordinator.We spoke to the incident advisor, who was able todescribe their role and responsibilities in supporting theincident coordinator (a senior executive).

• A manager described a simulated desktop exercise forgenerator failure that they completed in October 2016.The exercise tested the relevant telephone numbers,staff knowledge and staff response times. The managersaid the exercise gave them confidence staff wouldknow what to do if this situation arose. The managertold us the hospital held four major incident exercises inthe past year. This was in line with the businesscontinuity policy, which stated key staff should attend atleast one simulation exercise every two years.

• The hospital had two back-up generators that coveredall areas of the hospital, including theatres. Estates staffran a weekly test where they ran the generator for fiveminutes. Staff also ran a monthly full-load test, wherethey turned the mains power off and ran the generatorsfor two hours. We saw records showing evidence ofweekly and monthly testing. We also saw servicingrecords, which provided evidence of three-monthlygenerator servicing in line with the hospital’s generatorservicing contract. Generator testing and servicingrecords provided the hospital with assurances that thegenerator would provide back-up power and enableservices to continue in the event of a power failure.

• The hospital tested the fire alarms weekly and we sawthat they tested the alarms during our visit. Nominatedfire wardens and fire marshals completed annualface-to-face training to ensure their knowledge in thisarea was current. Hospital data showed 100% of firemarshals held up-to-date training at the time of ourvisit. The data showed 97% of relevant nursing andmidwifery-registered staff held up-to-date fire warden

training. However, only 50% of relevant non-registeredclinical staff and 41% of non-clinical staff heldup-to-date fire warden training. This meant that not allfire wardens had up-to-date training in this role.

Are surgery services effective?

Good –––

We rated effective as good.

Evidence-based care and treatment

• We reviewed policies and procedures relating to surgery.All policies we saw were within their review dates andreferenced relevant national guidance. This includedNational Institute for Health and Care Excellence (NICE)and the Association for Perioperative Practice (AfPP).Staff could access policies and procedures electronicallythrough the hospital intranet and knew how to do this.

• The service audited staff compliance with trust policiesin several areas and reported the results monthly. Forexample, we saw monthly WHO surgical safety checklist,NEWS and mental capacity assessment audits. We sawstaff meeting minutes, which demonstrated staffreceived feedback on local audit results and areas forimprovement.

• Theatres had yearly external audits from the AfPP. Wesaw the most recent AfPP audit (dated November 2016).The audit measured evidence-based care against AfPPguidance including “Standards and Recommendationsfor Safe Perioperative Practice” (2016) and “ThePerioperative Audit Tool” (2014). The reportdemonstrated the department had achieved itsobjectives from the 2015 audit. These included clearleadership of all operating lists and consistency ofpractice in the counting of needles, swabs andinstruments. The 2016 report also noted the departmenthad improved its governance of controlled drugs.However, it made a further recommendation for agencystaff to have further induction around medicinesmanagement policies. Independent audits such asthese allowed the department to identify areas forcontinuous improvement and gave the hospitalassurances around evidence-based practice.

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• In theatres, and in the patient notes, we saw evidence ofthe hospital providing surgery in line local policies andnational guidelines such as NICE guideline CG74:Surgical site infections: prevention and treatment. Forexample, we saw evidence of antibiotic assessment infive sets of patient notes, along with prescription (ornon-prescription) or prophylactic antibiotics in line withthe guidance.

• We reviewed five patient records, which all showed,evidence of regular observations, for example, bloodpressure and oxygen saturation, to monitor the patient’shealth post-surgery. Staff had completed all threeobservation charts in line with NICE guideline CG50:Acutely ill patients in hospital- recognising andresponding to deterioration.

• Patient notes showed pre-assessment nurses performedpre-operative tests such as electrocardiogram forpatients with pre-existing heart conditions. This is in linewith NICE guideline NCG45: Routine preoperative testsfor elective surgery.

Pain relief

• The service used a numerical pain assessment scale tomonitor patients’ pain levels. During routineobservations, staff asked patients to rate their painbetween one and 10 (one meaning no pain and 10 beingextreme pain). We saw pain scores recorded in all fivesets of notes we reviewed.

• All patients we spoke with said their pain was wellcontrolled. One patient told us they had notexperienced any pain after their operation. Anotherpatient told us staff responded promptly when theyneeded additional pain relief.

• The hospital’s “day surgery customer feedback” resultsfor November and December 2016 showed 98.5% ofpatients felt staff definitely did all they could to controltheir pain. The remaining 1.5% of patients said staff dideverything they could to some extent. In January 2017,97.8% of patients felt staff did everything they could tocontrol their pain. The remaining 2.2% said staff dideverything they could to some extent. This meant staffresponded to control all patients’ pain following daysurgery.

• In theatres, we saw a surgeon monitoring the pain levelsfor a patient who had spinal anaesthesia. The surgeonregularly checked that the patient’s pain was wellcontrolled before continuing with the operation.

• There was no dedicated pain team at the hospital.However, consultant anaesthetists with an interest inpain relief gave advice on pain management.

Nutrition and hydration

• The service followed the Royal College of Anaesthetistsguidance on fasting prior to surgery. The guidancesuggested patients could eat food up to six hours anddrink clear fluids up to two hours before surgery.Administrative staff sent admission letters topre-operative patients before surgery, which includedinformation on fasting times. Patients having operationsin the afternoon could have an early breakfast on theday of surgery. This was in line with best practice. Wesaw that staff asked patients to confirm the time theylast ate and drank before surgery. This ensured theservice complied with the Royal College of Anaesthetistsguidelines.

• The service measured patients’ body mass index (BMI)at pre-assessment. If a patient had a very low or highBMI, staff discussed additional nutritional needs. Staffon Bensan Ward gave us an example of a patient with aBMI of 17 who had parenteral nutrition. Parenteralnutrition is a method of intravenous feeding for patientswho are unable to obtain sufficient nutrition from thefood they eat. We reviewed the notes of a patient whoreported difficulties swallowing at pre-assessment. Theservice subsequently ensured appropriate foods wereavailable for the patient.

• The service audited post-operative nausea and vomitingfollowing major gynaecology surgery in January 2016.We saw the audit results, which showed only 2% ofpatients experienced severe nausea and vomiting 24hours after surgery. Twelve per cent of patients reportednausea or vomiting at some point within the first 24hours after surgery. This was better than the hospital’s20% target based on published research. We saw apatient who had an anti-emetic (medicine to preventvomiting) before surgery following vomiting after aprevious operation. These observations showed thehospital managed post-operative nausea and vomitingeffectively.

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• The hospital had a dietician who provided nutritionalsupport and expertise to bariatric patients before andafter surgery. The dietician also provided additionalsupport and advice for other surgical patients.

• For patients who needed to lose weight before surgery,the service signposted them to weight loss clinics withinthe hospitals catchment area to help them. Researchhas shown patients find it easier to lose weight withappropriate medical support.

Patient outcomes

• The hospital participated in the National Joint Registry(NJR) for hip and knee replacements. The most recentpublished data at the time of our inspection related toNHS-funded patients treated in April 2014 – March 2015.The NJR published this data in February 2016. NJR datashowed seven patients who had hip replacementneeded a revision (a further operation) within one yearof surgery. The rate of hip replacement revisions withinone year of surgery was 1.44%. This was similar to thenational average of 0.75% for all hospitals whosubmitted data to the NJR. The hospital’s hipreplacement revision rate at three years was 2.39% (fivepatients out of 209 linkable cases). This was similar tothe NJR average of 1.6%. At five years post-surgery, thehospital’s hip replacement revision rate was 3.23% (onepatient out of 31 linkable cases). This was similar to theNJR national average of 2.62%.Benchmarking datashowed the hospital’s standardised revision rate for hipsurgery was within the expected range.

• NJR data for April 2014 – March 2015 showed 0% ofpatients had a knee replacement revision within oneyear of surgery. In this period, there were 673 linkablecases. This was better than the NJR national average of0.48%. The knee replacement revision rate at three yearswas 0.99% (three patients out of 302 linkable cases).This was better than the NJR national average of 1.83%.At five years post-surgery, the hospital’s kneereplacement revision rate was 0%. There were 39linkable cases in the same period. This was better thanthe NJR national average of 2.64%. Benchmarking datashowed the hospital’s standardised revision rate forknee surgery was within the expected range.

• The hospital provided data to national PatientReportable Outcomes Measures (PROMS). PROMS used

patient questionnaires to assess the quality of care andoutcome measures following surgery. The hospitalprovided PROMS data from two areas: primary hipreplacement and primary knee replacement.

• PROMS data for April 2014 to March 2015 showed 100%of patients reported that their health had improvedfollowing knee replacement according to the Oxfordknee score. This was the most recent available data atthe time of our inspection, with the 2015-16 data notdue for publication until May 2017. The adjusted healthgain in relation to the Oxford knee score was 19.0, whichwas better than the England average of 16.1. There were38 knee replacement procedures included in the dataduring this period.

• PROMS data for April 2014 to March 2015 showed 100%of patients reported that their health had improvedfollowing hip replacement according to the Oxford hipscore. However, there were only 28 procedures at thehospital included in the data. This meant the hospital’sperformance was not eligible for benchmarking againstthe England average. It was necessary to submit data forat least 30 procedures for national comparison.

• The hospital reported six cases of unplanned transfer ofan inpatient to another hospital between October 2015and September 2016. The rate of unplanned transferswas not high when compared to other independentacute hospitals that submitted performance data toCQC. We saw that the hospital investigated allunplanned transfers appropriately. We reviewed all sixunplanned transfers and saw that there were nocommon themes. All patients made a good recoveryfollowing transfer.

• The hospital reported two cases of unplannedreadmission within 28 days of discharge betweenOctober 2015 and September 2016. The rate ofunplanned readmissions was not high when comparedto other independent acute hospitals that submittedperformance data to CQC. We reviewed the twounplanned readmissions and saw that the reason forone was post-operative pain. The other involved thetransfer of a patient who previously transferred to anNHS hospital for high-dependency care back toBenenden Hospital to continue their recovery.

• The hospital reported four cases of unplanned return tothe operating theatre between July 2015 and June 2016.

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We reviewed the incident investigations, which showedthe reasons for three of the returns to theatre werepost-operative complications. In the fourth case, thepatient had suspected post-operative internal bleedingbased on a very low haemoglobin result. Haemoglobinis the red pigment in blood cells, and very low levelsmay indicate post-operative bleeding. However, intheatre, staff found there was no internal bleeding.Laboratory results showed staff had made a bloodsampling error, which give a false result. The servicelearned from this incident and provided further trainingto staff to prevent a recurrence.

• Two of the four returns to theatre happened outside ofnormal theatre operating hours. Incident investigationsshowed the theatre on-call processes workedeffectively. All four patients who returned to theatre hadan uneventful recovery.

• The theatre department had a comprehensive annualaudit programme to measure performance. We saw theaudit schedule, which included areas such asanaesthetics and pain management.

• The hospital started a subscription with the PrivateHealthcare Information Network (PHIN) in 2014. PHINallows independent hospitals to share performancedata in accordance with legal requirements regulated bythe Competition Markets Authority. The hospitalsubmitted their 2015 data for non-NHS funded patientsto third party contractor for inclusion in PHIN before theSeptember 2016 deadline. The hospital told us theywere making changes to their patient feedbackquestionnaires and changes to their PROMS processesto meet the PHIN submission requirements for 2017.

Competent staff

• Hospital data showed 100% of inpatient nurses, theatrenurses and ODPs had up-to-date professionalrevalidation. Staff we spoke to told us the hospitalsupported them with the process of revalidation. Dataalso showed 100% of doctors with practicing privilegeshad up-to-date professional revalidation. This meantthe hospital had assurances that all registered stafftreating surgical patients met the practicingrequirements of the relevant professional body.

• Hospital data showed 100% of nurses, ODPs and HCAstreating surgical patients had a performance appraisalin 2016. This meant the service reviewed staffperformance and held assurances around thecompetencies of all staff.

• Hospital data showed 51 doctors with practicingprivileges treated surgical inpatients. Of these, 48(94.1%) carried out 10 or more episodes of care betweenOctober 2015 and September 2016. The remaining threedoctors (5.9%) carried out between one and nineepisodes of care during the same period. Doctors withpracticing privileges therefore worked at the hospitalregularly. This meant they were more likely to befamiliar with the hospital’s environment, staff, policiesand ways of working.

• The hospital’s medical advisory committee (MAC)reviewed applications for practicing privileges andadvised the medical director of individual consultants’eligibility. The hospital only granted practicing privilegesto consultants who had held a substantive consultantpost in the NHS within the past five years. This was inline with the hospital’s “Practicing Privileges Policy forConsultant Medical Practitioners” (dated October 2016).Consultants who did not meet this requirement may beawarded practicing privileges if they could “demonstrateexperience of independent practice over a sustainedperiod applicable to working in the independent sector”in line with the practicing privileges policy. The hospitaldid not award practicing privileges for any proceduresoutside a consultant’s normal scope of practice in linewith its practicing privileges policy. These processesdemonstrated the hospital only awarded practicingprivileges to consultants who demonstrated appropriatecompetencies.

• The MAC reviewed consultants’ practicing privilegesevery three years in line with the “Practicing PrivilegesPolicy for Consultant Medical Practitioners”. Anyconsultants without a current NHS contract had anannual review. The hospital reviewed a comprehensiverange of data in line with the GMC guidance, “GoodMedical Practice” (2013). This included individualperformance data and evidence of continuingprofessional development (CPD). We saw evidence in

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MAC minutes that showed the MAC took action toensure all consultants submitted the required evidenceto continue practicing at the hospital. This includedevidence of current medical indemnity insurance.

• Hospital data showed the hospital suspended oneconsultant’s practicing privileges between October 2015and September 2016. This demonstrated the hospitaltook action when consultants did not provide evidenceof meeting the required standards of practice.

• The hospital’s clinical governance committee reviewedmonthly key performance data for individualconsultants. This included returns to theatre, surgicalsite infections and transfers to other acute hospitalswith critical care facilities. The hospital also heldperformance data for individual orthopaedic surgeons,which it submitted to the NJR. The NJR also allowedconsultant outcome comparisons on a national scale.This allowed the hospital to monitor and compareoutcomes between consultants and take action if anindividual’s performance deteriorated.

• The hospital employed its own staff to carry out the firstassistant’s role during surgery. Consultant surgeonsnever brought in first assistants from outside thehospital. The role of the surgical first assistant was toprovide continuous assistance to the surgeonthroughout an operation. We reviewed the trainingrecords for two surgical care practitioners (SCPS) whoacted as surgical first assistants as part of their roles. Inboth records, we saw a completed competencyframework providing evidence of the requiredcompetencies for this role. This meant the hospital hadassurances around the competencies of staff thatperformed first assistant duties.

• The clinical skills facilitator ran a sepsis scenario-basedtraining exercise for staff. This exercise identified somelearning for staff around the temperature range forpatients with sepsis. The service gave feedback to staffto improve sepsis recognition. The matron felt stafftraining in this area helped staff recognise and respondto sepsis quickly when a patient developed sepsis in2016.

• The clinical skills facilitator provided a range ofscenario-based training exercises for staff, includingresuscitation. Staff told us they found the exercisesuseful and the training helped them keep their clinicalskills up-to-date.


• The hospital had a daily, multidisciplinary “10 at 10”meeting. The 10-minute meeting, held daily at 10am,allowed staff to discuss any immediate issues includingstaffing and incidents. The hospital’s director of patientservices chaired the meeting we observed, whicharound 30 staff attended. We saw effectivemultidisciplinary communication and representationfrom areas including theatres, ward, sterile servicesdepartment, diagnostic imaging, porters and pharmacy.

• Entries in the medical records we revieweddemonstrated a range of professional input intopatients’ care. This included physiotherapy andpharmacy. Staff we spoke with reported positivemultidisciplinary working relationships with colleagues.

• The service did not discharge any patients late at night.To avoid late discharges, the service converted any daycase patients not fit for discharge by early evening to anovernight stay. Evidence in the patient notes wereviewed showed the service assessed a patientsanticipated post-discharge needs at pre-assessment.This allowed the service time to ensure appropriatesupport was in place, including any mobility equipmentneeded for the recovery period, before a patient wenthome after their operation. We saw that the serviceinvolved patients’ relatives and carers in dischargeplanning. The service ensured patients had someone tohelp care for them at home in the immediate recoveryperiod where necessary.

Seven-day services

• Physiotherapists treated orthopaedic patientsrecovering from surgery twice daily on the ward. Thephysiotherapy team provided seven-day cover. Thismeant patients recovering from surgery at theweekends had the same access to physiotherapyservices as recovering during the week.

• The diagnostic imaging department provided a 24-hour,seven days a week service for urgent ultrasound or X-rayimaging requests to aid clinical decision-making.

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However, the hospital did not have in-house MRI or CTscanners. A mobile MRI and CT clinic visited the hospital,but not at weekends. This meant there was noseven-day access to MRI or CT services. However, MRIand CT scanning facilities were coming back into thehospital as part of the new building works in 2017. Amatron told us the absence of weekend MRI or CTfacilities had never caused any problems for patients.

• The hospital’s “Practicing Privileges Policy forConsultant Medical Practitioners” required consultantsto review all patients on the ward at least once daily.Staff on Bensan Ward told us all consultants reviewedpatients daily, including at weekends, in line with thepolicy.

• The pharmacy opening hours were Monday – Friday,9am – 5pm. We saw the hospital had policies to ensurepatients could access medicines outside these hours.For medicines to take out (TTO), the RMO wroteprescriptions. Nurses on Bensan Ward gave theprescribed medicines to patients from the TTOcupboard.

• For inpatients needing medicines not stocked on theward, the registered manager and senior nurse on dutyhad access to the hospital pharmacy. The RMO couldsubsequently dispense medicines from the hospitalpharmacy, with the senior nurse on duty providing asecond check to ensure correct dispensing. The hospitaldid not have any service level agreements (SLAs) forpharmacy support. However, staff could access adviceon an informal basis from a nearby NHS hospital ifneeded.

Access to information

• Staff could access local policies and procedureselectronically, and all staff we spoke to knew how to dothis. Staff could access national guidance via theinternet, and we saw computers available in staff areasto enable them to do this.

• The hospital held integrated patient records on-site. Aswell as keeping confidential patient data safe, thisensured timely access to all the information needed forpatient care. We reviewed five sets of notes for surgicalpatients. All five contained sufficient information toenable staff to provide appropriate patient care. Thisincluded diagnostic test results and care plans.

• We observed a discharge on Bensan Ward and saw staffgave the patient comprehensive written and verbalinformation about their ongoing care. This includedwound care, follow-up appointments, counselling onTTO medicines and VTE advice. This helped patientsunderstand how to care for themselves and recogniseany post-operative complications while they continuedrecovering at home.

• The hospital provided discharge letters for patients’ GPs.We saw that discharge letters included all relevantinformation to allow continuity of care in the patient’scommunity. This included operation details, prescribedmedications and wound care. Discharge letterscontained details of the treating consultant so that thepatient’s GP could contact them if needed.

Consent, Mental Capacity Act and Deprivation ofLiberty Safeguards

• We reviewed seven consent forms for surgery. On allseven forms, we saw consultants had documented therisks and benefits of surgery, in line with GMC guidance.In six out of the seven forms, we saw patients andconsultants signed consent forms before the day ofsurgery. This was in line with guidance from the RoyalCollege of Surgeons (RCS) “Good Surgical Practice 2014”,which states staff should “Obtain the patient’s consentprior to surgery and ensure that the patient hassufficient time and information to make an informeddecision”. Patients and consultants then provided anadditional signature on the day of surgery to confirmtheir consent to proceed in line with best practiceguidance.

• However, one patient had signed their consent form forthe first time on the day of surgery. This was not in linewith the RCS “Good Surgical Practice 2014”. Wediscussed this case with a matron, who told us thepatient transferred their care from another hospital. Thehospital subsequently fitted in their operation at shortnotice, and the consultant did not have an opportunityto obtain consent in advance of the day. The matrontold us this was an unusual situation. Following ourfeedback, they told us they would monitor patients whotransferred from another hospital more closely as part ofthe theatre department’s consent audits.

• The hospital used a “consent form four- statement ofhealthcare professional for adults who are unable to

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consent to investigation or treatment”. Thisdocumented the best interests’ decision-making of stafffor patients who lacked capacity in accordance with theMental Capacity Act 2005. A nurse on Bensan Ward gaveus an example of a time a consultant completed aconsent form four to document a best interests decisionto catheterise a patient who had urinary retentionpost-surgery. The nurse told us staff discussed the bestinterests’ decision with the patients’ family and keptthem informed in line with best practice guidance.

• New clinical staff completed training in the MentalCapacity Act (MCA 2005) and deprivation of libertysafeguards (DoLS) as part of their induction. Hospitaldata showed 97% of registered nurses, 94% of alliedhealth professionals and 95% of unregistered nurses/HCAs had training in the MCA 2005 and DoLS. This wasabout the same as the hospital target of 95%. Thehospital also provided guidance to staff in its “MentalCapacity Act 2005” and “Deprivation of LibertySafeguards Practice and Procedures” policies. We spokewith a senior nurse on Bensan Ward who demonstratedclear understanding of the correct processes aroundDoLS, including use of the least restrictive options. Thenurse told us they had never had to apply for a DoLS atBenenden Hospital, but knew exactly what to do if apatient needed one to keep them safe. Thisdemonstrated staff had an appropriate level of trainingand awareness of the MCA 2005 and DoLS.

• Clinical staff completed mandatory training in informedconsent as part of their induction. Hospital data showed100% of registered nurses had training in informedconsent. This was better than the hospital target of 95%.However, 92% of allied health professionals and 81% ofunregistered nurses/HCAs had training in informedconsent. This was worse than the 95% target. However,we saw clear guidance available to all staff as part of thehospital’s “Informed consent policy”.

Are surgery services caring?

Outstanding –

We rated caring as outstanding.

Compassionate care

• Feedback from patients and those close to them wascontinually positive about the way staff treated them.We spoke with nine patients who had surgery at thehospital and one patient's relative. All patients we spokewith felt staff were very caring, and the care theyreceived often exceeded their expectations. Patientsdescribed staff as “amazing” and “lovely”. One patienttold us they felt “really secure and looked after” and saidthey “couldn’t have asked for better care”. Anotherpatient said they “couldn’t fault it” and there wasnothing they would want to change about their care. Intheatres, we saw that all staff showed kindness andcompassion towards patients during all interactions.

• Staff on Bensan Ward gave us examples of how theyprovided compassionate care and “went the extra mile”for patients. Examples included massaging patients’ feetand helping patients celebrate their birthday if theyspent it in hospital. The service prided itself on givingstaff "the time to care", and staff described how theyspent plenty of time talking and listening to patients.

• Patients' emotional needs were highly valued by staffand embedded in their care and treatment. Staff tookthe time to help boost patients' self-esteem, forexample by helping patients style their hair and put onmake-up during their stay on the ward.

• There was a strong emphasis on helping patients feel asnormal as possible following surgery. Staff understoodthe importance of this to patients’ self-esteem. Theservice encouraged early mobilisation on the same dayof surgery for orthopaedic patients as part of theirenhanced recovery programme. We saw that patientswho had surgery the previous day were out of bed anddressed.

• We saw staff on Bensan Ward respecting patients’privacy by knocking on the door before entering patientrooms. A patient comment card we reviewed stated,“Dignity and respect [was] outstanding”.

• The hospital used patient experience surveys to recordfeedback from patients. The patient experience surveysincluded asking patients whether they wouldrecommend the service to their family and friends. Wereviewed patient experience data for November 2016 toJanuary 2017. This showed between 97% and 98% ofday surgery patients would recommend the serviceduring this period. The results ranged from 97% to 100%

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for inpatients, and 99% to 100% for patients who hadeye surgery. This demonstrated a high level of patientsatisfaction and meant almost all patients wouldrecommend the service to friends and family.

• The hospital participated in the NHS friends and familytest (FFT) for NHS-funded patients. Data for April toSeptember 2016 showed between 95% and 100% ofpatients would recommend the hospital to their familyand friends. This meant nearly all NHS-funded patientswould recommend the hospital.

• NHS FFT recommendation rates were about the same asthe England average for other independent hospitals inEngland in April to September 2016. Survey responserates varied from 36% to 65% during the reportingperiod. In four out of six months during the reportingperiod, response rates were better than the Englandaverage for other independent hospitals.

• The hospital signed up to the national “Hello, my nameis” campaign. This was a national initiative to encouragehospital staff to always tell patients their name andintroduce themselves. We saw that staff alwaysintroduced themselves when they met a patient for thefirst time. This was in line with NICE QS15, Statement 3,“Patient awareness of names, roles and responsibilitiesof healthcare professionals”.

• The hospital subscribed to the six C’s of nursing. The sixC’s are national set of values that underpin compassionin practice. These are competence, caring, compassion,commitment, communication, and courage. Ourinterviews with patients and staff demonstrated staffworked in a way that showed commitment to the six C’sof nursing.


• Relationships between patients, those close to themand staff were strong, caring and supportive. All patientsrecovering from surgery on Bensan Ward had namednurses to care for them. This allowed patients and theirrelatives to build positive relationships with the stafflooking after them. A patient we met spoke very highlyof “my nurse”.

• In theatres, we saw that all staff took extra care toensure all patients felt relaxed, comfortable and at ease.Staff consistently modelled this behaviour throughout

our visit. We saw that staff always talked to patients andreassured them while they waited for surgery to start.We saw a surgeon explaining what was happening atevery stage to a patient who had spinal anaesthesia andwas awake during their operation. The surgeon regularlychecked the patient was comfortable and pain-freethroughout the procedure. We also saw an anaesthetisttaking the time to talk to a patient, reassuring them andhelping them feel at ease in the anaesthetic room.

• Patients and those close to them were active partners intheir care. Patients we spoke with told us staff involvedthem and their relatives in discussions about their care.One patient told us, “My consultant is lovely. He is opento questions, and answers them to allow me to makedecisions”. The patient described the consultant’sapproach as “very reassuring” and “very informative”. Apatient comment card we reviewed stated,“Conversations were acted on”.

• The hospital’s “day surgery customer feedback” resultsfor November 2016 to January 2017 showed 100%of day surgery patients felt involved in their care andtreatment. This demonstrated staff were fullycommitted to working in partnership with patients.Theresults for November and December 2016 showed95.2% of patients felt involved as much as they wantedto be in decisions about their care and treatment. Theremaining 4.8% of patients said they felt involved tosome extent. The results for January 2017 showed97.8% of patients felt involved as much as they wantedto be. The remaining 2.2% said they felt involved tosome extent.

Emotional support

• A patient we spoke with told us they felt very nervousbefore surgery. They described how their surgeon andanaesthetist made them feel at ease. A comment cardfrom another patient stated, “I was very nervous andthey made me feel really good”. We saw that all staff intheatres considered the emotional needs of patientsand helped them feel comfortable and relaxed beforetheir operation. This showed staff understood theemotional needs of patients and took action to ensurepatients felt comfortable.

• Bensan Ward had extended visiting until 8pm everyevening. For an additional charge, visitors could eat ameal on the ward with their relative or friend. These

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measures allowed patients to receive emotionalsupport from family and friends while they were inhospital. One patient commented, “The care afforded toall visitors was exemplary”.

• The hospital had its own chapel and a chaplain couldprovide emotional and spiritual support to patients andtheir loved ones upon request.

• The hospital’s “day surgery customer feedback” resultsfor November and December 2016 showed 98.9% of daysurgery patients found a member of staff to talk toabout their worries or fears. The results for January 2017showed 99.4% of day surgery patients who had anyworries or fears discussed them with a member of staff.This demonstrated patients felt able to confide in staffto provide emotional support.

• Benenden Society members could access counsellingservices to help them cope with the emotional impact ofsurgery. They could also access a psychologicalwellbeing helpline 24 hours a day, seven days a week.This allowed them to receive emotional support from acounsellor over the telephone and signposting towardssupport services in their local area. The hospital couldrefer patients who were not Benenden Society patientsto their GP for signposting to counselling services intheir local area.

Are surgery services responsive?

Good –––

We rated responsive as good.


• The hospital underwent the first phase of an extensiveredevelopment in 2016. This included a new theatredepartment, a new ward (Bensan Ward) and a newambulatory care unit. We saw that the new facilitieswere spacious and fit for purpose. Staff and patients wespoke with were very positive about the new building.

• The second phase of building work was taking place atthe time of our visit. This included a new eyedepartment and a new, onsite magnetic resonanceimaging (MRI) and computed tomography (CT) suite.The new facilities were part of a completely new

building. This meant patients could still have treatmentin the existing facilities during the development.Therefore, there was no adverse effect on servicedelivery during the redevelopment. The opening of thenew MRI and CT suite later in 2017 would allow rapidaccess for urgent imaging requests for surgicalinpatients 24 hours a day, seven days a week.

• Between October 2015 and September 2016, there were8,169 visits to theatre. Of these, 6,729 patients (82.3%)had day case surgery and 1,440 (17.7%) had anovernight stay.

• The service provided a diverse range of elective surgeryto meet the needs of the local population. This includedorthopaedic surgery, gynaecology surgery, urologysurgery, vascular surgery and eye surgery.

• The hospital accepted a range of treatment fundingoptions. These were self-paying, private medicalinsurance, Benenden Society membership and NHSfunding. Data showed 33% of inpatients hadNHS-funded treatment at the hospital between October2015 and September 2016.

• The hospital regularly met with local NHScommissioners to plan services and review theirperformance. The service also engaged with externalservices to help with service planning and delivery. Forexample, the hospital had an external review of thenursing establishment on Bensan Ward in September2016.

• All admissions for surgery planned in advance wereelective procedures. Due to surgery being elective at thehospital, service planning was straightforward as theworkload was mostly predictable.

Access and flow

• The theatre team had an on-call rota to cover anyunplanned returns to theatre outside of normaloperating hours. Anaesthetists also participated in anon-call anaesthetic rota to ensure 24-hour anaestheticcover. We saw evidence of two incident investigationswhere patients returned to theatres out of hours. Wesaw that the theatre team, including surgeon andanaesthetist, attended promptly and managed thesituations effectively.

• The hospital reported 91 cancelled procedures for anon-clinical reason in October 2015 to September 2016.

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During the same period, there were 8,169 visits totheatre. This meant only 1.1% of operations werecancelled. The hospital treated 66 patients (73%) within28 days of the cancelled appointment. However, thehospital offered patients a choice of dates and somepatients chose to have their operation later than 28 daysafter the cancellation.

• The hospital director told us the reason for somecancellations was patient choice. For example, somepatients chose to cancel their scheduled operation if anearlier date became available. This meant they had theirsurgery sooner than planned. However, the hospitalreported all rearranged operations as cancellations.Consultants gave 48 hours’ notice if they needed tocancel an operating list for a non-clinical reason otherthan unexpected sickness.

• The hospitals aimed to treat at least 80% of BenendenSociety members, insured and self-funding patientswithin 11 weeks of referral from their GP. Hospital datashowed 85% of patients in these groups had theiroperation within 11 weeks of referral in October 2015 –September 2016. This was better than the hospital’s80% target.

• For NHS-funded patients, the hospital aimed to treat90% of patients within 18 weeks of referral as agreedwith commissioners. Data for October 2015 toSeptember 2016 showed referral to treatment (RTT)within 18 weeks was worse than the 90% agreedcommissioning target in five months of the reportingperiod. The worst performing month was September2016, when only 79% of NHS-funded patients had theiroperation within 18 weeks of referral. The bestperforming months were December 2015, March 2016and April 2016, when 94% of patients had their surgerywithin 18 weeks of referral.

• The hospital told us there was some data entry andquality issues around RTT for NHS-funded patients in2016. This was because their internal reporting systemsused different measures. This meant the hospital didnot become aware of the dip in RTT performance untilDecember 2016. However, the hospital took immediateaction to address these issues and changed theirperformance measures. This allowed them to monitor

RTT accurately and address any decline in performance.The hospital reported improved RTT performance of95% at the time of our visit. This was better than thecommissioner’s target of 90%.

• The hospital frequently converted day case patients toovernight stays. This was because patients were notmedically fit for discharge on the day of their operation.This did not affect admission times for the next daybecause Bensan Ward had a sufficient number of bedsfor unexpected overnight stays. However, it did meanadditional, unplanned time in hospital for somepatients. A nurse told us there were five day case toovernight conversions on one day the week before ourvisit. Staff reported day case to overnight conversions asclinical incidents. We saw that this was the mostcommon category of clinical incident at the hospital.

• Staff felt the scheduling of operations was the reason forthe high number of conversions of day case to overnightstay. This was because the hospital scheduled operatinglists according to consultant availability rather than thetype of surgery. For example, patients havinggynaecology or general surgery may take longer to be fitfor discharge. Therefore, operating on these groups ofpatients on an afternoon, rather than morning, listincreased their risk of needing an overnight stay. Theexecutive team were aware of these issues and wereconsidering how to address them.

• The hospital did not stagger admission times forsurgery. Patients having surgery arrived at 7am foradmission onto a morning operating list and 12.30pmfor an afternoon list. This meant patients at the end ofthe list often waited for over five hours before going totheatres. The hospital informed patients of theoperating time window in their pre-admission letters.However, staff on Bensan Ward told us patients oftencomplained about the length of time they waitedbetween admission and surgery. We reviewed acomment card from a patient who waited from 1.30pmto 6.30pm for their operation. We also saw two formalcomplaints, which included details of excessive waitsbetween admission and surgery for patients at the endof the list.


• Nurses assessed patients’ individual needs atpre-assessment clinic. Staff on Bensan Ward told us

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pre-assessment nurses communicated any additionalneeds to them in advance. This allowed staff on theward to make appropriate arrangements beforeadmission. A matron we spoke with felt pre-assessmentwas thorough and effective at identifying additionalneeds.

• The hospital had access to face-to-face and telephoneinterpreters for a range of different languages. Staff wespoke with knew how to book interpreters and gave usexamples of times patients had used translationservices.

• The hospital had suitable facilities to allow them to treatbariatric patients. The hospital accepted admissionsfrom bariatric patients with a body mass index (BMI) ofup to 55, subject to pre-assessment with ananaesthetist. We saw bariatric equipment includingbeds, seats and shower chairs provided in two of thelarger patient rooms on Bensan Ward.

• The theatre department and Bensan Ward wereaccessible for wheelchair users. On Bensan Ward, therewere two larger patient rooms, which gave wheelchairusers additional space. We saw that all patient ensuitebathrooms on Bensan Ward were “wet room” with levelaccess shower facilities. We also saw additional aids tosupport patients with limited mobility such as showerchairs. This allowed wheelchair users to access serviceson an equal basis to others.

• Staff gave us examples of action they had taken to meetindividual patients’ complex needs, such as learningdisability and dementia. On Bensan Ward, staffallocated any patients with dementia to a roomadjacent to the nurses’ station. The ward allowed familymembers of patients living with dementia or learningdisabilities to stay overnight in an adjacent room. Intheatres, staff gave us an example of a patient withlearning disabilities whose parents came into theanaesthetic room with them before surgery. The parentsalso waited in recovery to greet the patient when theywoke up from general anaesthetic. This allowedpatients with additional needs to have their loved oneswith them to provide additional comfort and support.

• A senior nurse on Bensan Ward described briefing allstaff, including the housekeeping team, on any patientswith additional needs. The ward sometimes allocated

additional HCAs to shifts where there were patients withadditional needs on the ward. This allowed staff tospend additional time with patients to ensure they feltsupported and comfortable.

• All staff completed dementia awareness training atinduction and then every three years. Hospital datashowed 98% of unregistered nurses/HCAs, 95% ofregistered nurses and allied health professionals and94% of non-clinical staff had up-to-date training. Thiswas about the same as the hospital target of 95%. Thismeant all staff groups had awareness of how to meetthe needs of patients living with dementia.

• We saw the hospital’s “Dementia Strategy and AnnualPlan” for 2016 – 2019. The hospital was working towardsgaining national dementia-friendly status in 2017. Tohelp towards achieving this, Bensan Ward wasbeginning to introduce the national “blue butterflyscheme”. The scheme provided a discrete way to helpstaff easily identify patients living with dementia andbetter meet their needs. The hospital had a lead nursefor dementia care and planned to train a dementiachampion in every area of the hospital by 2019. Thehospital planned to look at benchmarking with theKing’s Fund assessment tool for dementia environment.

• We reviewed patient menus on Bensan Ward and sawthey included a range of healthy choices, includingoptions for vegetarians. The service noted any specificdietary needs such as allergies and intolerances atpre-assessment. This allowed the catering team toprepare suitable meals in advance for patients withspecific dietary needs.


• The hospital encouraged patients to raise concernsinformally in the first instance so staff could try toresolve any issues immediately. The hospital displayedposters encouraging patients to raise any concerns witha matron or department manager. We saw “Feedbackand Complaints” leaflets available throughout thehospital. The leaflets gave details of how to raiseconcerns and make a formal complaint. The leafletsalso described escalation measures such asindependent external review for any patients whowanted to escalate their complaint. Staff told us theygave a copy of the leaflet to any patient who raisedconcerns they were unable to immediately address.

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• Data showed the hospital received 19 formal complaintsbetween October 2015 and September 2016. Of these,10 complaints related to surgery. No patients escalatedtheir complaint to the Parliamentary and Health ServiceOmbudsman (PHSO) or the Independent SectorComplaints Adjudication Service (ISACS) forindependent review. The number of formal complaintsimproved significantly from the previous year, when thehospital received 70 complaints. This demonstrated theservice acted on patient feedback and addressedconcerns promptly to avoid the need for escalation.

• The hospital aimed to acknowledge formal complaintswithin two days and provide a full response within 20working days. We reviewed the hospital’s complaint logfor April to September 2016. This showed the hospitalmet their target response time for four out of sevencomplaints relating to surgery during this period.However, we saw that the hospital apologised topatients where they did not meet the 20-day target. Intwo out of the three cases where the hospital did notmeet the 20-day target, hospital staff had met with thepatients in the interim. This allowed the patients todiscuss their concerns further and for staff to updatethem on progress around the investigation.

• The relevant matron or department lead, such as thetheatre matron or ward manager, investigatedcomplaints relating to surgery. We reviewed fourcomplaints relating to surgery and the hospital’sresponses. In all four cases, we saw evidence ofinvestigation, explanation and apology. We saw thehospital was honest in its responses, for example, if staffhad made mistakes or should have done thingsdifferently. This was in line with the regulatory duty ofcandour (DoC) under the Health and Social Care Act(Regulated Activities Regulations) 2014.

• We saw evidence of learning from complaints. For,example, a patient complaint regarding cancelledsurgery due to an expired MRSA result led to a change inscreening practices. As a result of this investigation, theservice took patients swabs and blood samples at preassessment and not at the first clinic appointment. Stafftold us they received feedback from complaints atdepartmental meetings. Ward and theatre meetingminutes we reviewed reflected this.

• The hospital actively sought patient feedback. We sawpatient experience questionnaires available in clinical

areas. We saw the hospital took action to makeimprovements based on patient feedback. For example,two patients felt they did not have enough informationabout how their vision might be in the first few hoursafter eye surgery. Staff subsequently received feedbackon the importance of providing patients with theappropriate information leaflets before their operation.

Are surgery services well-led?

Outstanding –

We rated well-led as outstanding.

Leadership / culture of service related to this coreservice

• The service had a clear reporting structure. Staff intheatres reported to the theatre matron. Staff on BensanWard and the ambulatory care unit reported to thematron for wards and ambulatory care. The matronsreported to the director of patient services who sat onthe hospital’s executive committee.

• Every member of staff we met spoke positively abouttheir relationships with both their line manager and thesenior management team. Staff told us managers wereapproachable and dealt with any issues in a timelyfashion. Examples included a matron resolving an issuewith staff behaviour, and the dismissal of a member ofthe theatre team for misappropriation of controlleddrugs.

• Staff told us the senior management team (SMT) werevisible and approachable. The Director of PatientServices led the daily, multidisciplinary “ten at ten”meeting and discussed any concerns for the day withstaff. The SMT had an “open door” policy, and staff wespoke told us they would feel confident to approach theSMT with any concerns.

• The hospital funded managers and team leaders toattend a three-day residential leadership course. Thishelped managers develop and continually improve theirleadership skills. The hospital also ran an internal stafftraining and leadership programme, which more than120 staff had attended at the time of our visit. A memberof staff who attended the course found it beneficial fortheir continuing professional development (CPD).

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• The hospital offered a range of internal external trainingopportunities to help staff continually learn. Thisincluded the “Lord Plant travelling fellowship”. This wasan annual grant to allow staff to travel to other hospitalsand share best practice.

• Staff told us one of the best things about working at thehospital was the team. Staff descriptions of the cultureincluded “friendly”, “happy” and “really lovely”. Weobserved positive working relationships between staff.Due to the small size of the service, everyone knew eachother’s names and we observed friendly interactionsbetween staff from all departments in the hospital. Allstaff we spoke with were proud to work at the hospital.We met several members of staff who had been happyworking at the hospital for many years.

• The hospital demonstrated commitment to its value ofwellbeing. Initiatives to support staff wellbeing includedproviding free counselling and physiotherapy. Thehospital ran lunchtime clubs such as yoga and walkingto encourage staff to exercise in their lunch breaks. Thehospital also provided on-site vegetable growing plotsfor staff.

• There was a strong culture of openness andtransparency. For example, we saw that the vastmajority of incidents the hospital reported were “noharm”. The service actively encouraged staff to raiseconcerns. The hospital subscribed to the national “Signup to safety” campaign. One of the pledges of thiscampaign was to “be honest”. We saw posters aroundthe hospital encouraging staff to raise concerns andreport incidents. All staff we spoke with knew what Dutyof Candour meant and could describe theirresponsibilities relating to it.

• The hospital had clear referral pathways for BenendenSociety members, self-funded, private insured andNHS-funded patients. All pathways required patients tohave a GP referral to the hospital. This prevented anyconsultant from referring private patients to the hospitalin line with Competitions and Marketing Authorityrequirements.

Vision and strategy for this this core service

• Surgical services shared the hospital’s vision to be “Thepatients’ choice, providing high quality, caring andresponsive health and wellbeing services”. The hospital’sstrategic goals were growth, excellence and efficiency.

The hospital shared the vision and strategic goals withstaff in open sessions. The hospital also providedwritten information on the vision and values to newstaff. Staff we spoke with demonstrated awareness ofthe vision. All staff were aware of the three strategicgoals, which were printed on staff lanyards.

• The strategy for surgical services fed into the hospital’sstrategic goals. For example, the hospital was growingand expanding and range of surgical services. Thehospital introduced bariatric surgery in 2016 and wasbeginning to develop this new service. As part of thesecond phase of the hospital’s redevelopment, thehospital was building a new eye unit to replace theexisting facilities. It was part of the hospital’s “strategicvision and goals 2016 -2018” to expand the range of eyeprocedures. This included the introduction of laser eyesurgery and refractive lens exchange (surgery toreplaces the lens of the eye). Theatres were beginning toembed a six-day working week as part of their 2017“continuous improvement plan”.

• Surgical services followed the hospital’s values. Thesewere care, mutuality, sustainability and wellbeing. Staffwe spoke with knew the hospital’s values and describedhow they incorporated the values into their work.Examples included taking the time to listen to patients(care) and supporting colleagues (mutuality). Thisdemonstrated the hospital values were embedded intothe service.

Governance, risk management and qualitymeasurement

• The hospital had a clinical governance committee (CGC)which provided quality and safety assurances to theexecutive team. We saw that the matron for theatresand the matron for the ward and ambulatory care unitrepresented surgery on the CGC. A range ofsub-committees fed into the CGC. These included theinfection prevention and control committee (IPCC) andthe resuscitation advisory committee.

• The Clinical Governance Committee (CGC) met quarterlyand discussed complaints and incidents, patient safetyissues such as safeguarding and infection control, andclinical audit review. We saw the minutes fromNovember 2015, February, April, and July 2016 which

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reflected this. The hospital followed their corporate“Clinical Governance Policy” (October 2016), whichincluded roles and responsibilities, monitoring,reviewing, and auditing.

• Theatres and Bensan Ward held monthly teammeetings. The relevant matron in these areas escalatedany risks or areas of concern to the CGC. We saw copiesof the minutes, which showed staff received feedbackon incidents and complaints. This allowed the service tocontinually improve the quality of care.

• The hospital’s medical advisory committee (MAC)provided the formal organisational structure throughwhich consultants communicated. The MAC advised thehospital’s medical director, who was a hospitalemployee, and worked to maintain high standards andimprove the quality of services. A consultant surgeonrepresented surgery on the MAC. The MAC met everythree months.

• We reviewed MAC minutes from December 2015, andApril, July and September 2016. The minutes showedstaff discussed key governance areas such as NationalInstitute for Health and Care Excellence (NICE)guidelines, outcomes from root cause analysis,mandatory training and compliance data and incidentswere discussed. This showed the MAC took action tocontinually improve the quality of care.

• The hospital held departmental risk registers. We sawthat items on the theatre department risk registeraligned with areas staff told us were on their “worry list”.The risk register also aligned with areas of risk weidentified. For example, the intermittent problem withthe doors into the theatre department givinguncontrolled access was listed as a risk. This showedthe hospital understood the areas of risk relating tosurgery.

• The hospital had a performance dashboard, whichmonitored monthly performance in a range of key areasrelating to surgery. These included monthly WHO fivesteps to safer surgery audits, NEWS chart completion,dementia screening and early mobilisation. We saw thatstaff received feedback on key performance indicatorsat department meetings. This meant the serviceaddressed any deterioration in performance andhighlighted positive practice.


• The hospital actively engaged with staff through openstaff forums, an annual staff survey, and local awards torecognise staff achievement. The hospital held anannual “Best of Benenden” awards ceremony, withdinner at a local hotel for around 150 staff. A HCA onBensan Ward won the 2016 award for “Leading andinspiring others”. Staff spoke positively about theceremony and those who received nominations fordifferent awards told us it made them feel valued.

• The hospital’s annual staff survey provided a means ofengaging with staff and seeking their views. The 2015results reflected the positive and inclusive culture weobserved; with 90.7% of staff saying they felt part of ahappy and healthy workforce. The 2016 results were notyet available at the time of our visit. We saw that thehospital was taking forwards some of the suggestionsfor improvement from the survey. For example, thehospital was working towards full, six-day theatre lists.

• The hospital engaged with the local community througha range of projects. The hospital sponsored localmidsummer and midwinter fairs in 2015 and 2016. Atthese events, the hospital carried out free health checksfor cholesterol, body mass index, blood pressure andblood sugar. The hospital supported community eventsrun by a local newspaper group and received apartnership award in March 2016 as recognition of theirsupport. The hospital also chose a charity to supporteach year through fundraising events. In 2016, thehospital supported a local air ambulance charity.

• The hospital engaged with patients and their relativesthrough patient experience surveys and the NHS friendsand family test (FFT) for NHS-funded patients. Thehospital received a nomination for the “Best FFTinitiative” at the NHS friends and family awards 2016.The hospital also ran focused patient surveys seekingfeedback in specific areas. These included “spotlight ondoctors”, “spotlight on nursing” and “spotlight on sitedevelopment”.

• The hospital had an active patient engagement forum,which it introduced in September 2015. The forum gavepatients and their relatives the opportunity to givefeedback and make suggestions for improvement in aface-to-face environment.


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• The hospital completed phase one of an extensiveredevelopment in 2016. This included new theatres, anew ward (Bensan Ward) and a new ambulatory careunit. The hospital had started phase two of theredevelopment at the time of our visit. This included anew eye unit and an in-house MRI and CT suite.

• The hospital participated in a regional academic andhealth science network. Benenden Hospital staff werefinalists at the network’s 2016 awards ceremony for theirposter, “Improving the end to end pathway forenhanced recovery”. The hospital worked to encouragepatients to mobilise on the day of joint replacementsurgery. As a result of early mobilisation, the hospital’saverage length of stay following orthopaedic surgerywas only three days. This was better than the averagelength of stay of 4.9 days for other independenthospitals that participated in the national joint registry(NJR). The hospital was working to reduce the averagelength of stay to less than three days by furtherpromoting early mobilisation and improved painmanagement.

• The hospital received a national “Investors in PeopleSilver Award” in recognition of its commitment to staffhealth and wellbeing. The hospital was aiming forInvestors in People Gold Award at its next assessment inOctober 2017.

• The hospital was a finalist at a national awardsceremony for innovation in anaesthetics. The hospital’sinnovations in anaesthetics included the use of amulti-purpose anaesthetic breathing system. Thesystem recycled anaesthetic gases, which reducedanaesthetic gas wastage into the environment. Thissaved money and reduced pollution in the theatreenvironment. In 2016, Benenden Hospital used a newdevice for difficult airway management that containedan integrated single-use flexible video scope.Anaesthetists at the hospital received training from theequipment manufacturer before the hospital introducedthe device. This piece of equipment was disposable,which reduced the time needed for complex cleaningprocedures associated with re-usable video scopes.

• Two members of theatre staff won the Best of Benenden“Innovation of the year” award for preparing a businesscase for a new human waste management system forthe collection and disposal of surgical fluid waste.Theatres introduced the three new waste managementsuction units in 2016.

Surgery

Surgery

Outstanding –


Safe Good –––

Effective

Caring Good –––

Responsive Outstanding –


Are outpatients and diagnostic imagingservices safe?

Good –––

We rated safe as good.

Incidents

• An electronic based system was used to reportincidents. Staff were aware of the system and felt it waseasy to use. Staff told us that if they reported a clinicalincident on the electronic reporting system, they wouldreceive feedback on the investigation and any outcomesor actions following it.

• The hospital did not report any ‘never events’ betweenOctober 2015 and September 2016. ‘Never events’ areserious patient safety incidents that should not happenif healthcare providers follow national guidance on howto prevent them. Each never event type has thepotential to cause serious patient harm or death butneither need have happened for an incident to be anever event.

• The hospital reported no serious injuries betweenOctober 2015 and September 2016.

• Hospital data showed that between October 2015 andSeptember 2016, there had been 771 clinical incidentsreported across the hospital. Of these, 190 (25%)occurred within outpatients and diagnostic imaging.The rate was variable thorough out the year.

• Staff told us they were encouraged to report incidentsand that they were confident about reporting issues andraising concerns with senior staff. Staff were able to

clearly describe the process for reporting incidents. Theywere aware of the type of incidents they needed toescalate and report. Staff told us they made time toreport incidents. Staff also said there was an openno-blame culture for reporting incidents. This meant thehospital could be confident that all incidents including‘low risk’ or near ‘misses’ were reported.

• All staff gave examples of incidents such as medicationerrors and injuries in the department.

• In the diagnostic imaging department, there were clearprocesses for reporting incidents relating to IonisingRadiation Regulation (IRR) and the Ionising Radiation(Medical Exposure) Regulations 2000 (IR (ME) R).Hospitals are required to report any unnecessaryexposure of radiation to patients under the IR (ME) Rregulations. Diagnostic imaging services had proceduresto report incidents to the correct organisations,including the Care Quality Commission (CQC).

• Staff we spoke with in the radiology department told usthey were encouraged to report incidents using thepaper reporting system, this including both radiationand non-radiation related incidents. A service levelagreement (SLA) with a local NHS hospital’s medicalphysics and engineering department. This departmentoversaw any radiation related exposure incidents aswell as providing expert Radiation Protection supportand advice.

• Radiation protection supervisors (RPS) employed byBenenden hospital ensured compliance with IR (ME) R.The RPS are the first point of reference in theinvestigation of all radiation related incidents.

• There was one IR (ME) R reportable incident to the CQCbetween July 2015 and June 2016. This was in relationto a radiographer changing a request form from a skull

Outpatientsanddiagnosticimaging

Outpatients and diagnosticimaging

Outstanding –


x-ray to a computerised tomography (CT) scan to detectthe present of metal fragments prior to undergoing amagnetic resonance imaging (MRI) scan. This increasedthe patient’s exposure to radiation. This was reportedappropriately in line with protocol and investigated andlearning was shared to improve and checkcommunication procedures. We saw this incident wasalso discussed at the Radiation Protection Committee.

• Hospital data showed that between October 2015 andSeptember 2016, there were 213 non-clinical incidentsacross the hospital. Of these, 33 (15%) occurred inoutpatients and digital imaging.

• Staff described the principle and application of duty ofcandour, Regulation 20 of the Health and Social Care Act2008, which relates to openness and transparency. Itrequires providers of health and social care services tonotify patients (or other relevant person) of ‘certainnotifiable safety incidents’ and provide reasonablesupport to that person. Patients and their families weretold when they were affected by an event wheresomething unexpected or unintentional had happened.There were no incidents in which duty of candouractions had been required. Staff described how theywould action any incidents in which they felt duty ofcandour was needed, and were clear that they wouldalways inform their line manager for guidance andsupport. We spoke to one radiographer who gave us anexample of duty of candour following and incident theywere involved in. The radiographer had x-rayed thewrong site on the patient. They explained how had triedto contact the patient, explain what had happened andapologise. At the time of inspection, they had beenunable to contact the patient.


• All the areas we visited in the outpatients departmentwere visibly clean and tidy and we saw good infectioncontrol practices in place. For example, we saw all staffin departments we visited were ‘bare below the elbow’.This was in line with the hospital’s ‘hand hygiene policy’.In addition, we saw posters in consulting roomsreminding staff to be bare below the elbow.

• There were sufficient numbers of hand washing basinsavailable. Soap and disposable hand towels wereavailable next to sinks. Information was displayed aboutthe World Health Organisation (WHO) ‘five moments for

hand hygiene’ near handwashing sinks. This served toremind staff of the importance of cleaning their handsbefore or after key activities, such as patient contact.Alcohol hand sanitising gel was readily availablethroughout the departments.

• However, not all hand wash basins were compliant withHBN 00-09, which says clinical hand-wash basins shouldnot have plugs or overflows. Some of the hand washbasins had overflows present (although plugs had beenremoved). In addition, we found not all hand washbasins had mixer taps present. HBN 00-09 3.46-3.47 saysthat ‘Health and safety regulations (The Workplace(Health, Safety and Welfare) Regulations, 1992) requirethat both hot and cold running water should beavailable in areas where employees are expected towash their hands. Hands should always be washedunder running water; mixer taps allow this to bepractised in safety in healthcare settings where hotwater temperatures may be high to control Legionella’.However, the hospital was aware of the non-compliantsinks. At time of our visit, the outpatients departmentwas waiting to move into a newly built part of thehospital. All sinks in the new building will be fullycompliant with current guidelines.

• Hospital data showed that the outpatient departmenthand hygiene compliance rate was 96% in for April andMay 2016 and 97% in June 2016. For diagnostic imaging,the hand hygiene compliance rate for May 2016 was100%, and for June was 92%. Where there episodes ofnon-compliance we saw that members of staff werespoken to immediately. This meant the hospital couldbe confident staff were cleaning their hands in line withpolicy, and that staff were willing to challengenon-compliant behaviour.

• Equipment was visibly clean throughout thedepartment, and staff had a good understanding ofresponsibilities in relation to cleaning and infectioncontrol. All equipment we saw had ‘I am clean’ labels onthem, which indicated the date the equipment hadbeen clean and was safe to use.

• Personal protective equipment (PPE), such as glovesand aprons, were readily available for staff in all clinicalareas, to ensure their safety when performing



Outstanding –


procedures. This meant staff had the correct equipmentavailable to adequately ensure staff safety and reducethe risk of cross infection when staff performedprocedures.

• Not all seating in the outpatients and diagnosticimaging department was covered with a wipe-cleanfabric. This was not in line with HBN 00-09 section 3.133for furnishings, which states all seating, should becovered in a material that is impermeable, easy to cleanand compatible with detergents and disinfectants.However, were told all new furnishings in the newdepartments in the newly built part of the hospital, willbe fully compliant with current guidelines.

• We found gowns and towels in the disabled toilet. Stafftold us the gowns were in the toilet as it had been usedas a changing cubicle, but not at the moment. No staffcould explain why towels were present. Linen should bestored in designated areas such as cupboards or trolleydoors closed to prevent airborne contamination.

• We saw cleaning rotas for each consulting room, whichindicated what needed to be cleaned and how often. Wechecked six of the cleaning rotas and saw they were fullycompleted and up to date.

• We saw the infection control environment and clinicalpractice audit for the outpatient department, which wasundertaken in August 2016. The audit included aninspection of the cleanliness of the environment andequipment, management of sharps, waste and linen,hand hygiene and the use of PPE. The department wascompliant in the environment section in 17 out of 18standards. Non-compliances included furniture that wasno longer intact and chairs that were not wipe-clean. Inthe clinical practice section of the audit, the departmentwas compliant in 22 out of 24 standards.Non-compliances included, re-use of single use scissors,and sharps bins were found older than three monthsold.

• We saw a completed action plan for any issue that didnot meet the required standard. Action plans weremonitored and had been completed within the requiredtimescales.

• The examination couches seen within the consultingand treatment rooms were clean, intact and made ofwipe-clean materials. This meant the couches couldeasily be cleaned between patients.

• There were ‘sharps’ bins available in all the consultationrooms. We noted the bins were correctly assembled,and none of these bins were more than half-full, whichreduced the risk of needle-stick injury. However, wenoted in three out of the six sharps bins reviewed, onehad not been labelled and dated before being put intouse and the other two were older than three months.This was not in accordance with Health TechnicalMemorandum (HTM) 07-01: Safe management ofhealthcare waste, which says, “If the sharps receptacle isseldom used, it should be collected after a maximum ofthree months, regardless of the filled capacity”. Webought this to the attention of the outpatient sisterduring our inspection, who immediately removed thesharps bins from use. Checking of sharps bins wasadded to the weekly rota for each room, to prevent thisfrom happening again.

• Waste was separated and in different coloured bags tosignify the different categories of waste. This was inaccordance with the HTM 07-01, control of substancehazardous to health (COSHH), health, and safety at workregulations

• Some areas of the department (corridors) had carpet,which could not be as easily cleaned as the laminatedflooring when spills occurred. Department of Health’sHealth Building Note (HBN) 00-09: infection control inthe built environment states ‘Spillage can occur in allclinical areas, corridors and entrances’ and ‘in areas offrequent spillage or heavy traffic, they can quicklybecome unsightly’. However, the carpets were visiblyclean and when the department moves to the new buildall flooring will be compliant with current guidance.

• The outpatient department also undertookexaminations of patients using nasendoscopes(procedure for looking at the roof of the mouth andthroat). We were unable to observe procedures duringour inspection. However, we spoke with staff at length(in outpatients and in the sterile services department)who explained the procedure of safe transfer ofnasendoscopes, to and from outpatients to theendoscopy department. The service transferrednasendoscopes between the departments in a lidded,rigid plastic container. This meant staff coulddifferentiate between clean and dirty nasendoscopes.When transferring clean nasendoscopes, a green sterilefitted single use cover will be in place. For dirty a red



Outstanding –


sterile fitted single use cover will be in place. The tray islined with a clear fitted single use liner; this is to preventdrying out of the scope before cleaning, which couldmake it difficult to clean. This is in line with HealthTechnical Memorandum (HTM) 01-06: Decontaminationof flexible endoscopes Part A: Policy and management.

• Once the scopes arrived in the endoscopy department atrained member of the endoscopy team wouldmanually cleaning the scope prior to placing into anendoscope washer-disinfector for cleaning. Themachine printed a receipt providing assurance it hadperformed complete cleaning after every cycle. Staff toldus the printout alerted them if the machine had notworked correctly. This allowed staff to resolve any faultsand re-process the endoscopes to ensure completecleaning.

• The endoscope washer-disinfector had a barcodetracking system. This enabled the hospital to track thecleaning of endoscopes used by individual patients forquality control.

• The number of nasendoscopes enabled the schedulednasendoscopy lists to proceed uninterrupted.

• In the diagnostic imaging department, we sawultrasound probes were cleaned between each use witha triple cleaning system. At the end of each of the threestages of cleaning, a label was stuck in a record book,which demonstrated which wipe staff had used. Therecords showed each time a probe was cleaned with thethree stages completed. We saw records were complete.

• Single use items of sterile equipment were readilyavailable and stored appropriately in all areas checked.Instruments used for patient treatment that requireddecontamination and sterilisation were processed viathe on–site sterile supplies department, to ensurecompliance with regulatory requirements for cleaning(decontamination), Health Technical Memorandum(HTM) 01-01: management and decontamination ofsurgical instruments (medical devices) used in acutecare.

• The hospital had a designated decontamination lead, inline with the recommendations of the Code of Practiceon the prevention and control of infections and relatedguidance (the code), Criterion 1 that describes thesystems to manage and monitor the prevention and

control of infection. We saw that both the sterilesupplies and endoscopy department had been audited.We saw copies of these audits, along with action plansarising from them.

• The hospitals lead for infection prevention and control(IPC), who is also the director of IPC (DIPC), maintainedlinks with the local NHS trusts infection control team.The DIPC monitored audit activity, provided guidancefor wards and departments, as well as at meetings, andmanaged the infection prevention programme. Thisincluded training and supporting 14 link practitioners, inall departments and areas of the hospital. Linkpractitioners are members of the department, with anexpressed interest in a specialty; they act as linkbetween their own clinical area and the infectioncontrol team. Their role is to increase awareness ofinfection control issues in their department and tomotivate staff to improve practice.


• The environment in all department areas we visitedappeared uncluttered, and tidy.

• The consulting rooms were tidy and equipped with adesk and chairs and a couch area for procedures. Therewere trolleys in the rooms, which contained steriledisposable items, such a syringes, needles, and wounddressings, all these items were in date. Disposablecurtains were in place and had been changed within thelast six months.

• Some of the consulting rooms contained facilitiesappropriate to the speciality of the consultant, forexample equipment for an exercise tolerance test (ETT),such as a treadmill. An ETT is a test to see how the heartresponds to stress, and usually involves walking on atreadmill at increasing levels of difficulty, while theelectrocardiogram, heart rate and blood pressure aremonitored.

• We looked at three resuscitation trolleys in thediagnostic imaging and outpatients department. Alltrolleys were locked. Records indicated that the trolleyswere checked daily on days when clinic operated. Alldrawers had the correct consumables and medicines inaccordance with the checklist; we saw they were in date.



Outstanding –


The automatic electrical defibrillator worked andsuction equipment was in order. This meant staff hadaccess to equipment needed in the event of a medicalemergency.

• The environment for diagnostic imaging was crampedand cluttered, due to the building works that werecurrently being undertaken throughout the hospital.However, the imaging rooms and equipment was visiblyclean.

• The diagnostic imaging department had changingcubicles available for patients to use to prepare for anexamination. The cubicles had lockable doors to ensurepatient privacy. Patients carried their clothes in suppliedbaskets with them into the imaging rooms, whichguaranteed the safety of their personal items

• However, the changing cubicles were not designatedmale or female and opened directly into the mainwaiting area. Staff advised us that the majority of thetime patients remained in the changing room until theywent into the imaging suite. However, privacy anddignity could not be guaranteed in the mixed sexwaiting area outside of the changing area for patientsawaiting procedures.

• In the digital imaging department, we saw specialistpersonal protective equipment such as lead apronswere available. We saw staff use them. The effectivenessof their protection was checked with regular audits. Wesaw copies of the audits that showed examinations hadbeen undertaken to screen the PPE to see if any cracksor folds have appeared. We observed each item waslabelled with the thickness of lead and we were told bythe radiographer that visual examinations take placeregularly and screening of the PPE will take placeannually to ascertain if any cracks or folds haveappeared. This complied with Regulation 9 (3) of theIonising Radiation Regulations 1999. (IRR’99).

• We saw staff wearing personal radiation dose monitorsand these were monitored in accordance with therelevant legislation.

• There were systems and processes in place to ensurethe maintenance and servicing of imaging equipment.Across the department, we saw that a quality assurance(QA) programme was in place for all radiographicequipment requiring all checks to be performed at

regular intervals on all equipment, as required bycurrent legislation. This meant the hospital hadassurances imaging equipment was safe and fit forpurpose.

• The physiotherapy department consisted of twotreatment rooms and a gym where individual or grouprehabilitation sessions were held. The department wastidy and well equipped.

• During our inspection, we looked at 10 pieces ofequipment. All items had labels in place to show theyhad been tested for electrical safety, and were safe touse. This meant the hospital had assurance that allpieces of medical equipment were tested for electricalsafety.

• Maintenance was generally undertaken using twomethods: planned preventative maintenance (PPM) orreactive maintenance. PPM was undertaken on a regularprogramme (weekly, monthly, quarterly, yearly) to meetstatutory requirements, legislation, manufacturer’sguidance, and industry good practice. Reactivemaintenance was undertaken on an as required basis toaddress damage, breakdowns, or failure.

• The hospitals estates department was responsible for allnon-medical electrical equipment, as well as thegenerator, and boiler and ventilation. The hospital had aservice level agreement (SLA) with another hospital’selectronics and medical engineering department(EBME), who maintained the medical equipment.Representatives from the other hospital’s EBMEdepartment visited the hospital every Monday,Wednesday, and Friday to undertake PPM, but wereavailable in the event of an urgent medical equipmentfailure.

• Staff we spoke with had no concerns about equipmentavailability. If any equipment required repair, theyreported it and it was fixed quickly. Staff were aware ofthe process for reporting faulty equipment.

Medicines

• Staff followed an up-to-date ‘Medicines ManagementPolicy’, which included roles and responsibilities,monitoring, reviewing, and auditing.

• The outpatients department did not hold any stock ofcontrolled drugs. Controlled drugs are medicines liablefor misuse that require special management.



Outstanding –


• Emergency drug packs for cardiac arrest, anaphylaxis(allergic reaction), and deteriorating patients wereavailable and standardised across the service. Thismeant staff were familiar with them as they were thesame throughout the hospital.

• We saw medicines were stored securely and handledsafely. In the outpatient department, we saw thatmedicines were stored in a locked room. Only nursingstaff had access to the room using a coded keypadaccess. In the room, medicines were stored in the lockedcupboards, which were accessed via key, which onlytrained nurses held.

• Staff told us every week a senior member of staffchecked the medicines to ensure they were all in date,during our inspection we randomly checked medicinesand found all of them to be in date.

• Appropriate medicines were stored in dedicatedmedicines fridges. We saw records, which showed dailytemperature checks were undertaken. This providedassurance the hospital stored refrigerated medicineswithin the recommended temperature range tomaintain their function and safety. We also sawrecommended actions to be taken if the fridgetemperatures were not in the correct range.

• We reviewed the hospitals prescription pad records.Initially, we found prescription pads were blank with noserial number or log book-recording serial number, dateand time when the prescription pads were last used.They were also stored in an unlocked drawer in themedicine room. This meant it would not be possible toestablish if any had been removed from the drawer, andno reliable system to track any that had been used.

• We highlighted our concerns around prescription padsto the pharmacy and outpatient managers, who tookimmediate action to correct this. All blank prescriptionswere removed from the outpatient department, andstored in pharmacy. All prescriptions will now be givenan individual serial number, and recorded when theyare removed. Prescriptions will be collected on day ofclinic and stored in a locked cupboard in thedepartment, they will be given to the consultants asrequested and prescribing pad log completed. Duringour unannounced visit, we saw this new system was inplace.

• For our detailed findings on medicines, please see theSafe section in the surgery report.

Records

• The hospital had an up to date ‘Policy for Managementof Health Records and Clinical Information’. The policyincluded retention, secure storage and tracking ofhealth records, order of filing and guidance ontransporting health records.

• All medical records were kept on site or recalled from amedical records store in time for the patient’s outpatientappointment. During clinics medical records were keptin staffed rooms, if staff left, the offices would be locked.Medical records were transferred to the consultant whenthe patient arrived.

• There was a specific team in the hospital that preparedthe medical records one to two days in advance of aclinic to allow sufficient time to identify any gaps orissues. Medical records were checked and set up by thedepartment in advance of the appointment. This wasdone in order to make sure the medical records werereadily available and checked for accuracy and to makesure all relevant documentation was present. Medicalrecords were taken back to the medical records storagearea after clinics. Staff told us consultants were notallowed to take medical records off site to ensurepatient notes were always available.

• There was an electronic tracker system in place, whichwe saw; this meant staff knew where the medicalrecords were at all times.

• In the event a consultant wanted to take the medicalrecords off site, they would have to complete a requestform and obtain permission from a member of thehospital executive team. In advance of the medicalrecords, being taken off site an agreement must bereceived and documented from the consultant, with thedate they would return the records. The records wouldbe tracked out of the hospital and to the consultant onthe hospital electronic tracker system.

• Patient records in the outpatient department werepaper based. We reviewed four sets of patient records.All records were legible, signed and dated. This was



Outstanding –


in-line with guidance from the General Medical Council.Records contained all the relevant information,including referral letters, and any procedures ordiscussion that had taken place.

• Staff told us they had no problems with accessingpatient notes for their clinics, and could not remember atime when patient records were not available. Dataprovided by the hospital showed that between Octoberto December 2016, no patients were seen without theirmedical records present.

• The Picture Archiving and Communication System(PACS), a nationally recognised system used to reportand store patient images was available and used acrossthe hospital. The radiology department also had accessto an image exchange portal (IEP) for images held onother systems. This meant staff could view patientexisting images instead of exposing them tounnecessary repeat procedures.

Safeguarding

• There was an up-to-date ‘Safeguarding Policy’, whichcombined both vulnerable adult and child safeguarding.The policy included roles and responsibilities,definitions and actions to take, if staff suspected asafeguarding issue.

• There have been no safeguarding concerns reported tothe CQC between October 2015 and September 2016.

• All staff we spoke with knew who the lead was forsafeguarding, and could explain the actions they wouldtake if they had a safeguarding concern; this was in linewith the policy. We saw there were posters on display inall areas of the outpatients and diagnostic imagingdepartment, which gave contact name and numbers if asafeguarding concern was identified.

• Staff received mandatory training in the safeguarding ofadults and children, as part of their induction followedby refresher training every three years.

• Safeguarding of vulnerable adults was undertaken everythree years for all levels. Data indicated that over 99%and over of required staff had completed level one and95% and over had completed level two, which is equalto and better than Benenden Hospital Trust target of95%. Data indicated 100% of required staff hadcompleted level three safeguarding of vulnerable adultstraining. This was in line with national guidance.

• Data showed 100% of required staff had completedsafeguarding children level one training. This was betterthan the Benenden Hospital Trust target of 95%. Over93% of relevant staff completed level safeguardingchildren level two. Data indicated 100% of required staffhad completed level three safeguarding of childrentraining.

• The matron for inpatients and ambulatory care was thesafeguarding lead. The Director of Patient Services (DPS)was the hospitals executive safeguarding lead, and thechair of the Medical Advisory Committee (MAC) was thenamed doctor for safeguarding.

• We saw there were systems in place to ensure the rightperson, gets the right radiological scan at the right time.This included justification of the request forms. Onreceipt of the request by the modality, radiologist orradiographer could redirect to another imagingmodality if it was felt the request examination was notappropriate. For example, an external companyprovided computerised tomography (CT) and magneticresonance imaging (MRI). However, a radiologistreviewed all requests for these images beforeundertaking the procedure. This meant the hospitalcould be confident the imaging department ensuredjustification of exposure to keep patients safe.

• We observed two patients undergoing radiological scanduring our inspection, and saw that staff ‘paused andchecked’ patients identifications before proceeding.This ensured the right person received the rightradiological scan.

Mandatory training

• Mandatory training for all staff groups wascomprehensive with modules accessed either throughan online learning system or via face-to-face session.Mandatory training modules included safeguardingvulnerable adults, dementia awareness, fire safetyawareness, infection control, manual handling andsafeguarding children and young people. Other trainingwas role-specific for example, fire wardens and firemarshals training, food safety general awareness,emergency first aid at work, and medical gasesawareness.

• The Benenden Hospital Trust target for mandatorytraining compliance was 95%. Figures provided by to usshowed that registered nurses were expected to



Outstanding –


undertake 35 mandatory training modules. As of 25October 2016, compliance for mandatory training for all35 modules ranged between 80% and 100%. Infectioncontrol for link nurses had the worst completion rate of80%. Twenty-three out of the 35 mandatory trainingmodules had 95% and above completion rates in linewith the hospital target. Twenty-seven out of 35modules had 90% and above compliance. This meantthe hospital could be confident the majority of staffwere aware of their roles and responsibilities to keeppatients safe.

• Allied healthcare professionals, such as physiotherapistsand radiographers were expected to undertake 34mandatory training modules. As of 25 October 2016,compliance for mandatory training for all 34 modulesranged between 67% and 100%.Intravenousadministration and updates being the worst at 67%.Eighteen out of the 34 mandatory training moduleswere 95% and above, and twenty-three out of 34modules were 90% and above. This meant the hospitalcould be confident the majority of staff were aware oftheir roles and responsibilities to keep patients safe.

• Non-registered clinical staff, such as clinical supportworkers (CSWs), were expected to undertake 24mandatory training modules. As of 25 October 2016,compliance for mandatory training for all 24 modulesranged between 50% and 100%, with infection controlfor link workers and fire wardens level three as the worstat 50%. Eighteen out of the 24 mandatory trainingmodules were 95% and above, and twenty-one out of 24modules were 90% and above. This meant the hospitalcould be confident the majority of staff were aware oftheir roles and responsibilities to keep patients safe.

• Non-clinical staff, such as receptionists, were expectedto undertake 39 mandatory training modules. As of 25October 2016, compliance with mandatory training forall 39 modules ranged between 41% and 100%, with firewardens level three as the worst at 41%. Twenty-nineout of the 39 mandatory training modules were 95%and above, and thirty-three out of 39 modules were 90%and above. This meant the hospital could be confidentthe majority of staff were aware of their roles andresponsibilities to keep patients safe.

• The resident medical officers (RMO) were required toundertake their mandatory training with the agency thatsupplied them as part of their contract.

• Consultants had to complete mandatory training withthe trust they worked for as part of their appraisalprocess and practising privilege.

Assessing and responding to patient risk

• We observed good practice for reducing exposure toradiation in the Radiology department. Local rules wereavailable in the areas we visited. All rooms that performradiographic examinations had all the necessarywarning notices on the doors and illuminated boxesoutside the rooms that light up when a radiographicexposure is made. Staff checked the warning signschecked regularly to ensure they worked correctly, andwe saw evidence of these checks. This was inaccordance with current legislation.

• There were two appointed and trained radiologyprotection supervisors (RPS). The RPS role was toensure equipment safety and quality checks andionising radiation procedures were carried out inaccordance with national guidance and localprocedures.

• There were emergency procedures in place in theoutpatient department including call bells to alert otherstaff in the case of a deteriorating patient or in anemergency. The hospital allocated staff to respond to anemergency with the resident medical officer (RMO). Thisincluded dialling 2222 for the resuscitation team. Anypatients requiring further interventions would betransferred to the neighbouring NHS Trust. We sawposters on display, prompting staff to dial this numberin the event of an emergency.

• The hospital had access to a resident medical officer(RMO), on duty. The RMO was trained in advanced lifesupport and advanced paediatric advanced life support(APLs). The RMO provided support to the outpatientstaff if a patient became unwell. Patients who becamemedically unwell in outpatients would be transferred tothe local acute NHS Trust in line with the emergencytransfer policy. Staff reported this rarely happened.

• Nursing staff told us if a patient was identified as havingany health related risks then they would move thepatient from the main waiting area, to one of theconsulting rooms. They would make sure a trained staffmember would remain with the patient



Outstanding –


• Staff, in outpatients told us they did not routinely takepatient’s base line observations, as patients did notusually require this. However, they would record thepatient’s observations if requested to do so, or if theyassessed the patient as unwell. They would then reportthis to the consultant immediately.

• We did not see any signs prompting women to informstaff if there was a possibility they could be pregnant.Staff in diagnostic imaging confirmed they would notcarry out a scan on a female patient of childbearing age,without asking the patient first, and document this ontheir system. To comply with IR (ME) R, as departmentshave to establish the pregnancy status of a patient priorto any relevant medical exposure.

Nursing staffing

• There are no national guidelines on staffing levels foroutpatient departments. Outpatient departmentstaffing levels and skill mix were planned using a localprotocol that ensured a mix of registered nurses andclinical support workers, depending on the number andspeciality of the clinics running.

• As of 1 October 2016, there was 8.4 whole timeequivalent (WTE) outpatient registered nursing staff and10.9 WTE clinical support workers (CSW) for outpatients.The outpatient department had a ratio of nurse to CSWof 1 to 1.3.

• As of 1 October 2016, there were 1.8 WTE posts vacantfor outpatient registered nurses given a vacancy rate of18%. For CSWs, there were 0.21 WTE posts vacant givinga vacancy rate of 2%.

• Between October 2015 and September 2016, the use ofbank and agency nurses in the outpatient departmentwas worse than the average of other independenthospitals we hold data for. Agency use was worse thanthe average for other independent hospitals in all excepttwo months during this period (October and November2015).

• Between October 2015 and September 2016, the use ofbank and agency CSWs in the outpatient departmentwas variable when compared to other independenthospitals we hold data for. Rates were worse inNovember and December 2015, February, April and May2016.

Allied Health Professional Staffing

• There was a team of three physiotherapists, one fulltimeand two part time, who provided inpatient andoutpatient care. The service also used three bankphysiotherapists to provide cover on the ward at theweekend.

Radiology staffing

• The radiology department consisted of 11 permanentmembers of staff. There was 1.0 WTE lead radiographer,3.2 WTE radiographers, 1.2 WTE MR Radiographer, and1.5 WTE sonographers. They were supported by 2.0 WTEreceptionists and 0.96 WTE medical secretaries. Theservice also used six bank staff to provide cover whenrequired.

• In addition, a Clinical Nurse Specialist in continencecare provides support once a week for Trans rectalultrasound of the prostate (TRUS). TRUS isanultrasoundtechnique that is used to view a man'sprostate and surrounding tissues.

Medical staffing

• There were 116 consultants who had practisingprivileges at the hospital. Practising privileges is a termused when doctors have been granted the right topractise in an independent hospital. The majority ofthese also worked at other NHS trusts in the area.

• The hospital had two RMOs onsite 24-hours a day, sevendays a week. The RMOs worked a one week on, followedby one week off, on a rotational basis. The RMO wouldprovide support to the outpatient and digital imagingdepartment in the event of an emergency or withpatients requiring additional medical support.

• For our detailed findings on medical staffing please seethe Safe section in the surgery report.


• The hospital did not receive emergency patientsfollowing a major incident. The hospital had an up todate ‘Business Continuity Policy, Plan, and Procedure’,which included roles and responsibilities, definitionsand the procedure including escalation, of what to do inthe event of something happening.

• The hospital ran regular exercises such as fire drillsthroughout the year to ensure all staff were trained inthe requirements of emergency incidents. For example,staff completed fire safety training level two on



Outstanding –


induction and then yearly. Hospital data showed as of25 October 2016, 96% of required staff had completedtheir fire safety training. This meant the hospital hadassurances staff were aware of their responsibilities androles to keep patients safe in the event of a fire.

• Fire wardens and Fire Marshalls were expected toundertake level three training and 100% of fire marshalhad undertaken their training. However, only 63% of firewardens had completed level three training. This meantthat not all fire wardens had up-to-date training in thisrole.

• The hospital had backup generators in case of powersupply to ensure services were not affected. Managersinformed us that regular testing of generators took placeas part of the business continuity plan. We looked atrecords to show that back-up generators were servicedand tested regularly.

Are outpatients and diagnostic imagingservices effective?

We inspected but did not rate effective, as we do notcurrently collect sufficient evidence to rate this.

Evidence-based care and treatment

• The diagnostic imaging department had comprehensivepolicies and procedures in place. We saw these were indate, in line with regulations under IR (ME) R and inaccordance with the Royal College of Radiographersstandards

• We saw evidence of standard operating procedures,clinical protocols, and local referral guidelines. Thesewere based on the Royal College of Radiologistsguidelines, justification policy to ensure all medicalexposures were justified prior to the exposure beingmade.

• The imaging department used diagnostic referencelevels (DRLs) as an aid to optimisation in medicalexposure. DRLs were cross-referenced to national auditlevels and if they were found to be high, a report to theradiation protection advisor (RPA) would be made. Wesaw evidence that systems were in place for the hospital

to report ‘much greater than intended’ incidents to theCare Quality Commission (CQC). This is a statutoryrequirement and the hospital actively engaged with theCQC.

• The Ionising Radiation Regulations1999 (IRR ’99) aims toprotect the public and the health of the staff who workwith ionising radiation by specifying the duties of thehospital to ensure compliance to the regulations. Weobserved compliance with the regulations through riskassessments, and quality assurance programmes. Aswell as, the provision of PPE, the development of localrules for each modality and the employment ofradiation protection supervisors.

• Radiation protection policies, including Local Rules,were available within clinical areas. Staff in outpatients,radiology, and physiotherapy had a good awareness ofand had read local policies. They were able to give usexamples of how to find policies and when they hadused them.

• The outpatients department undertook a variety of localaudits. They were to check equipment, medicinesmanagement, electronic records, hand hygiene, andmonthly spot check audits. We saw copies of theseaudits, along with action plans arising from them.

• The hospital had recently developed a dementiastrategy, to be rolled out over the next three years. Thestrategy was based on the National Institute of Healthand Care Excellence (NICE) guidance, including NICECG42 Dementia: supporting people with dementia andtheir carers in health and social care.

Pain relief

• During our inspection, we did not find any patients whowere in pain, or required pain relief. However, Staffdescribed how they would offer support to patients whoreported being in pain. Staff said that they would assessthe level of pain and speak with the consultant for painrelief to be prescribed.

• Consultants discussed pain management within theconsultation process for patients who were going to bebooked in for a surgical procedure.

• The Physiotherapy department offered acupunctureand ultrasound therapy to provide pain relief, whichthey offered to the appropriate patients. Ultrasoundisoften used to provide deep heating to soft tissue



Outstanding –


structures in the body. Deep heating tendons, muscles,or ligaments increase circulation to those tissues, whichis thought to help the healing process. Increasing tissuetemperature withultrasoundis also used to helpdecrease pain.

• Patients received written advice on any pain reliefmedicines they may need to use at home, during theirrecovery from their outpatient procedure. For example,we saw in the patient information for patients followingan injection with cortisone (a type of steroid). Theinformation recommended the type of pain relief theyshould take at home, following the procedure.

• Nutrition and hydration

• There were water fountains in each department, whichpatients could use. Hot drinks were available from thehospital restaurant free of charge. Patients and staffcould also buy hot and cold food from the restaurant.

• We looked at two patient information letters sent topatients before attending for an interventionalradiological examination. These letters providedguidance to patients around nutritional and hydrationrequirements before the investigation. For example,patients who may be diabetic were requested to contactthe department prior to attending to ensure thepatient’s health was not compromised prior to theexamination.

• The hospital had a five star rating in the local authority‘Food Hygiene Certification Scheme’. This gaveassurance that all best practice in food hygienestandards were adhered to.

Patient outcomes

• There were a variety of processes described to measureand audit patient outcomes, including an internal auditprogramme.

• The hospitals clinical audit schedule outlined, when,how often and who would undertake the audits invarious areas. There were a number of local auditsplanned for outpatient and diagnostics. These includedauditing of consent, standards of record keeping,imaging request forms, knowledge skills andcompetency and wrong site delivery / local rules.

• At a corporate level, the provider was working with thePrivate Health Information Network (PHIN). PHIN

planned to provide information for the public from April2017 on 11 key performance measures. This meant apatient could make an informed choice where to havetheir care and treatment for providers offering privatelyfunded healthcare.

• Physiotherapy staff asked all patients to complete apatient reported outcome measure (PROM). Thisenabled staff to measure the effect of treatment on eachpatient. See the main surgery report for a breakdown ofthe PROMs data.

• The hospital did not participate in imaging accreditationschemes or improving quality in physiological servicesscheme. The Imaging Services Accreditation Scheme(ISAS) is a patient-focused assessment. Diagnosticimaging accreditation programme is designed to helpdiagnostic imaging services ensure their patientsconsistently receive high quality services, delivered bycompetent staff in safe environments. However, themanager told us they had plans to gain accreditation by2018.

• For our detailed findings on Patient outcomes, pleasesee the Effective section in the surgery report.

Competent staff

• Staff training and professional development needs wereidentified through informal one to one meetings withtheir managers, and annual appraisals. Duringappraisals, personal development goals were agreed,and individual performance was agreed.

• Hospital data showed between January to December2016, 100% of nursing and clinical support workers(CSW) received an annual appraisal. This meant theservice was able to address any potential staffperformance issues. Staff told us appraisals were useful,and there were two-way discussions aroundperformance and opportunities for training andprogression.

• All new staff completed an induction programme. Stafftold us the comprehensive programme includeddepartment tours, introduction to colleagues andcompletion of an induction booklet. During ourinspection, we looked at three induction booklets and



Outstanding –


saw they were either completed or in the process ofcompletion. This demonstrated the hospital ensurednew staff had all the information and competencies theyneeded to do their jobs.

• Staff confirmed they were well supported to maintainand further develop their professional skill andexperience. For example, CSWs working in outpatientdepartment were given competency assessments sothey could assist in certain procedures. These includedvenepuncture, testing urine, measuring and recordingheight and weight, blood pressures, oxygen saturations,and undertaking a 12 lead electrocardiogram (ECG) ofthe heart. During our inspection, we looked at fourcompetency folders for CSWs, and saw they were allcompleted and up to date. This meant the hospital hadup-to-date assurances of CSW competencies.

• All staff we spoke with in during our inspection told usthey completed competency assessments to ensurethey had the skills and knowledge to carry out the rolesthey were employed to do. Staff were also encouragedto undertake continuous professional development(CPD), and were given opportunities to develop theirclinical skills and knowledge though training relevant totheir role. During our inspection, we saw six CDP foldersfor nursing staff. All certificates were up to date, forexample, life support and safeguarding training, andcompetency assessments were completed. This meantthe hospital had up-to-date assurances of nursingcompetencies.

• There were two radiation protection supervisors (RPS)on site, they had certificates of competence and hadattended the required training. We saw the certificate ofcompetence update for one of the RPS, which wasdated 11 May 2016.

• One-hundred percent of nurses, who worked within theoutpatient department for six months or more, hadrecorded validation of professional registration. Thismeant the hospital conducted annual checks to ensureall the nurses were registered with the Nursing andMidwifery Council (NMC).

• All Radiographic staff were trained by the Society andCollege of Radiographers (SCoR) and held either aDiploma of the College of Radiographers (DCRR) or aBSc (Hons) in radiology. All staff were registered on atwo-year basis with the Health and Care Professionals

Council (HCPC).There are codes of Practise for both theSCoR and the HCPC which must be followed, anybreaches will result in a radiographer being reported. Nostaff had been referred to either professional body formisconduct.

• There were appropriate systems in place to ensure thatall consultants’ practising privileges were keptup-to-date. Evidence of this was seen in the MedicalAdvisory Committee (MAC) minutes, during theinspection.

• Patients we spoke with told us they felt staff wereappropriately trained and competent to provide thecare they needed.


• There was a strong multi-disciplinary team (MDT)approach across all of the areas we visited. From thecare we observed, there was good collaborative workingand communication amongst all members of the MDT.Staff of all grades, clinical and non-clinical workedalongside each other throughout the hospital. Staff wespoke with told us that they worked well as a team.

• Staff told us that they were proud of goodmultidisciplinary team working, and we saw this inpractice. Staff were courteous and supportive of oneanother.

• As part of the justification process to carry out exposureto radiation, the imaging service always attempted tomake use of previous images of the same personrequiring the test, even if these have been takenelsewhere, via the image exchange portal (IEP).

• Physiotherapy supported effective recovery andrehabilitation, including an appointment atpre-operative assessment for patients havingorthopaedic surgery. At this appointment, staff gavepatients exercises to perform before surgery.Physiotherapists also saw patients recovering fromsurgery at follow up appointments in outpatient clinics.

• The department had service level agreements (SLA’s)with several different organisations. These includedpathology services, medical equipment maintenance,and provision of Magnetic Resonance Imaging (MRI) andComputed Tomography (CT) scanning. Contracts werein place and review dates documented.



Outstanding –


• Nominated link staff went to meetings, such as infectioncontrol. They communicated relevant information tostaff in the department and took areas for escalationback to the meetings. We saw evidence of this indepartment meeting minutes.

Seven day Services

• The outpatient department ran clinics between 8.30amand 7pm, Monday to Friday. Saturday clinics wereprovided between 8.30am and 5pm. Staff cover wasprovided between these times.

• The diagnostic imaging department was open between8am and 7pm, Monday to Friday, and Saturday between8am and 2pm. A 24-hour a day, seven day a weekservice for urgent examination requests was available.

• There was a pharmacy service available at the hospital,Monday to Friday from 9am to 5pm.

• The physiotherapy department ran clinics at thehospital, Monday to Friday between 8am and 6pm.

Access to information

• Outpatient consultations within the hospital wereconsultant-led. Patients attending outpatients had anenclosed GP referral letter or their current medicalrecords from a previous appointment or admission atthe hospital.

• Images from other hospitals could be accessed via asecure computer network in the radiology department.Staff could see what previous scans or tests had beenundertaken. This enabled staff to ensure patients didnot receive repeat examinations and receive ahigherdose of radiation than required. The consultantsand RMO had access to these as required.

• Clinical and quality communication boards displayedthe hospitals compliance with key clinical indicators andwere shared within patient areas around the hospital.

• The hospital had daily ‘ten at ten’ meetings attended byrepresentatives from all departments in the hospital,including outpatients, radiology, and physiotherapy.These meetings allowed for escalation of concerns orshortfalls in staffing. All departments of the hospitalwere represented at this meeting. During our inspection,we attended one of these meetings and observedpositive multidisciplinary working between all staffgroups.

• The Picture Archiving and Communication System(PACS) link all the patients’ examinations and reportstogether. This meant Radiologists could access allexaminations and reports during the reporting process,for individual patients. Report results were availablepromptly from the radiology management computersystem.

• The Radiology staff told us that an Image exchangeportal (IEP) which connects to other hospitals includingtwo local NHS trust was in place to transfer images oftheir patients who have either received treatment atBenenden hospital or at other NHS trusts. This meantthat images were shared between providers to preventunjustified re-imaging of patients.

• Staff reported timely access to test results such as frombloods and diagnostic imaging. Results were availablefor the next appointment or during the same visit. Thisenabled prompt discussion with the patient on thefindings and treatment plan.

• Doctors dictated clinic letters and they were typed bymedical secretaries onsite. GPs were sent the clinicletter and a copy was retained on the patient records.

• There was a 48 hour reporting time for most scans. Itwas only in exceptional circumstances where a scanneeded a second opinion that reporting and sending ofresults would take longer. GPs would then have thereport faxed to them.

• Staff could access the hospitals policies and proceduresvia the hospitals intranet page. During our inspection,staff showed us how they did this.

Consent, Mental Capacity Act and Deprivation ofLiberty Safeguards

• Staff followed the hospital’s ‘Mental Capacity Act 2005;practice and procedure Policy’ (April 2016).This includedresponsibilities and duties, definitions, procedure andmonitoring, review and audit.

• Staff followed the hospital’s ‘Deprivation of LibertySafeguards; practice and procedures Policy’ (April 2016).This included responsibilities and duties, definitions,procedure and monitoring, review and audit

• Staff in outpatients, imaging, and physiotherapy told usthey rarely encountered patients with dementia or wholacked capacity. They were able to describe the process



Outstanding –


they would follow if they suspected a patient lackedcapacity and knew who to contact for further support oradvice on this. We saw there was a flowchart on displayin consulting rooms, for staff so they know who tocontact if they have any concerns.

• During our inspection, we looked at five consent forms,for the diagnostic imaging department. We found all theforms to be fully completed.

• For our detailed findings on Consent, Mental CapacityAct and Deprivation of Liberty Safeguards, please seethe Effective section in the surgery report.

Are outpatients and diagnostic imagingservices caring?

Good –––

We rated caring as good.

Compassionate care

• Staff treated patients with kindness, dignity, andrespect. Staff interacted with patients in a positive,professional, and informative manner. This was in linewith National Institute for Health and Care Excellence(NICE) QS15.

• We spoke with six patients in outpatients. All patients wespoke with said the care they received was of a goodstandard. One patient told us “all aspects were firstclass”. Another patient told us “we have received 100%excellent service from all staff”, and a third said, “Theservice provided is excellent in all respects”. Indiagnostic imaging, a patient told us staff were “warmand professional”.

• Staff introduced themselves with “my name is”. Thiscampaign is focused on reminding staff to introducethemselves to patients.

• We witnessed staff approach people rather than waitingfor requests for assistance. A patient told us “staff werevery friendly and approachable, and always willing tohelp”. Patients we spoke with were overwhelminglypositive about the way staff treated them. Patients toldus staff were “wonderful”, “fantastic”, “helpful”,“supportive”, “friendly” and “nothing is too muchtrouble”.

• We saw staff taking the time of interact with patients, ina friendly and welcoming manner. We observedinstances where patients that had attended clinic on aregular basis had built positive relationships with thestaff that worked there. We saw examples of caringinteractions by staff, for example getting down to apatient level to interact with them and maintaining eyecontact. We saw that consultants introducedthemselves and shook patients’ hands when they calledthem in for their appointment.

• Consulting room and treatment room doors were keptclosed. We saw staff knocked and waited for permissionbefore entering, to maintain patient’s privacy. Eachconsulting room or treatment room door clearlydisplayed whether or not the room was actively in use.Staff made use of this signage, therefore protectingprivacy and dignity of patients during consultations andprocedures.

• Patients in the waiting areas appeared comfortable andrelaxed.

• The outpatients and diagnostic imaging departmentprovided an accompanying or chaperone service duringphysical or intimate care. This person acted as asafeguard and a witness for patients or healthcareprofessionals during intimate medical examinations orprocedures.

• Chaperones were available. The hospital followed theirup to date ‘chaperones policy’, which outlined roles andresponsibilities, training and best practice guidance. Wealso saw that for some ultrasound procedures, patientswere sent written information telling them that achaperone could be arranged for their procedure. Inaddition, due to the intimate nature of some of theprocedures, they could also arrange for same sex staff toundertake the examination. For example, for ultrasoundscans of the scrotum and testes, they could arrange for amale sonographer to perform this procedure, ifpreferred.

• Posters informing patients that chaperones wereavailable on display in the waiting areas and in all theconsulting and treatment rooms. Patients were giventhe opportunity to accept or decline a chaperone duringtheir appointment with a consultant.



Outstanding –


• We saw that enquiries made at the reception desks wereresponded to in a polite and helpful manner. We sawpatients being redirected to the waiting room or otherlocations in the hospital, such as the restaurant, with aclear and reassuring approach.

• The NHS Friends and Family Test is a satisfaction surveythat measures patient’s satisfaction with the care theyhave received. The data for all patients between April2016 and September 2016 showed the hospital scored95% and above. The hospital was the same or betterthan the England average for May, June, and September2016. The response rates for this survey varied between36% and 65%. The response rate for April to September2016 was the same as the England average, except forMay and September, when it was worse than thenational average response rate, with a response rate of36% and 41%. This showed that most patients werepositive about recommending the hospital to theirfamily and friends.

• We received 40 comment cards from patients whorecently attended the outpatient department at thehospital. All were very positive about the care andtreatment they received. Comments included, “excellentstaff”, “professional”, “helpful”, “kind and caring”, and “Ihave nothing but praise for the staff and the doctors”.


• Staff responded positively to patients’ questions andtook time to explain things in a way the patient couldunderstand.

• All patients we spoke with told us that their care wasdiscussed in detail with them. Patients told us they weregiven time and were able to ask any questions and feltincluded in the decisions that were made about theircare. One patient told us staff “fully explained treatmentand made time to explain details”, another patient toldus they received an “excellent explanation” of theirtreatment. A third told us “you get treated as someonespecial”.

• Clear concise information was provided to patients priorto their appointment. They told us the reception stafftreated them kindness and respect.

• Staff photographs of who were on duty that day andtheir names were clearly and legibly displayed on the

reception room wall. In addition, there was a poster withan explanation of the uniforms staff wore. For example,the colours that would be worn by registered nurse,clinical support workers and the department sister. Thismeant patient could easily identify staff that wereresponsible for their care and treatment during theirvisit.

• Patients’ families or carers could accompany them fortheir consultation as long as the patient agreed.However, they respected the decision of patients whenthey chose not to involve their loved ones. Clear andconcise information was provided to patients beforetheir appointment.

• We saw patients and people close to them beingconsulted before radiology procedures and staff wereattentive to the needs of the patients.

• We saw patients and people close to them beingconsulted prior to radiology procedures and staff wereattentive to the needs of the patients. There were nodelays evident to patients care and treatment during thecourse of our visit to the radiology department.

• Patient feedback cards were available in the hospitalreception area, allowing patients to leave comments,compliments, or concerns in relation to theirexperience. During our visit, we reviewed 10 hospitalown feedback cards, which had been placed in our CQCfeedback boxes. All feedback cards were extremelypositive about the care and treatment received.Feedback cards were returned to the outpatientdepartment for the hospital to use.

Emotional support

• All treatment and consultation rooms were private andcould be used to deliver any bad news, which mayadversely affect a patient’s future. Nurses told us theconsultants would inform them if they were about tobreak bad news to a patient so they would be availableto support them. They spent as much time as wasneeded with the patient and those close to them. Theyprovided support and gave them guidance on where toget further help and support.

• Counselling services for patients was available toBenenden members only. Other patients who requiredcounselling would be referred back to their GP.



Outstanding –


Are outpatients and diagnostic imagingservices responsive?

Outstanding –

We rated responsive as Outstanding.


• A range of outpatient clinics was available to meet theneeds of the client group. According to data provided bythe hospital, this included cardiology, dermatology, ear,nose and throat, gastroenterology, general medicine,general surgery, neurology, orthopaedics,rheumatology, spinal services, urology, vascular andophthalmology. Orthopaedics, general surgery, ear noseand throat, and ophthalmology had the highestattendance rates.

• On arrival patients reported to the main reception areawhere receptionists booked them in via an electronicbooking system, directed them towards the appropriateclinics, and waiting areas.

• Some consultation rooms were used for specificspecialties, with dedicated equipment, for example;cardiology, audiology and ophthalmology. This meantconsultant would be able to work in an appropriateroom according to their specialty and staff could bearranged to support and deliver the service.

• There were two waiting areas within the outpatientdepartment (OPD) which were spacious and hadcomfortable seating for patients and visitors. There werecold drinks available in all of the areas and hot drinkswere available free of charge in the restaurant.Magazines and newspapers were also available.However, the temporary waiting area in diagnosticimaging was small and cramped.

• Extended opening hours for outpatient, and diagnosticimaging meant patients could be seen after work and onSaturday mornings. In addition, the outpatientdepartment offered booked and a walk-in service forpre-operative assessment clinics. The walk-inpre-operative assessment clinic ran between 8.30am

and 7pm, Monday to Friday. Saturday clinics wereprovided between 8.30am and 5pm. This allowedpatients who work Monday to Friday 9am to 5pm toaccess healthcare at a time that suited their needs.

• An outside company supplied the mobile MagneticResonance Imaging (MRI) scanner. The diagnosticimaging department did not staff the scanner, butmanaged the scanner’s appointments. However, in theplans for the newly developed area of diagnosticimaging, the MRI and CT service will be within confinesthe department.

• There were no waiting times for physiotherapytreatment and staff members used the service as well asNHS and private patients. The physiotherapydepartment told us they could offer an appointmentwithin 48 hours of referral if appropriate for the patient.The physiotherapy department had a gymnasium areawith fitness equipment and provided exercise classesincluding Pilates.

• There was sufficient consultant staff to cover OPDclinics. OPD clinics were timetabled to suit eachspecialist’s availability and obligation as part of theconsultants practicing privileges contract.

• The hospital was going through a major rebuild andlandscaping programme at the time of our inspection.Free parking was available but patients told us it wassometimes difficult to park. The car park anddepartment was clearly signposted.

• Clinics cancellations are monitored by the hospital.Consultants are required to give six weeks notice. Thehospital told us no clinics have had to be cancelled orrescheduled, within six weeks of the date it is due totake place.

• When a clinic had to be cancelled at short notice,patients were contacted at the earliest opportunity.They were offered of an alternative consultant to see, orthe next available appointment with their chosendoctor.

Access and flow

• There were 4,234 NHS funded patients who attendedthe outpatient and diagnostic imaging department for



Outstanding –


their first appointment from October 2015 to September2016. There were 6,676 NHS patients who attended theoutpatient and diagnostic imaging department forfollow up in the same period.

• There were 15,240 patients who were other funded(Benenden Healthcare members, hospital funded(charitable cases), private health insurance, andself-pay) who attended the outpatient and diagnosticimaging department for their first appointment fromOctober 2016 to September 2016. There were 19,979other funded patients who attended the outpatientsand diagnostic imaging department for follow up in thesame period.

• Outpatients initially booked in at the OPD receptiondesk, they were then directed to one of two waitingrooms or could go to the restaurant to wait. We sawthere were TV screens in both waiting rooms and therestaurant, so patients could see when they were calledfor their appointment. The TV screens also gave thelocation of the patient, in case staff had to go and findthem, for example, we saw there were patients who hadbooked in, but their location was the restaurant.

• Receptionists alerted patients if clinics were runninglate and allow patients to rebook if they could not wait.We observed reception staff keeping patients informedby letting them know at check-in that clinics wereover-running. In addition, the TV screens showedpatients if the clinics were behind time. We saw duringour inspection, that two clinics were running late by nomore than 15 minutes.

• All the patients we spoke to told us they were happywith the length of time they had waited to be seenfollowing referral and had been offered timesconvenient to them.

• The hospital met the target of 92% of patients onincomplete pathways 18 weeks or less from time ofreferral in the reporting period (October 2015 toSeptember 2016), except for February, May andSeptember 2016.

• In physiotherapy patients were seen within 24 hours ofreferral. For staff who self-refer to the service, they wouldbe seen within 48 hours of referral.

• Pathology services were provided by a local NHS trustand samples were transported from the departmentthree times a day. Staff said results were easilyaccessible online.

• The length of appointments was tailored according tospeciality and treatment required. We were told that themajority of consultants requested an initialappointment time of 30 minutes. The physiotherapydepartment told us the initial appointment length was60 minutes.

• There were no delays evident to patients care andtreatment during the course of our visit to the radiologydepartment.


• Patients who were attending outpatients’ and thephysiotherapy department initially presented at themain building which was opposite from the car park.The hospital provided patients with umbrellas to use,when walking to the outpatient building in wet weather.For patients who were unable to walk between thebuildings the hospital provided a minibus, if this wasnecessary the receptionists would radio for the minibuson an individual basis.

• The outpatients’ department was located on the firstfloor and the physiotherapy department was on thelower ground floor of the outpatient building. This wasseparate from the main building. Both departments hadstair and lift access. The digital imaging department wason the lower ground floor in the main building, with liftand stair access Wheelchair access was via a ramp at themain entrance with automated doors. It was accessibleto all patients, including wheelchair users.

• Staff helped patients out of vehicles and into thedepartment and provided a wheelchair if required. Thematron of the outpatient department also told us theyaccommodated assistance dogs if required. Assistancedogs are trained to aid or assist an individual with adisability. For example, guide dogs to assist the blind orvisually impaired, or hearing dogs that assist peoplewho are deaf or hard of hearing. Others include medicalresponse dog, which assist an individual who has amedical disability such as hypo alert dogs who alerttheir diabetic owners of dangerous changes in theirblood sugar levels.



Outstanding –


• The hospital had wheelchair-accessible toilets withinthe outpatient and main buildings of the hospital.

• Patients had access to a variety of information leaflets inthe hospital. All information leaflets were in English.However, staff told us they could access written patientinformation in other languages through an electronicsystem and obtained when required.

• An interpreting service for patients who did not speakEnglish was available and staff knew how to access it.

• Free Wi-Fi was available for patients to use to enablethem to make contact with their family and friends oruse social media.

• Staff in outpatients and diagnostic imaging told us theyrarely encountered patients living with dementia or wholacked capacity. They were able to describe the processthey would follow if they suspected a patient lackedcapacity and knew who to contact for further support oradvice on this.

• Two staff nurses in the outpatient department werenominated “dementia champions”. They acted as apoint of contact for staff that required more informationabout dementia issues. Staff knew who the championswere in the department. There were plans for providingfurther training for staff to become “dementia friends”.Adementia friendis someone who encourages others tomake a positive difference to people living withdementia. They do this by giving them informationabout the personal impact of dementia, and what theycan do to help.

• Data provided by the hospital showed that more than94% of all staff had undertaken Dementia awarenesstraining, which meant staff was aware of their roles andresponsibilities for dealing with patient who are livingwith dementia. The hospital was in the process ofdeveloping a dementia strategy based on the NationalInstitute of Health and Care Excellence (NICE) guidance,such as NICE CG42 Dementia: supporting people withdementia and their carers in health and social care. Thedementia champions also told us the hospital hadcontacted the local town, which was “dementia friendly”and the use of a bus which is a mobile virtual dementiatour. This was to raise awareness among staff as it takesaway people's primary senses, to let them experiencethe fear and frustration people living with dementia gothrough on a daily basis.


• The hospital received 19 complaints between October2015 and September 2016. No complaints have beenreferred to the Parliamentary and Health Ombudsmen(PHSO), the Independent Sector ComplaintsAdjudication Service (ISACS) or the Care QualityCommission (CQC).

• The hospital had a clear process in place for dealingwith complaints, including an up to date ‘ComplaintsPolicy’, which provided a framework within whichcomplaints were to be responded to. Staff we spoke towere aware of the complaints procedure.

• Where possible all complaints were dealt with atdepartment level, through either the matron or thedepartment manager. A senior manager had overallresponsibility for responding to written complaints. Thehospital acknowledged the complaint in two workingdays of receiving the complaint with an aim to have thecomplaint reviewed and completed within 20 days. Ifthis could not be done, a letter was sent to thecomplainant explaining why. We reviewed threecomplaints relating to outpatients and saw they hadbeen answered within the specified timeframe.

• A patient information leaflet was available in thedepartments we inspected, that outlined the formalcomplaints procedure. The Benenden Hospital leaflets‘Feedback and complaints’ were located throughout thehospital and contained information on how to raise anyconcerns.

• For our detailed findings on learning from concerns andcomplaints, please see the Responsive section in thesurgery report.

Are outpatients and diagnostic imagingservices well-led?

Outstanding –

We rated well-led as Outstanding.

Leadership and culture of service

• Outpatient staff reported to the outpatients’ manager,radiology staff reported to the radiology manager, and



Outstanding –


physiotherapy staff reported the lead physiotherapist.All departmental leads reported to the outpatients anddiagnostic imaging matron, who in turn reported to thedirector of patient services.

• Staff told us that the outpatient department anddiagnostic imaging service were well led. Staff told usthey felt able to raise concerns and felt that the hospitalwas transparent with a “non-judgemental, no blame”culture. We heard there was a strong culture ofopenness from junior to senior staff, clinical andnon-clinical. All staff told us the senior managementteam were approachable and supportive.

• Clinical staff said they “really loved working at thehospital, it’s like one big family, everyone knows eachother” and that they felt valued and respected andwere listened to.

• We observed a positive staff culture across the hospital.The staff told us they were positively encouraged toengage in “open and frank dialogue” with all themembers of the team. They described a “no blameculture”. Nurses and administrative staff confirmed therewas a supportive, nurturing culture within the hospital.

• Many staff had worked at the hospital for a long time,and said they enjoyed working there. Staff spokepositively about their relationships with their immediatemangers.

• There was a positive regard for the welfare of staff. Wewere told of an example where a member of staff hadrequired support and assistance in their personal lives.The extent of the support provided to staff went beyondwhat would usually have been expected from anemployer.

• Sickness rates for outpatient nurses were higher thanaverage for the other independent acute hospitals wehold this type of data for form October 2015 to June2016 of the reporting period (October 2015 toSeptember 2016). Except in October 2015 and May 2016,where it was the same or lower.

• Sickness rates for outpatient healthcare assistants werehigher than average of other independent acutehospitals we hold this type of data for from October2015 to June 2016 of the reporting period (October 2015to September 2016). Except in February 2016, where itwas the same or lower.

• Sickness rates for physiotherapists between October toDecember 2016, was 0%. For radiology staff, the rate forOctober 2016 was 1.53%, but was 0% for November andDecember 2016.

Vision and strategy for this this core service

• The hospitals vision was to be “the patients’ choice,providing high quality, caring and responsive andwellbeing services”. This was underpinned by fourvalues of “care”, “mutuality”, “sustainability” and“wellbeing”. The hospital told us staff helped developedthe values, which staff confirmed when we spoke withthem.

• Staff told us they provided best quality care, by makingsure they listened to patients, staying up to date withcurrent practice, and ensured they learned fromfeedback.

• The values were prominently displayed on noticeboards in the departments. The hospital values werewell embedded with staff, who were able to explain thehospitals vision and values across the outpatient anddigital imaging department. Appraisals were linked tothe hospital values.

Governance, risk management and qualitymeasurement

• The hospital had defined governance and reportingstructure. There was a clinical governance committee(CGC) with a range of sub committees that fed into it.These included the infection prevention and controlcommittee (IPCC), radiation protection committee,resuscitation advisory committee, occupational healthand safety committee and information security forum.

• The clinical governance committee (CGC) wasresponsible for ensuring that the appropriate structure,systems, and processes were in place in the hospital toensure the safe delivery of high quality clinical services.The matron for outpatients, physiotherapy, anddiagnostic imaging was a member of the CGC, so thatany problems within these departments could be raisedfor discussion with other hospital staff.

• The Clinical Governance Committee (CGC) met quarterlyand discussed complaints and incidents, patient safety



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issues such as safeguarding and infection control, andclinical audit review. During our inspection, we saw theminutes of the CGC held in November 2015, February,April, and July 2016.

• The hospital followed their corporate ‘ClinicalGovernance Policy’ (October 2016), which included rolesand responsibilities, monitoring, reviewing, andauditing.

• A Medical Advisory Committee (MAC) meeting was heldquarterly. We reviewed the minutes of December 2015,and April, July and September 2016. The minutesshowed key governance areas such as National Instituteof Health and Care Excellence (NICE) guidelines,outcomes from root cause analysis, mandatory trainingand compliance data and incidents were discussed. Thismeant through the work of a multidisciplinary groupand the MAC, action was taken to continuously improvethe quality of care.

• The MAC and CGC committees fed into the hospitalexecutive meeting, which met monthly. The minutes ofAugust, September and October 2016 were reviewed.The minutes showed items discussed includedregulatory compliance, incidents, inspections, hospitalwide projects, and site development.

• The hospital held team meetings in each departmentincluding outpatients and the diagnostic imaging. Staffused the meetings for two-way information sharing. Welooked at the minutes of August and September 2016outpatient department team meeting, which showedmanagers shared information and learning with staff.We also reviewed the July and August 2016 minutes ofthe outpatient and diagnostic imaging leads meeting.These provided evidence managers discussed keyissues such as the risk register, audit schedule, andfeedback from all departments.

• The hospital had a Radiation Protection Committee(RPC), which met twice a year. The RPC was animportant part of the radiation clinical governanceprocess. The radiology manager chaired the group butattendees included the RPA, a consultant radiologist,and the hospital executive director.

• On reviewing the minutes of the last RPC, we sawradiation audits, the quality assurance programme, riskassessments, incidents, and radiation staff training were

all discussed. This gave assurance that radiation safetywas a high priority across the hospital and theappropriate systems were in place to monitor radiationsafety.

• The department managers logged identified risks onlocal risk registers. Key risks were placed on thehospital-wide corporate risk register.

• The hospital wide risk register highlighted key risks tothe service. Actions taken to control or minimise therisks were detailed. Following these actions there was aresidual risk (low and moderate risk) there was clearactions that were required or was being taken to furthermitigate or minimise the risk. This included a timeframefor completion.

• For our detailed findings on governance, riskmanagement and quality measurement, please see thewell-led section in the surgery report.


• Patients were regularly asked to complete satisfactionsurveys on the quality of care and service provided. Wesaw there were boxes throughout the hospital to placecompleted forms. The hospital also gathered patientopinion from the friends and family test (FFT).Departments used the results of the survey to improvethe services.

• Staff told us they took part in team meetings and wereconfident to talk about ideas and sharing of good newsas well as issues occurring in the previous days orplanning for anticipated problems.

• Systems were in place to gather staff feedback to enablemore effective working and improved patientexperiences. Staff in the outpatients department,participated in productive outpatient processes. Thepurpose of these was to gather staff views, identifyactions to improve safety and efficiency, and increasetime with patients. For example, staff in the outpatientdepartment had recently taken a personality test; byusing the four-colour personality test to determine howbest to address each personality with the goal ofcreating a balanced and productive environment.Understanding the different personalities allowsindividuals learn how to better deal with colleagues, byacknowledging their strengths and weaknesses. This



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meant the department had awareness that staffrequired different leadership styles, had particularexpertise, and were flexible in their approach to theneeds of their teams.

• There were rewards for staff that had been exceptionalfor example; there was a “Best of Benenden” awardscheme, which was currently in its second year. Staffcould nominate a colleague. Successes were awarded infour categories clinical excellence, innovation of theyear, leading and inspiring others and support servicesexcellence. Staff told us they received an email to saythey had been nominated, which made them feel“honoured”, as they knew a peer had nominated them.

• During inspection we were given the Benenden HospitalTrust 2016 Yearbook, which showed the recipients onthe ”Best of Benenden” awards, these included theinfection control link practitioners who won “clinicalexcellence” forworking as a focused, enthusiastic andcommitted team. We also saw the housekeeping teamwon “support services excellence” for being cheerful,passionate, and helpful, despite the challenges of thenew build.

• We saw that a radiographer and two clinical supportworkers won the “Lord Plant Travelling Fellowship”. The

fellowship allows staff to apply for a grant carry out aproject for professional or personal development.During our inspection, we spoke with the two clinicalsupport workers who were going to visit a gynaecologydepartment at a German hospital. They told us they felt“privileged” and “proud” to have received this award.


• The hospital was currently undergoing a programme ofbuilding work. The outpatient, diagnostic imaging, andphysiotherapy planned to move to a new location bysummer 2017. Staff felt involved in decision-making andfuture service planning, including best use of facilities.For example, a clinical support worker told us they hadbeen asked to join a group, which was looking at thenew facilities and workflow.

• Staff signposted patients who needed to lose weightbefore surgery to various weight loss clinics within thehospital’s catchment area. Staff told us this was becauseresearch had shown patients find it easier to lose weightwith brief advice to motivate weight loss through referralto behavioural weight loss programmes. We saw therewas also a board in the waiting rooms, with thisinformation prominently displayed.



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Outstanding practice

• We identified the hospital’s commitment to staffwellbeing and their “Investors in People SilverAward” as an area of outstanding practice.

• We identified the hospital’s work in enhancedrecovery pathways to reduce the length of hospitalstay for orthopaedic patients as an area ofoutstanding practice. As a result of earlymobilisation, the hospital’s average length of stayfollowing orthopaedic surgery was only three days.This was better than the average length of stay of 4.9days for other independent hospitals thatparticipated in the national joint registry (NJR). Thehospital was working to reduce the average length ofstay to less than three days by further promotingearly mobilisation and improved pain management.

• We identified the hospital’s innovations inanaesthetics as an area of outstanding practice. Thehospital won a national award for innovations inanaesthetics in 2016. Innovations in this areaincluded use of a multi-purpose anaestheticbreathing system which recycled anaesthetic gasesand reduced pollution in theatres.

• We identified the infection prevention and controlleadership of the hospital and staffs commitmentwas an area of outstanding practice, with staffinspired to provide a good service to patients.

Areas for improvement

Action the provider SHOULD take to improve

• The hospital take action to ensure there ispermanent control of access into the theatredepartment.

• The hospital should take action to address operatingschedules to reduce the number of day case patientsneeding to convert to an overnight stay.

• The hospital should take action to addressadmission times for surgery to ensure patients donot experience long waits in hospital on the day oftheir operation.

• The hospital should ensure signatures of clinical staffare legible with printed names in patient records.

• The hospital should ensure all staff completesafeguarding training for children and vulnerableadults at an appropriate level.

Outstandingpracticeandareasforimprovement

Outstanding practice and areasfor improvement


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