InHealth Endoscopy Unit - Cirencester Hospital … · 2020-02-04 · Ourjudgementsabouteachofthemainservices Service Rating Summaryofeachmainservice Endoscopy Good ––– Theserviceprovidesdiagnosticendoscopyforadults

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 Good –––

Are services safe? Requires improvement –––

Are services effective?

Are services caring? Good –––

Are services responsive? Good –––

Are services well-led? Good –––

Overall summary

InHealth Endoscopy Unit – Cirencester Hospital isoperated by InHealth Limited. The service iscommissioned by Gloucester Clinical CommissioningGroup to deliver diagnostic services. The service is hostedby local NHS trust through contractual arrangements. The

service offers clinics on Mondays and Thursdays only atthis location. It accepts adult patient referrals and doesnot see any children or young people under the age of 18years.

The endoscopy unit is located on the first floor of thebuilding. The premises were refurbished in 2010 to ensure

InHeInHealthalth EndoscEndoscopyopy UnitUnit --CirCirencencestesterer HospitHospitalalQuality Report

Tetbury RoadCirencesterGloucestershireGL7 1UYTel: 0333 202 0300Website: www.inhealthgroup.com/location/cirencester-community-hospital/

Date of inspection visit: 03 January & 14 January2019Date of publication: 15/03/2019

1 InHealth Endoscopy Unit - Cirencester Hospital Quality Report 15/03/2019

it met accreditation standards. The unit consists of adedicated waiting area, admission/consent room, oneprocedure room, separate clean and dirtydecontamination rooms with pass through washers.There is a recovery area with three cubicles, a secondstage seated recovery area and a discharge room locatedoutside of the main unit. There were two offices used forthe unit manager and for reception/administration.

The inspection was unannounced meaning the servicedid not know we were coming to inspect. We carried outthe inspection on 3 January and 14 January 2019, usingour comprehensive inspection methodology.

To get to the heart of patients’ experiences of care andtreatment, we ask the same five questions of all services:are they safe, effective, caring, responsive to people'sneeds, and well-led? Where we have a legal duty to do sowe rate services’ performance against each key questionas outstanding, good, requires improvement orinadequate.

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

Services we rate

This was the first time the service was rated, although ithad been previously inspected in 2014.

We rated it as Good overall.

• Staff had completed their mandatory safeguardingtraining and knew which actions to take if they hadconcerns about patients.

• The service had enough staff with the rightqualifications, skills, training and experience to keeppeople safe from avoidable harm and to provide theright care and treatment.

• The service provided care and treatment based onnational guidance.

• The service gained Joint Advisory Group (JAG)accreditation in July 2018.

• There was effective multidisciplinary working withother healthcare providers to ensure patients receivedthe right care.

• Staff were compassionate and supportive to patientsand relatives in their care.

• Staff communicated with patients in manner that mettheir needs and offered opportunities for patients toask questions.

• Patients’ dignity was maintained at all times.• There were effective arrangements to involve relatives

as much as patients wanted.• Feedback from patients and relatives was positive.• The service took account of patients’ individual needs

and made reasonable adjustments to meet these asrequired.

• Leaders had the right skills and experience to run aservice providing high-quality sustainable care.

• We observed a positive culture amongst staff and theyfelt supported by their leaders and by InHealth.

• There was an effective governance structure, whichensured effective monitoring of the service andcommunication pathways.

• There were systems to identify risks and mitigatingactions to manage these.

• Staff had access to relevant and current informationabout patients to deliver safe care.

However, we found areas of practice that requireimprovement.

• Medicines were not prescribed and administered inline with national guidance and legislation.

• Documentation used for consenting was ambiguousand did not confirm that risks had been discussed withpatients. Staff did not always assess if patients hadmental capacity to consent to procedures.

• The service did not always meet the needs of localpeople. There was a waiting list of patients waiting toattend for an endoscopy procedure.

• The service did not meet targets for referral totreatment in nine of 12 months between October 2017and September 2018.

• Meetings were not always held as often as they shouldbe in accordance with the schedule of regularmeetings.

• Paper-based patient records were not disposed ofsafely.

Nigel Acheson

Deputy Chief Inspector of Hospitals (London and South)

Summary of findings


Our judgements about each of the main services

Service Rating Summary of each main service

Endoscopy

Good –––

The service provides diagnostic endoscopy for adults.We rated this service as good for caring, responsiveand well-led. The service was rated as requiresimprovement for safe. We do not rate the effectivedomain for independent endoscopy services.

Summary of findings


Contents

PageSummary of this inspectionBackground to InHealth Endoscopy Unit - Cirencester Hospital 6

Our inspection team 6

Information about InHealth Endoscopy Unit - Cirencester Hospital 6

The five questions we ask about services and what we found 8

Detailed findings from this inspectionOverview of ratings 11

Outstanding practice 29

Areas for improvement 29

Action we have told the provider to take 30

Summary of findings


InHealth Endoscopy Unit -Cirencester Hospital

Services we looked atEndoscopy

InHealthEndoscopyUnit-CirencesterHospital

Good –––


Background to InHealth Endoscopy Unit - Cirencester Hospital

InHealth Endoscopy Unit – Cirencester Hospital isoperated by InHealth Limited. The service was acquiredin 2012. It operates from facilities owned and managed bya local NHS trust.

The service carries out three different endoscopyprocedures:

• Oesophagogastroduodenoscopy (thin, flexible tubecalled an endoscope is used to look inside theoesophagus (gullet), stomach and first part of thesmall intestine).

• flexible sigmoidoscopy (examination of the rectumand the lower (sigmoid) colon using an endoscope).

• colonoscopy (examination of the large bowels using acolonoscope).

The service has a registered manager who has been inpost since May 2012, when the service was registered.

The InHealth Endoscopy Service delivered from thislocation, achieved Joint Advisory Group (JAG)accreditation in July 2018.

Our inspection team

The team that inspected the service comprised a CQClead inspector and a specialist advisor with expertise incommunity endoscopy services.The inspection team wasoverseen by inspection Manager, Marie Cox and MaryCridge, Head of Hospital Inspections (South West).

Information about InHealth Endoscopy Unit - Cirencester Hospital

The service leased, by way of contract, the facility and thenursing staff for the services provided by InHealth. Theservice serves the communities of Gloucestershire. It alsoaccepts patient referrals from outside this area.

The service is registered to provide the followingregulated activities:

• Diagnostics and screening procedures

During the inspection, we spoke with 15 staff includingregistered nurses, health care assistants, reception/administrator staff, endoscopist and senior managers. Wespoke with four patients and one relative and reviewedfive sets of patient records.

There were no special reviews or investigations of thehospital ongoing by the Care Quality Commission at anytime during the 12 months prior to this inspection. Theservice was last inspected in January 2014, which foundthat the service met all standards of quality and safety itwas inspected against.

Summaryofthisinspection

Summary of this inspection


Activity (October 2017 to September 2018)

In the reporting period October 2017 to September 2018,the service carried out 575 gastroscopies, 84 flexiblesigmoidoscopies and 454 colonoscopies. This amountedto 1,113 diagnostic endoscopy procedures in thereporting period. All procedures were NHS-funded as theservice did not provide privately funded diagnosticprocedures.

Three endoscopists and one nurse endoscopist workedfor the service at this location under practising privileges.In addition, there was another nurse endoscopistemployed by InHealth Ltd, who worked full time acrosseight InHealth services. The service did not employ anynursing staff as these were provided under a contractualarrangement with the host organisation. The accountableofficer for controlled drugs was employed by the hostorganisation.

Track record on safety (October 2017 toSeptember 2018):

• There had been no never events or deaths.• There had been no serious incidents reported.• There had been five clinical incidents of which two

were classified as causing minor harm and the otherthree causing insignificant harm.

• No incidences of hospital acquired Methicillin-resistantStaphylococcus aureus (MRSA)

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

• No incidences of hospital acquired Clostridium difficile(C.diff)

• No incidences of hospital acquired E-Coli• The service had received five complaints

Services accredited by a national body:

• Joint Advisory Group on GI endoscopy (JAG)accreditation

Services provided at the hospital under service levelagreement:

• Interpreting services• Maintenance of medical equipment• Pathology and histology




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 it as Requires improvement

• Medicines were not prescribed and administered in line withnational guidance and legislation. Prescriptions were notsigned and staff that administered medicines did not alwayssign the medicines chart themselves.

• Infection prevention and control measures were not alwaysadhered to in line with national guidance.

• The security of patient details was not always maintained.There was a risk unauthorised people could access personaldetails about patients.

• Compliance with mandatory training was varied. Medical staffand nurse endoscopists’ mandatory training compliance didnot meet targets.

• Results from documentation audits were not always sharedwith staff to improve the completion of patient records.

However,

• Staff had completed their mandatory safeguarding training andknew which actions to take if they had concerns about patients.

• Staffing levels met Joint Advisory Group standards.

Requires improvement –––

Are services effective?We do not rate the effective domain for independent singlespeciality endoscopy services.

We found the following areas of good practice:

• The service provided care and treatment based on nationalguidance. The service gained Joint Advisory Group (JAG)accreditation in July 2018.

• Staff assessed and monitored patients regularly to see if theywere in pain and gave additional pain relief if required.

• Managers monitored the effectiveness of care and treatmentand used the findings to improve them. They compared localresults with those of other services to learn from them.

• Staff had the right skills, knowledge and experience to providesafe care and treatment for patients.

• There was effective multidisciplinary working with otherhealthcare providers to ensure patients received the right care.

However, we also found the following issue that the service providerneeds to improve:




• Consent was sought from patients but staff did not alwaysdiscuss and check patients’ understanding of risks associatedwith endoscopy procedures. Documentation used forconsenting was ambiguous and did not confirm that risks hadbeen discussed with patients. Staff did not always assess ifpatients had mental capacity to consent to procedures.

Are services caring?We rated it as Good because:

• Staff were compassionate and supportive to patients andrelatives in their care.

• Staff communicated with patients in a manner that suited theirneeds and offered opportunities for patients to ask questions.

• Patients dignity was maintained at all times.• Staff understood how to identify if patients felt anxious and

offered support to alleviate anxiety when this was required.• There were effective arrangements to involve relatives as much

as patients’ wanted.• Feedback from patients and relatives were positive.

Good –––

Are services responsive?We rated it as Good because:

• The service took account of patients’ individual needs andmade reasonable adjustments to meet these as required.

• There were processes for patients who wished to complainabout the service and the service received few complaintsabout care from patients.

However,

• The service did not always meet the needs of local people.There was a waiting list of patients waiting to attend for anendoscopy procedure.

• Procedure slot utilisation was not always managed well.• The service did not meet targets for referral to treatment in nine

of 12 months between October 2017 and September 2018.

Good –––

Are services well-led?We rated it as Good because:

• Leaders had the right skills and experience to run a serviceproviding high-quality sustainable care.

• There was a corporate vision and a local business plan todeliver a sustainable service.

• We observed a positive culture amongst staff and they feltsupported by their leaders and by InHealth.

Good –––




• There was an effective governance structure, which ensuredeffective monitoring of the service and communicationpathways.

• There were systems to identify risks and mitigating actions tomanage these.

• Staff had access to relevant and current information aboutpatients to deliver safe care.

• Information about patients were mostly stored to ensurepatient confidentiality was maintained.

However,

• Meetings were not always held as often as they should be inaccordance with the schedule of regular meetings.

• Systems and processes did not ensure that paper based patientrecords were able to be disposed of safely.




Overview of ratings

Our ratings for this location are:

Safe Effective Caring Responsive Well-led Overall

Endoscopy Requiresimprovement N/A Good Good Good Good

Overall Requiresimprovement N/A Good Good Good Good

Detailed findings from this inspection


Safe Requires improvement –––

Effective

Caring Good –––

Responsive Good –––

Well-led Good –––

Are diagnostic imaging and endoscopyservices safe?

Requires improvement –––

We rated it as requires improvement.

Mandatory training

• Staff received mandatory training and regularupdates. The service monitored staff compliancewith mandatory training and took action to remindstaff when their regular mandatory trainingupdates were due.

• Staff received mandatory training and regular updatesin a range of subjects dependent on their role. Allclinical staff received training and regular updates insubjects such as basic/immediate life support, firesafety, manual handling and information governance.

• Mandatory training compliance varied. Endoscopistsreceived mandatory training from their usual place ofworking or through self-funded courses. Somemandatory training required face-to-face attendancebut most subjects could be completed online using anelectronic learning platform. Mandatory trainingcompliance was monitored at corporate level byInHealth and endoscopists completed mandatorytraining as and when required. Endoscopists wererequired to complete basic life support training andrecords demonstrated that all but one endoscopist hadcompleted this training within the last 12 months. Datademonstrated that staff had received training for 14subjects with some staff highlighted as needing to

complete refresher training to remain compliant.However, compliance with customer care andcomplaints was 63% against a compliance target of90%.

• Nursing staff were employed by the host organisationand received mandatory training and regular updatesfrom their employer. The service monitored mandatorytraining compliance through regular contract reviews.Data demonstrated nursing staff compliance was 85%(September 2018) across 12 subjects against a target of92%. All staff had completed basic or immediate lifesupport, health, safety and welfare training and preventtraining. All registered nurses received immediate lifesupport training (75% compliant with the remainingbooked to ensure compliance). However, compliancewith fire safety was 81% as three members of staff hadnot completed their regular update within a year. Therewere a further four members of the nursing staff teamwho were ‘flagged up’ as needing to complete theirtraining before it was overdue.

Safeguarding

• Staff understood how to protect patients fromabuse and the service worked well with otheragencies to do so. Staff received training on how torecognise and report abuse and they knew how toapply it.

• There was an InHealth Safeguarding Adults Policy (2016)and a Safeguarding Children Policy (2018). The policiesincluded information and guidance for staff such asinformation about what abuse is and a flow chart ofactions to take if safeguarding concerns were raised.The policies were aligned with those from the hostingorganisation, to avoid confusion for staff about actionsto take if they had concerns. Staff understood their

Endoscopy

Endoscopy

Good –––


responsibilities to report safeguarding concerns but toldus they had never had to make a safeguarding referralfor any patient who attended the clinic. Staff had accessto paper copies of InHealth policies.

• Staff received training and regular updates aboutsafeguarding, which included female genital mutilation.There was a named safeguarding lead employed by thehosting organisation in accordance with nationalguidance (Royal College of Nursing: Adult Safeguarding:Roles and Competencies for Health Care Staff (2018).Training records (January 2019) demonstrated allendoscopists had completed training within the last 12months with one endoscopist highlighted as needing tocomplete their annual update to remain compliant. Allnurses were up-to-date with their mandatorysafeguarding training at the time of our inspection.

• Inhealth Limited performed safety checks on all newemployees. Endoscopists were checked against thecriteria as outlined by the Disclosure and BarringService, before they started working for the service. Stafffiles were held centrally at the corporate head office andwe did therefore not review any these. Compliance wasdiscussed at the annual review/appraisal of allendoscopists.

• Compliance with safety checks such as Disclosure andBarring Services for nursing staff was managed by thehost organisation.

Cleanliness, infection control and hygiene

• The service usually controlled infection risk well.Staff kept themselves, equipment and the premisesclean.In the reporting period from October 2017 toSeptember 2018, there were no incidences of healthcare acquired infections.

• The unit looked visibly clean. The cleaning of thefacilities was the responsibility of the hosting hospital.We observed staff cleaning equipment used betweenpatients such as trolleys and monitoring equipment.However, in the procedure room, we observed a displayscreen that was not cleaned even though it had beentouched during the procedure.

• We observed most staff following national guidance forhand hygiene. Staff followed national guidance such asNational Institute for Health and Care Excellence (QS61:Infection prevention and control: Statement three, 2014)and the World Health Organisation (WHO, 2006): Fivemoments of hand hygiene, meaning staff washed theirhands before and after patient contact. The service

audited compliance with hand hygiene in accordancewith the World Health Organisations ‘five moments forhand hygiene’. We reviewed audit results fromDecember 2017 to November 2018 and found all ofthem met 100% compliance, meaning staff washed/decontaminated their hands when they needed to inaccordance with national guidance. However, weobserved in the procedure room, staff did not alwaysremove gloves and wash their hands, when they shouldhave done to adhere to evidence based practice(National Institute for Health and Care Excellence QS61,2014).

• Staff did not always follow national guidance wheninserting cannulas for patients who required conscioussedation during the procedure. We observed a memberof staff insert a cannula (a small tube inserted into a veinfor the administration of medicines), without wearingpersonal protective equipment (PPE) such as gloves andapron. This was not in accordance with nationalguidance (National Institute for Care and HealthExcellence. CG139, 2012).

• Cleaning and decontamination of scopes used forendoscopy procedures was managed well. There weredecontamination facilities which met nationalstandards (Health Technical memorandum 01-06 (2016).There were separate pathways for equipment, whichensured clean and contaminated equipment did notcross over.

• Cleaning agents used for decontamination processeswere kept in a metal cupboard in a storage room whichwas keypad controlled. Staff only removed smallquantities of detergents which were kept in thedecontamination area. There were risk assessments forcleaning agents used in line with Control of SubstancesHazardous to Health Regulations 2002. External auditsof the quality of the air for health care workers, nearpotential harmful detergents (and medical gasses), waschecked annually and met standards it was assessedagainst. There was adequate lighting and ventilation inthe decontamination room. Staff had access to suitablesinks for manual cleaning of endoscopes (tubularinstrument used to look into the body).

• Staff followed national guidance for the use of personalprotective equipment (PPE) such as gloves, aprons andvisors when carrying out manual cleaning of theendoscopes. We observed staff remove PPE and washtheir hands before leaving the decontamination roomand enter the clean room for emptying of the

Endoscopy

Endoscopy

Good –––


endoscope washer-disinfector (EWD). Clean endoscopeswere placed in drying cupboards and there werearrangements to ensure recommended standards foruse of clean scopes did not exceed the three-hour expirytime in line with national guidance (Health Technicalmemorandum 01-06, 2016.) Staff from the hostingorganisation were responsible for water testingprocedures in line with national guidance. Test resultswere shared with and available to the service manager.

• Clinical waste was handled, stored and removed in asafe way. Staff segregated and handled waste in linewith national guidance such as Health TechnicalMemorandum: HMT07-01 (2013). Further disposal ofwaste was managed by the host organisation.

• There were effective arrangements to receive and actupon Medicines and Healthcare Products RegulatoryAgency (MHRA) alerts and other patient safety alerts.Any alerts with potential impact on the endoscopyservice, were discussed in regular quarterly clinicalgovernance meetings. We saw in minutes of a meetingin clinical governance meeting held March 2018, that analert from NHS Improvements about failure to obtainand continue flow from oxygen cylinders, werediscussed with all staff.

Environment and equipment

• The service had suitable premises and equipmentand looked after them well.The service leased allfacilities and most of the equipment from the hostingorganisation through contractual arrangements.

• The premises and facilities were accredited by the JointAdvisory Group (JAG) as being suitable for the delivery ofendoscopy services. This included facilities to ensuregender separation. The recovery area was mixed sex butthe bays were separated by semi-permanent walls,which meant that patients could not see each other andthey provided privacy.

• There were contractual arrangements to reviewenvironmental risks annually to ensure mitigatingactions were appropriate to reduce the level of risks.Risks assessments were available to InHealth staff andwere last reviewed annually in 2018.

• Fire evacuation routes were clearly signed, kept free andfire equipment was serviced regularly.

• We reviewed randomly chosen consumables used bythe service and found these to be within date and insealed packaging.

• There was a succession of rooms (procedure room,decontamination room and clean utility room) thatensured the movement of used equipment in a safemanner. Equipment was labelled to ensure informationabout decontamination was recorded and traceable.This included information about the time ofdecontamination procedures to ensure usage if theequipment was within the recommend three-hourperiod. This was in accordance with national guidancesuch as British Society of Gastroenterology: Guidancefor decontamination of equipment for GastrointestinalEndoscopy (2016).

• Staff had access to suitable equipment, which wasmostly owned by and leased from the hostingorganisation. Staff told us there were enoughendoscopes (tubular instrument used to look into thebody) to complete procedure lists. There were sufficientendoscope washer-disinfectors (EWDs) to ensureendoscopes were washed and disinfected in line withnational guidance. Endoscope and EWD maintenancewas the responsibility of the hosting organisation andInHealth had access to maintenance records. We lookedat five pieces of equipment and found these were allwithin their service date.

• InHealth owned two of the nasal endoscopes used insome OGDs (oesophagogastroduodenoscopy: thin,flexible tube called an endoscope is used to look insidethe oesophagus (gullet), stomach and first part of thesmall intestine). These were maintained through aservice contract with the manufacturer.

• Staff had access to emergency equipment in the eventof a major clinical emergency. There was a resuscitationtrolley in the recovery area, which was used throughoutthe unit if required. The trolley was tamper evident andchecked daily when the unit was operational. Wereviewed records from October to December 2018 andfound that daily checks had been carried out every daybut one.

• Emergency equipment was available for staff in theevent a patient suffered a major haemorrhage (bloodloss) during a procedure. There were emergenciesprocedures for staff to follow. These included the use ofclips to stop bleeding. These were available for allprocedures and staff were familiar with how theseshould be fitted. Patients with high risk of bleeding fromendoscopy procedures were not accepted for diagnosticendoscopy procedures at this location although it wasnot included in the exclusion criteria.

Endoscopy

Endoscopy

Good –––


• Signposting to the unit was satisfactory and hospitalvolunteers were available to signpost patients to theendoscopy unit if required. There was not a formalreception area but the administration office/receptionwas signposted. Patients reported their arrival to theadministrator who was based in an office off the maincorridor. Once the patient had been registered asarrived, the administrator took patients and theirrelatives to a waiting area where the admission nursecollected them to be admitted for the procedure.

Assessing and responding to patient risk

• Staff completed and updated risk assessments foreach patient.They kept clear records and asked forsupport when necessary.

• Patient referrals were triaged by the InHealth PatientReferral Centre (PRC) and referred onto the differentservices/locations operated by Inhealth Limited. Thiswas to ensure they were suitable to undergo endoscopyprocedures in a community based service. The servicehad a list of referral criteria which included patientrelated exclusion criteria. For example, patients withspecific heart and lung conditions and patientsweighing over 220 kg (due to the weight limits onequipment such as trolleys). We observed a nursediscussing concerns about a patient living withdementia who attended for an appointment. The nursediscussed this with the endoscopist to ensure they wereaware and that it was safe for the procedure to becarried out in the community setting.

• All staff attended a safety ‘huddle’ at the start of theprocedure list to identify and discuss any risks topatients and the smooth running of the procedure list.

• Staff were confident about how to access help inemergencies and gave an example of this when arelative had become unwell. There was a standardoperating procedures (SOP), which belonged to the hostorganisation with information for staff to follow. TheSOP advised staff to call for an ambulance in the eventof a medical emergency. For patients requiringadmission overnight due to unforeseen complications,the SOP included information about who to contact.The service told us that no patients had required urgenttransfer to a NHS acute trust in the last 12 monthsbefore the inspection.

• Staff mostly used national guidance designed to reducethe risk to patients during invasive procedureseffectively. The unit manager was aware of National

Safety Standards for Invasive Procedures and the servicehad a safety checklist as recommended by the WorldHealth Organisation (WHO). The WHO checklist is aninitiative designed to strengthen the processes for staffto recognise and address safety issues in relation toinvasive procedures. We observed staff complete theWHO checklist at the beginning of each procedure bycompleting a checklist. All staff were involved andconfirmed the identity with the patient as well aschecking correct details had been entered onto theclinical IT software used to record findings. Althoughstaff did not carry out a ‘signing out’ process there wereeffective arrangements for the safe labelling andchecking of histology samples and to ensure there wasan audit trail to check when these were placed forcollection.

• Staff monitored patients before, during and afterprocedures and in particular for patients who receivedconscious sedation. Staff checked patients’ vitalobservations on admission and confirmed details of anyallergies, previous medical history including conditionsand treatment for diabetes, raised blood pressure and ifpatients took blood thinning medicines. Staff reviewedthe symptoms that led to a referral for an endoscopyprocedure and explained the procedure to patientsgiving them time to ask questions. This also included arisk assessment to determine if patients were suitable toreceive a medical gas used to manage pain duringprocedures. Staff checked with patients if prescribedpreparations known as ‘bowel prep’ had been taken andwhen the patient last had food and fluids. This wasdocumented in the endoscopy care pathway, whichfollowed the patient through the episode of care.

• Staff monitored patients throughout the procedure. Onemember of the nursing staff was allocated to this task.Patients’ vital observations were monitored andrecorded with regular intervals. They also spoke with thepatient as a way of observing their well-being includingany signs of pain and to keep them informed of whenchanges of position was required. Once the procedurewas completed the nurse handed over to a nurse fromthe recovery area.

• Staff monitored patients at regular intervals during therecovery phase until they had recovered sufficiently andwere able to be discharged. Nurses used a consultationroom to discharge patients, which allowed them to haveuninterrupted conversations with patients about theirprocedure, answer any questions and inform them of

Endoscopy

Endoscopy

Good –––


ongoing referrals. Staff gave an after-care informationleaflet specific to the procedure they had had. Theleaflet included information about any post proceduralinstructions such as when it was safe for them to eatand drink again if applicable. The information leafletalso held information about symptoms to look out forand when to contact emergency services. There was acontact number to ring for another near-by InHealthendoscopy unit in the event patients had additionalquestions about care they had received.

• Staff had access to guidance in the event of a patientdeteriorating during the admission. There was astandard operating procedure (SOP), which outlinedwhen and who to contact in the event of complicationsduring or after endoscopy procedures. The SOP waswritten by the hosting organisation and includedparameters such as NEWS scoring. The ‘national earlywarning scores’ (NEWS) is a national initiative to detectclinical deterioration and respond appropriately. Nursesreceived training in how to use the tool. However, theendoscopy pathway did not include patientobservations to be recorded using the NEWS tool toenable early detection of a clinical deterioration. Wespoke with the unit manager who explained staff hadaccess to charts for recording of vital observation usingthe NEWS tool. Therefore, there was a risk that patientswho deteriorated would not be recognised andtransferred for a review in a hospital setting.

• There was a local business continuity plan belonging tothe host organisation, which staff referred to for adviceand for relevant contact details. Examples included lossof vital services, staffing issues and equipment failure.

Nurse staffing

• The service had enough nursing staff, with the rightmix of qualification and skills, to keep patients safeand provide the right care and treatment.Nurseswere not directly employed by InHealth but provided bythe host organisation and met Joint Advisory Group(JAG) requirements.

• The service rarely used bank or agency nursingstaff.The last time temporary nursing staff had workedin the unit was March 2018. When bank/agency nurseswere required to work for the service, this was managedby the hosting organisation following their processesand procedures including local induction.

• There were two nurse endoscopists who worked acrosseight InHealth endoscopy units. One nurses wascontracted to work under practising privileges, the otherwas employed by InHealth.

Medical staffing

• The service had enough medical staff, with theright mix of qualification and skills, to keeppatients safe and provide the right care andtreatment.

• There were arrangements for regular granting andreview of medical staff working under practicingprivileges. This is a well-established process within theindependent hospital healthcare sector where amedical practitioner is granted permission to work in aprivate hospital or clinic in independent private practice.There were three GP endoscopists working underpracticing privileges. There were processes to ensuremedical staff working under practicing privileges hadaccess to support for revalidation and appraisals, whichwere managed at corporate level within InHealth. Allstaff working under practising privileges attended anannual review. At this meeting, they were asked toprovide evidence for their up-to-date training andcontinuous personal development to meet GeneralMedical Council standards.

Records

• Staff kept detailed records of patients’ care andtreatment. Records were clear, up-to-date andeasily available to all staff providing care.However,patient details were not always stored and disposed ofsecurely.

• Staff used a paper based endoscopy pathway todocument information, care and treatment given. Thiscovered care and treatment given during the admission,the procedure and the recovery phase through todischarge. The administrator prepared the paperdocuments for each clinic to ensure all documents wereavailable to staff. Patient records were kept in a closedbut unlocked trolley in the recovery area. However,there was always a nurse present in the area. There wasa printed procedure list taped to the top of the recordstrolley to provide an overview for nursing staff ofpatients that had arrived, who had been discharged or ifany patients had cancelled or not turned up for theirprocedure appointment. This list held information such

Endoscopy

Endoscopy

Good –––


as patient names and the procedure they wereattending for. Therefore, there was a risk that patientconfidentiality could be compromised as this data waseasily accessible.

• The service carried out regular documentation auditsalthough these were not part of a planned auditprogramme. The audit looked at patient medicalrecords from one list of procedures. We reviewed theresults from January, April and July 2018. The auditreport highlighted where findings did not comply withthe targets they were assessed against. The reportrecommended actions for improvement to be discussedin a team meeting. The audit asked for notes from onelist to be reviewed but did not state how many patientrecords were reviewed. The audit form includedrecommendations such as discussion of the findings inthe next ward meeting. We reviewed minutes of wardmeeting held in January, April and September 2018 andfound that although documentation was a standardagenda item, outcomes of the documentation auditswere not discussed. We also reviewed minutes of thesix-monthly Cirencester Quality Circle meeting held inApril 2018 and found documentation audits were notdiscussed in this meeting. We were therefore notassured that documentation audits were usedeffectively to improve the completion of patient records.

• During the inspection, we reviewed five patient recordsand found staff had completed these with all relevantinformation as directed by the care pathway.

• Following the discharge of patients, all paper recordswere scanned into an InHealth electronic patient recordsystem. InHealth had provided IT equipment with therequired InHealth software to record and store allinformation about patients. Only designated staff fromthe hosting organisation had access to the information,which was password protected. Paper records werediscarded into a confidential waste bin, which wascollected weekly and disposed of by the hostingorganisation. However, the waste bin was open meaningthat unauthorised people could access confidentialinformation about patients.

Medicines

• The service did not always comply with nationalguidance and legislation when administeringmedicines used for conscious sedation. The servicefollowed the endoscopy pathway when

administering and recording medicines given topatients. Medicines were ordered and storedsecurely.Patients received the right medication at theright dose at the right time.

• Prescribing of medicines did not follow nationalguidance and legislation. Standard medicines used forendoscopy procedures were documented on theendoscopy pathway. These were medicines given forprocedures performed under conscious sedationincluding controlled drugs (CDs). Two nurses preparedthe medicines to be given intravenously and labelledthese correctly. We were told that medicines were mostoften administered by the endoscopist. However, nursessigned for the administration of medicines given by theendoscopist by writing ‘given by’. This meant that theendoscopist did not prescribe the medicines to beadministered by nurses or sign for the medicines theyadministered. Nurses were not non-medical prescribers.We were not assured that medicines were alwaysprescribed and managed correctly as outlined innational guidance and in accordance with the Misuse ofDrugs Act 1971. We raised this with the service andasked the service to present an action plan of how thiswas resolved. The action plan we received, clearly setout changes in practice to ensure the safe and correctprocesses for prescribing and administering ofmedicines followed national guidance and legislation.

• There were safe arrangements for the ordering, storageand disposal of controlled drugs (CDs). We checkedarrangements for the ordering, storage and stockchecking of controlled drugs (CDs), which was in linewith national guidance. Nursing staff recorded the doseof medicines given to patients and recorded the amountthat was discarded if not used. The CDs were discardedinto a safe disposal medium designed to absorb theliquid medicines.

• Staff had access to and were knowledgeable about theuse of a medicine to reverse the effects of conscioussedation. The strength of the sedating medicines was inline with guidance from the National Patient SafetyAgency (2008). The service monitored how often thereversal medicines had been required and datademonstrated reversal medicines had not been used inthe 12 months before to the inspection.

• Access to and use of all medicines were included in thecontract with the host organisation. The service did not

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prescribe or supply any medicines for patients to takehome. If new prescriptions were required, this wasdocumented in a detailed post-procedure report, whichwas shared with the patients’ GPs.

Incidents

• The service managed incidents well.There werearrangements to report incidents, near-misses andnon-clinical incidents. There was an InHealth ‘adverseevent (incident) reporting and management policy(2017) providing a framework for reporting andmanaging incidents. The policy stated the specificinvestigative enquires depended on the complexity ofthe incident. Actions were documented within theelectronic reporting system. There were no incidentsreported which had been investigated using a rootcause analysis approach as no incidents were serious orhad caused harm to patients.

• There had been no incidents reported between October2017 and September 2018 that required duty of candourto be applied. Providers of healthcare services must beopen and honest with service users and other ‘relevantpersons’ (people acting lawfully on behalf of serviceusers), when things go wrong with care and treatment,giving them reasonable support, truthful informationand a written apology. We spoke with the unit managerabout duty of candour who had a clear understandingof when and how to apply duty of candour.

• The service reported 19 incidents between October 2017and September 2018. Most of these (12) were classifiedas booking issues (12 incidents). There were five clinicalincidents reported, one equipment failure incident andone fall, which did not cause any harm to the patient.

• Staff reported incidents using the host organisation’selectronic incident reporting system. Key staff membersof the host organisation had access to the InHealthincident reporting system to log an incident. Wediscussed this with the unit manager and the InHealthregional operations manager who stated all nursing staffhad access to the electronic incident reporting systemused by the host organisation. Staff could reportincidents using this system and the unit manager wouldthen discuss the incidents with the regional operationsmanager.

• Incidents were jointly investigated by the regionaloperations manager and the unit manager. Incidentswere discussed by the InHealth clinical governanceteam every week. Lessons learned from incidents were

shared in a bi-annual quality circle meeting. However,the unit manager stated that learning from incidents,including those happening during InHealth procedureslists, were discussed in regular unit meetings. Wereviewed minutes of meetings from January, April andSeptember 2018, which confirmed incidents were partof a standard agenda and that incidents relating toInHealth procedure lists were identified and discussed.

Are diagnostic imaging and endoscopyservices effective?(for example, treatment is effective)

We do not rate the effective domain for independentendoscopy services.

Evidence-based care and treatment

• The service provided care and treatment based onnational guidance and evidence of its effectiveness.

• The service received Joint Advisory Group (JAG)accreditation in 2018. The service provided informationfor patients on discharge about how and when to seekhelp if they felt unwell following the procedure, whichwas in line with JAG clinical quality domain (QP6). Thisinformation included symptoms that may beexperienced as well as information about symptomsthat would require urgent medical assistance.

• Care and treatment was delivered in line with currentlegislation and nationally recognised evidence-basedguidance. For example, the service offered non-urgentgastroscopy for patients in line with guidance from theNational Institute for Care and Excellence (NICE): QS 96Dyspepsia and gastro-oesophageal reflux disease inadults (2015).

• The service audited 30 day readmission rates. Theservice obtained information about patients who hadreceived an endoscopy procedure and who hadattended hospital within 30 days of the their endoscopyprocedure. For example, between October andDecember 2018, 11 patients had been readmitted within30 days of their endoscopy procedure. Of these twoadmissions were from referrals for treatment followingtheir procedure and the remaining nine admission wereunrelated to the endoscopy procedure.This data related to two InHealth endoscopy units andwas reported to the clinical commissioning group (CCG)

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quarterly. The service did not routinely report on 30-daymortality (death occurring within 30 days of anendoscopy procedure). We were told this had notoccurred but would be investigated if it happened.

• Staff had access to guidelines and policies to helpinform their practice. Senior managers told us thepolicies and standard operating procedures used by thehosting organisation was used wherever possible toavoid confusion for staff. For example, the majorincident business continuity plan (2017) was written byand belonged to the hosting organisation. Policies,guidelines and patient information was reviewedregularly at corporate level to ensure these reflectedcurrent and evidence-based practice. New or updatedguidelines were discussed in the bi-annual Quality Circlemeeting.

Nutrition and hydration

• Staff offered refreshments to patients following theirprocedures if it was safe to do so. Patients who hadreceived local anaesthetic/throat spray receivedinformation about when it was safe for them to eat anddrink following the procedure.

Pain relief

• Staff assessed and monitored patients regularly tosee if they were in pain and gave additional painrelief if required.

• Staff took actions to manage patients’ discomfort duringprocedures. Staff monitored patients’ comfort duringprocedures. Patients attending for a gastroscopy weregiven an anaesthetic throat spray to numb the throatand reduce discomfort during the procedure. Patientsattending for flexible sigmoidoscopy and colonoscopywere offered conscious sedation during the procedure.Patients were also offered a medical gas (Nioxide andOxygen) to alleviate discomfort if this was notcontraindicated. During the admission process, patientswere asked about their preferred choice of pain reliefduring the procedure and risks assessments associatedwith medical gases were discussed. This was in line withguidance from the National Institute for Health and CareExcellence (QS15, standard 10, 2012).

• The endoscopist recorded patients’ comfort scorefollowing the procedure. This was entered onto the

Global Rating Scale as required by the Joint AdvisoryGroup. Data including comfort scores were used tobenchmark each endoscopist against each other andagainst national results

Patient outcomes

• Managers monitored the effectiveness of care andtreatment and used the findings to improvethem.They compared local results with those of otherservices to learn from them.

• The service monitored the number of procedurescarried out by each endoscopist and a range of qualitystandards in line with Joint Advisory Group (JAG) qualitystandards (2007). Data demonstrated that three of thefive endoscopist had carried out less than 100procedures at this location. We discussed this with theclinical lead and the InHealth regional operationsmanager who explained the figures only related toprocedures carried out at this service and did notinclude the number of procedures carried out in otherInHealth services. This data was held centrally andmanaged at corporate level.

• The service collected data which enabledbenchmarking of their performance against nationalstandards and for internal use. The service collectedapplicable data in line with the British Society forGastroenterology Quality and Safety Standards (2007)and as required by the Joint Advisory Group (JAG, 2005).For example, adenoma detection (benign tumour ofglandular tissue such as the lining of the large bowel)during colonoscopy procedures, was above 15% (betterthan the required standard) for three of the fourendoscopist who carried out this procedure. However,polyp retrieval rate (the removal of an abnormal growth)target of 90% was only met by one of the fourendoscopists. The average scope withdrawal time metstandards of lasting more than 6 minutes although auditresults demonstrated that during some colonoscopyprocedures the scope was withdrawn in 3 minutes (Aprilto May 2018). The withdrawal of the scope allows theendoscopist to have a second look at the bowel as thescope is withdrawn and an important part of theprocedure that should not be rushed.

• Patient outcomes were audited quarterly using a datacollection tool known as the Global Rating Scale anddiscussed with individual endoscopists at their annual

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review or sooner if this was required. InHealth hadsigned up to a new national endoscopy database, whichgave individual endoscopist access to real timeoutcome data as data was downloaded daily.

• There were arrangements for onward referral to otherhealthcare providers for further investigation and/ortreatment if this was required. During endoscopyprocedures, the endoscopist could take a sample of thelining of the intestines. Samples were sent to aneighbouring trust for processing and patients wereadvised to contact their GP for results and to discussfurther investigation and treatment. This informationwas also shared with the patients’ GP through andelectronic letter from the endoscopist in addition to theendoscopy report.

• The host organisation had an audit and qualityassurance programme. Results were available forInHealth staff to review at contract meetings and at abi-annual governance meeting (Cirencester QualityCircle (governance) meeting.

• Staff gave patients a written report of the investigationbefore they left on the day of the procedure. Endoscopyreports were sent electronically to the patients' GP thesame day. The endoscopist informed patients of theresult of the procedure either in the procedure room oronce they had recovered sufficiently from the medicinesthey had been given. The discharge nurse gave patientsa copy of the report and explained the findings againand answered any questions the patient may have.Patients’ relatives were invited to attend the dischargeconversation but were generally not encouraged toenter the recovery area.

Competent staff

• Staff had the skills, knowledge and experiencerequired of their roles to deliver effectivecare.There were systems to ensure professionalregistrations were checked regularly and arrangementsfor annual appraisals.

• There were arrangements for the granting and reviewingof practicing privileges. Staff working under practicingprivileges met annually with a named InHealth linemanager to review practice, appraisals, training andrevalidation. Data shared with us before the inspection,demonstrated all but one medical endoscopist was upto date with their annual appraisal. We were told that inaddition to the appraisal there was also an annualreview with each endoscopist where their individual

performance was discussed and benchmarked againstpeer endoscopists. Each medical endoscopist had anamed responsible officer to support them with theirannual appraisal and revalidation. The nurseendoscopist working under practising privilegesreceived their appraisals in the main place of working orfrom the InHealth lead nurse endoscopist of from theInHealth medical director. InHealth supported nurseendoscopist with revalidation by sharing of feedbackabout their care and supporting evidence of theirpractice hours.

• New staff employed by the host organisation received alocal induction and included health and safety briefingsand access to all IT systems required. Nursing staffreceived annual appraisals from the host organisation.InHealth personnel/the registered manager had accessto staff performance metrics and appraisal records forreview at contract review meetings or during abi-monthly meeting with the unit sister and the InHealthregional operations manager. All nursing staffcompleted endoscopy competencies and rotatedbetween the three different areas. Most of the nursingstaff (70%) had also completed competencies fordecontamination processes. This ensured there werealways staff on duty who had the right competencies tosupport the safe delivery of care before, during and afterendoscopy procedures.

• New endoscopists employed under practicing privilegesand by contractual arrangements received a briefingsession and a shadowing procedure list with theInHealth clinical lead. There was an induction checklistspecifically for InHealth processes, which wasunderpinned by induction/sign off processes for thehost organisations.

Multidisciplinary working

• Staff of different kinds worked together as a teamto benefit patients. Doctors, nurses and otherhealthcare professionals supported each other toprovide good care.

• The service worked with a laboratory in a neighbouringNHS trust for the processing of samples taken duringendoscopy procedures. Results were reviewed by theendoscopists who then completed a supplementaryendoscopy report. This report was sent to patients' GPsoutlining the results of the samples taken and anyrecommended actions. Patients were advised to makean appointment with their GP to discuss the result of

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samples taken. The service made referrals to the localNHS trust for onwards treatment and care as required.These referrals were time critical for patients to havefurther tests, commence treatment and formultidisciplinary review as required.

• There were good working relationships with local GPs.Patients procedure reports and information aboutsamples taken were shared with patients’ GPs

Consent and Mental Capacity Act

• Consent was sought from patients butdocumentation used for consenting wasambiguous and did not confirm that risks had beendiscussed with patients. Staff did not alwaysdiscuss or check patients’ understanding of risksassociated with endoscopy procedures.Staff did notalways assess if patients had mental capacity to consentto procedures.

• Consent was sought from patients before anyendoscopy intervention and before other care activitieswere started. All staff we spoke with had a goodunderstanding of consent. However, the documentationused for consenting patients was ambiguous. Thecentral InHealth hub sent out to patients the consentform within a ‘procedure pack’ for the procedurepatients were referred for. The consent form wastailored to explain the procedure for which consent wasbeing sought, side effects and associated risks involvedwith the procedure. This was explained in a manner thatallowed the individual to make an informed decisionabout consenting to the procedure, on the consentform. There was a space on the form, which encouragedpatients to note any questions or concerns they mayhave. When patients were admitted, nurses checked theform had been signed and noted if there were anyquestions highlighted, which they then answered.Following the inspection, we were informed of changesmade to the consent process to ensure risks werealways discussed and the forms were changed to avoidany ambiguity.

• Staff did not always follow the InHealth policy whenobtaining consent from patients. There was a ‘consentto treatment policy’ (2016) which provided guidance forstaff to follow when consent was discussed andconfirmed with patients. We observed three admissionsand heard that the procedures were very well explainedto patients but risks were not always discussed. Patients

had signed the form prior to admission for theendoscopic procedure. Patients were asked to indicatethey had understood the procedure and associatedcomplications and risks when they signed the consentform. However, this understanding was not confirmedon the admissions we observed in line with the InHealthconsent policy (2016). The nurse, who admitted thepatient could sign in one of two places although somenurses signed both but this was not consistent. The firstoption was to sign for ‘confirmation of consent’ (whichwas applicable when patients had signed the form inadvance). The admitting nurse signed to confirm theyhad discussed the options for sedation and use ofmedical gasses. The second option was used by thehealthcare professional when the patient was unable tosign the consent form. This applied to patients that wereunable to see or physically unable to sign the form. Theadmitting nurse (or healthcare professional) then signedto indicate they had explained the procedure includingbenefits and risks. We were therefore not assured thatpatients always understood risks as these were notalways explained or discussed during the admissionprocess.

• Consent was re-affirmed in the procedure room, as partof the WHO check list, by nursing staff asking the patientif they had signed the consent form. We did not observethe endoscopist discuss risks of the endoscopyprocedures with patients. We were not sure theendoscopist could always be assured that risksassociated with the procedure they were about toperform, was always understood by patients. This wasnot in line with guidance from the British MedicalAssociation on informed consent.

• Staff did not always demonstrate theirunderstanding and responsibilities under theMental Capacity Act 2005.The service did not alwaysfollow their admission criteria when accepting patientsfor procedures. We observed a procedure carried out fora patient living with dementia, although dementia wasamongst the service’s exclusion criteria. Consentprocesses for patients who lacked capacity did notfollow national guidance. There was only one kind ofconsent form, which did not include any informationabout patients’ mental capacity to make decisions. NHSEngland state that for consent to be valid it must bevoluntary and informed, and the person consentingmust have the capacity to make the decision. Theconsent form used stated a witness should sign if the

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patient was unable to sign but had indicated theirconsent. We observed an admitting nurse discussingwith the endoscopist, concerns related to a patientliving with dementia and that they were unsure that thepatient understood what the procedure entailed. Whenthe patient entered the procedure room, it was evidentthe patient did not have sufficient understanding of theprocedure to make a decision to give informed consent.We were concerned that staff did not fully understandtheir roles or apply their responsibilities as set out underthe Mental Capacity Act 2005.

• Staff did not receive specific training in how to assesspatient’s mental capacity although it was referenced inthe safeguarding training materials. Endoscopists andnurses were not required to complete specific mentalcapacity training. However, following the inspection wewere advised that InHealth had approved the roll out ofa mandatory training course in mental capacityassessment and deprivation of deprivation of libertysafeguards in May 2019.

Are diagnostic imaging and endoscopyservices caring?

Good –––

We rated it as good.

Compassionate care

• Staff cared for patients with compassion.Feedbackfrom patients confirmed that staff treated them well andwith kindness.

• We observed staff caring for patients with compassion.Staff introduced themselves to patients and confirmedhow staff should address them.

• Staff communicated with patients in a manner thatsuited their needs and took time to interact withpatients to answer their questions. We observed staffforming appropriate relationships with patients toenable them to communicate effectively. We observedappropriate use of humour when this was applicable.Staff were smiling, approachable and reassuring in theirinteractions with patients and their relatives.

• We observed that patients’ dignity was maintainedthroughout the appointment. Staff admitted patients inthe admissions room, which provided opportunities forconfidential conversations. There was a changing room

where patients could change in readiness for theprocedure. Dignity shorts were provided for patientsundergoing lower gastro-intestinal procedures. Therewere adequate toilet facilities for patients to use ifrequired. The recovery area was segregated intocubicles to provide privacy. Staff discharged patientsafter a conversation in a dedicated consultation roomfor this use. This ensured privacy for confidentialconversations and offered patients an opportunity toask additional questions.

• Staff supervised patients to avoid accidental entrance tothe clinical procedure room. Staff instructed patients towait in the changing room and that they would betransferred to the procedure room on a trolley.

• Patients and relatives spoke highly of the kindness ofthe staff. They told us staff gave them the informationthey needed

• The service sought the views of patients and theirrelatives through completion of the NHS friends andfamily test. We reviewed a result of these betweenOctober 2017 and March 2018. The response rate variedbetween 30% - 46% of those patients who had attendedfor a procedure. The results demonstrated that 100%were very likely or likely to recommend the service inJanuary and March 2018. In February the result was91.2%. The service looked at comments added andacted to implement service improvements.

Emotional support

• Staff provided emotional support to patients tominimise their distress.

• Staff understood the impact the procedures andpotential diagnosis could have on patients.

• Staff asked and observed non-verbal signs of patientsfeeling anxious. Staff took time to reassure patients andprovided additional explanations when this wasrequired. This was in line with guidance from theNational Institute for Care and Health Excellence (QS15,2012)

• Staff ensured patients had the right information andadvice on discharge. Staff gave patients an ‘aftercare’leaflet tailored to the procedure they had received. Thisinformation leaflet held information about expectedside effects and symptoms of when emergency careshould be sought.

Understanding and involvement of patients andthose close to them

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• Staff involved patients and those close to them indecisions about their care and treatment.

• The endoscopist provided feedback about findingsstraight after the procedure. This information includedfindings during the procedure, information aboutaftercare and onward referrals as applicable. Weobserved staff handover to the nurses in the recoveryarea that the endoscopist would see the patient beforethey were discharged, if they were not assured thepatient had fully understood or was affected by thesedation medicines.

• There were effective processes to involve patients andtheir relatives to enhance and ensure theirunderstanding of the procedure and aftercare. Staffwelcomed relatives to join in during the admission anddischarge stages of the appointment, if this was the wishof the patient. This encouraged opportunities forpatients and relatives to ask questions and discussinformation to ensure and promote understanding.

Are diagnostic imaging and endoscopyservices responsive to people’s needs?(for example, to feedback?)

Good –––


Service delivery to meet the needs of local people

• The service planned and mostly provided servicesin a way that met the needs of local people.Theservice worked under contract with the local clinicalcommissioning group. There were agreed referralcriteria for patients attending for procedures, which hadbeen agreed with commissioning stakeholders.

• Patients received ‘instruction notes’ particular to theprocedures they were referred for. This includedinformation about the procedure, fasting and of anypreparation that was required. There was specificinformation for patients with diabetes and for patientstaking blood thinning medicines. Patients were advisedto contact their GP or practice nurse if they were unsureabout the instructions.

• Overall the premises were appropriate for the service itdelivered. The endoscopy unit was situated on the firstfloor but there was access by lift if required. There wereample parking spaces free of charge for patientsattending for appointments.

Meeting people’s individual needs

• The service took account of patients’ individualneeds.Communication needs were assessed, flaggedup and reasonable adjustments implemented, toensure patients had the information they required inline with Accessible Information Standards (2017). Staffcould arrange for interpreters and written information inother formats or languages if this was required. Therewas a hearing loop installed to support patients withhearing aids.

• The service accepted patients without discrimination,including on the grounds of protected characteristicsunder the Equality Act 2010. There was easy access tothe facilities for patients with mobility difficulties.However, patients were required to be able to transferon to the trolley unaided and to change position duringthe procedure with minimal assistance. This wasoutlined in the referral criteria.

• The service had processes and systems to monitor,review and optimise patient comfort levels. Comfortscores during procedures were captured for eachpatient using the Global Rating Score. The servicemonitored the average comfort score level for eachendoscopist. The median comfort scores rangedbetween 0 (no discomfort) and 4.42 for colonoscopiesbut was not captured for flexible sigmoidoscopies andgastroscopies. The results were discussed at an annualperformance review or sooner if required.

• There were effective processes to ensure single sexchanging and toilet facilities. This was mainly becausethe unit was so small they only saw one patient at atime pre- procedure, meaning that opportunities formixed sex breaches did not arise.

• There were effective systems to ensure informationabout the procedure and aftercare was shared beforeappointments. Patients received a text message toremind them of their appointments. Staff told us theyinformed patients of any delays on the day patientsattended for their appointment.

Access and flow

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• People could not always access the service whenthey needed it. There was a weekly ‘capacity anddemand’ telephone call between the unit manager andthe InHealth regional operations manager, to reviewwaiting times, activity and referral to treatmentperformance. However, the service had not beencompliant with referral to treatment (RTT) six-weekstandards in nine of twelve months between October2017 and September 2018. The six week RTT was theonly standard the service was commissioned to deliver.Data received before the inspection, showed there was awaiting list of 107 patients waiting to be seen.Information shared by the provided showed that ofthese patients, 14 patients waited longer than six weeksfor their appointment. The service monitored thereasons for patients waiting longer than six weeks. Thereasons for the 14 breaches of the six week RTT were:lack of capacity (seven patients), some patients chose towait a little longer (three patients), two patients did notreceived their bowel prepatation in time, incorrect dateslogged and one patient breached the six week RTTwhilst being triaged. Wherever possible, the serviceoffered appointments at other nearby InHealthendoscopy services or worked with the hostingorganisation to secure additional procedure slots.Additional data we requested showed that sevenpatients waited less than one week after the breach onthe six week target, three patients were seen within twoweeks. The remaining four patients waited up to 18weeks before they attended for their appointment. Wediscussed this with the InHealth regional operationsmanager and national operational lead for endoscopywho recognised that the service provided at Cirencesterwas not sufficient to meet demands and they wereexploring options for expanding capacity in anotherlocation. They were also exploring furthercommissioning contracts to ensure the sustainability ofa further location for local people. This concern wasregistered on the local risk register.

• All booking and scheduling was managed from a centralInHealth hub. The service was sent a list of patientsscheduled for each day the service operated from thislocation. However, we heard that the process for‘choose and book’ was challenging for some patientsand sometimes patients were sent the wrong letterscausing confusion. We reviewed reported incidents andnoted there were 12 incidents reported about bookingprocedures. Of these, the cause of five incidents were

associated with staff at the central hub not followingprocedures and four incidents led to cancellation oftreatment on the day because patients had not receivedthe correct instructions and bowel preparations inadvance of the appointment. We discussed this with theInHealth regional operations manager and head ofgastroenterology who told us this had been raised andInHealth were working to resolve the issues. Followingthe inspection, we were informed of actions taken toensure all patients were sent the correct appointmentletters.

• The service monitored cancellations and the number ofpatients that did not attend. These were discussed in asix-monthly Quality Circle meeting. Data demonstratedthere had been 16 procedures cancelled by the servicebetween January and December 2018. Seven patientshad cancelled their appointment and 29 patients didnot attend for their planned endoscopy procedure inthe same period.

• Procedures were not always planned to utilise allavailable procedure slots. The service used a pointssystem to measure utilisation. A full session ofendoscopy procedures was equivalent to 12 points. Welooked at data between January and December 2018and found utilisation of available procedure slots weremet in 31 of 52 weeks. In the remaining 21 weeks,utilisation was less than 75% in nine weeks. Followingthe inspection, we asked the service about any actionstaken to improve procedure room utilisation. Theservice had reviewed the reasons for under utilisation ofthe procedure slots as they recognised this had animpact on waiting lists and meeting the six week referralto treatment standard. They found that a number ofpatients did not receive their bowel preparation in atimely manner. This had led to a pilot project workingwith a pharmacy provider to dispense/send out bowelpreparation products as existing processes could notmeet the demand.

Learning from complaints and concerns

• The service took concerns and complaintsseriously, investigated them and learned lessonsfrom the results, and shared these with all staff.

• There were processes to ensure patients and theirrelatives could make a complaint or raise a concern ifrequired. Information about how to make a complaint

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was sent with other information to the patient beforetheir appointment. The service aimed to resolve anyconcerns on the day. The unit manager (or their deputy)was available to discuss concerns raised by patients.

• The service investigated formal complaints in line withtheir policy (Complaint policy, 2015). The service hadreceived five complaints between September 2017 andSeptember 2018. There was one complaint relating tocommunication, one to patient pathway and three forclinical treatment.

Are diagnostic imaging and endoscopyservices well-led?

Good –––


Leadership

• Managers at all levels in the service had the rightskills and abilities to run a service providinghigh-quality sustainable care.Operational leadershipon the days the service provided InHealth endoscopyprocedures were listed, was provided by unit managerand the senior nursing team from the hostingorganisation. On these days, only the endoscopist wasemployed by InHealth and they carried overall clinicalresponsibility for the care of patients.

• Leadership of the service was provided by a smallmanagement team. The team consisted of the unitsister (employed by the hosting organisation), a clinicallead (a GP endoscopist) and an InHealth regionaloperations manager. There was a weekly telephone callattended by the unit manager and the InHealth regionaloperations manager. This meeting was based aroundcapacity but was also used to raise any concerns orqueries. The clinical lead monitored clinicalperformance and was involved with servicedevelopment projects with commissioners acrossGloucester and Oxford. The regional operationsmanager provided guidance and had overallresponsibility for the InHealth services provided at thislocation.

• Endoscopy services, as a speciality, was part of thespecialised services directorate within InHealth. Thismeant support was provided from a central hub forhuman resources support, governance and informationtechnology.

• Leaders understood the challenges to quality andsustainability of the service. They spoke of the risk of notmeeting demand due to limited capacity to twosessions per week and they understood the impact thishad on individual patients. InHealth managers werenegotiating plans to increase capacity in the local areato meet demand.

• Staff told us their leaders were approachable andsupportive. Leaders worked together to achieve qualitycare for patients. The relationship seemed to be open,honest and built on mutual respect.

• The hosting organisation provided administrativesupport to the effective running of the clinics. Theadministrator greeted patients and providedadministrative support primarily with regards to thepreparation and storage of patient records. They hadthe overview of who had attended and of anycancellations by patients. If patients cancelled theirappointment directly with the unit, the administratorwould agree another date for them to attend, utilisingany procedure slots in the procedure schedule.

Vision and strategy

• The service had a vision for what it wanted toachieve and workable plans to turn it into action,which it developed with staff working at the unit.

• There was a corporate InHealth ‘clinical quality strategy2016/19 vision and there was a local ‘business plan’ for2018/19. The plan set out a trajectory plan for referralsfrom October 2018 to September 2019, based on a 7%growth in GP referrals.

Culture

• Managers across the service promoted a positiveculture that supported and valued staff, creating asense of common purpose based on shared values.

• We observed staff working together with patient care asa priority. Staff were caring and compassionate towardspatients and their relatives. Staff took account ofindividual patients needs and took action to meet theirneeds. It was evident that a high standard of patientcare and patient safety was the most important factoramong staff.

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• The leadership team promoted a positive culture andvalued staff. We asked them what they were most proudof and they answered without hesitation the staff andteamwork.

• Staff told us they liked working within the endoscopyunit. We spoke with one new member of staff whoenjoyed the new challenges and confirmed they hadreceived a supportive and good induction process.

• We observed positive interactions and camaraderieamong staff. Staff helped each other when required andwere observant of each other’s needs.

• There was a set of InHealth values, which included trust,care, passion and fresh thinking. These were not sharedwith staff from the hosting organisation. However, thevalues were similar to the values of the hostingorganisation. We discussed this with the InHealthregional operations manager who did not think thatpromoting InHealth values as a separate concept wouldadd any benefits as they were so closely aligned.

Governance

• The service systematically improved servicequality and safeguarded high standards of care.

• The service had a governance structure, whichdemonstrated accountability and communicationpathways to ensure effective sharing of information.There were processes for effective communication fromthe service to the executive team and vice versa. Theservice’s local nursing team was accountable to theInHealth regional operations manager who representedthe service to the executive InHealth team, by attendingmonthly meetings. The clinical lead, who was also theregistered manager, was accountable to the InHealthmedical director whom they met with every six monthsor more often if required. This meant information wasshared with staff delivering the service every month.

• There was a corporate head of gastroenterology whohad overall responsibility for governance and riskmanagement across different locations deliveringendoscopy services on behalf of InHealth.

• There was an effective governance structure at unitlevel, senior level and at board level. There were localarrangements for incident reporting, complaintmanagement, performance overview and plannedmeetings to support the governance of the service. Atsenior level, there was a weekly review of complaints,incidents, litigation and compliments. This meeting was

attended by the InHealth regional operations manager.The InHealth board held monthly meetings whereperformance was reviewed and benchmarked againstother endoscopy units.

• There was a six-monthly Quality Circle Meeting. Themeeting was attended by clinical leads and nursing stafffrom the hosting organisation. We reviewed minutes ofthe last two meetings which included a standardisedagenda including reviews of guidelines and patientinformation, Global Rating System (GRS) reviews andaudits, adverse event and complaints.

• There were bimonthly unit meetings chaired by the unitmanager, which was also the endoscopy user groupmeetings. This was for nursing staff and covered allendoscopy services provided at this location. Whereagenda items were specifically relating to InHealthservices, this was highlighted in the minutes. In addition,there were six monthly Quality Circle meetings whichwas chaired by the InHealth clinical lead and attendedby InHealth managers and nursing staff providing theservices.

• Contract review meeting with the host organisationwere not always held regularly. Senior managers told usthere was weekly contact but that regular reviewmeeting was not always held quarterly. We reviewedminutes of the last two meetings held in January andJuly 2018. There was no set agenda and the minutes ofthe meetings were difficult to follow if managers had notbeen able to attend. This meant we were not assuredthat actions were always carried out to improve thedelivery of care.

• Audit compliance was monitored. There was an auditprogramme, which set out a plan for when 15 differentaudits were due. Some of these were monthly whileothers were required to be completed at six monthlyintervals. Audit results were discussed in the EndoscopyUser Group meetings and Quality Circle meeting. Theservice was planning to commence an audit forprocedure room ‘turn around’ times as this had beenidentified as not being as efficient as it could be.

• Leaders ensured employees who were involved in theinvasive procedures were educated in good safetypractice. We observed staff use the World HealthOrganisations (WHO) safety checklist to deliver safeprocedures for patients. However, we revieweddocumentation audits that showed the checklist wasnot always completed and there was no specific audit tomonitor WHO checklist completion. InHealth leaders

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told us this had also been highlighted in otherinspections by the Care Quality Commission but itseemed learning had not been shared across differentunits.

• There was a range of policies available to staff for reviewfor guidance. The policies were clearly laid out, date andversion controlled, meaning updates to the policy wereeasy to identify. Senior manager told us staff followedclinical procedures and policies from the hostorganisational as much as possible. These policies metthe expectations for InHealth and was available for themto review on request. InHealth policies followed astandard template setting out the purpose, roles andresponsibilities and monitoring requirements. Forexample, the complaints policy stated complaintreports should be reviewed quarterly by the corporateclinical governance teams and provided to the risk andgovernance committee.

• We reviewed minutes of the risk and governancecommittee from May, June and July 2018 and foundincidents were discussed as a planned agenda item.However, this policy was out of date as it should havebeen reviewed in November 2018.

Managing risks, issues and performance

• The service had systems to identify risks, plan toeliminate or reduce them.Risks were identified andmitigating actions developed to manage these. Therewas a local risk register. which included risks fromdifferent categories including quality, operations,human resources and health and safety. There were fiverisks added to the risk register. Three of these wereoperational, one was finance and the last risk wasrelated to information governance. The risk entriesdemonstrated identified actions to mitigate the risksand showed they were last reviewed in September2018.There was an identified ‘risk owner’, who was theregional operations manager, which ensured risks werecommunicate to corporate Clinical Quality SubCommittee and the Risk Governance Committee.

• Significant risks were added to the InHealth functionalor corporate risk register. These risks were reviewed andmonitored by the ‘complaint, litigation, incidents andcompliments’ (CLIC) group. The corporate head ofgastroenterology produced a quarterly risk report,which outlined risks across all endoscopy location. Thismeant information was shared between differentInHealth endoscopy services.

• There was InHealth corporate risk management policy(2016), which provided guidance about riskmanagement. The policy stated risks should bereviewed at least every quarter. We reviewed the localrisk register for services provided at this location andfound risks were reviewed monthly to ensure mitigatingactions were reviewed for their effectiveness inmanaging the risk.

• There were processes to raise awareness andimplement actions for national safety alerts such asthose communicated to the National Patient SafetyAgency (NPSA). These were reviewed at corporate leveland discussed at monthly InHealth Executivegovernance meetings. If actions were required, thesewere communicated to clinical leads at each locationfor action.

• During the inspection, we highlighted an area thatrequired action to improve the safety for patients. Theleadership team responded positively to this feedbackand through discussion, demonstrated the passion tounderstand what was required.

Managing information

• The service collected, analysed, managed and usedinformation well to support all its activities, usingsecure electronic systems with security safeguards.

• The service used an electronic platform to captureperformance data about endoscopy procedures tocapture compliance with national standards.

• Information stored electronically was secure. Computeraccess was password protected and we observed stafflogging out of computer systems when they left Itequipment.

• Staff had access to up-to-date, accurate informationabout patients. Information included previous medicalhistory, medicines and reasons for referral. Staff workedfrom paper copies and once the patient was dischargedthese were scanned into a specific IT software for safeelectronic storage. Only designated staff had access tothese records.

• The service reported on Workforce Race EqualityStandards through corporate reporting. The NHSEquality and Diversity Council announced on 31 July2014 that it had agreed action to ensure employeesfrom black and minority ethnic (BME) backgrounds,have equal access to career opportunities and receivefair treatment in the workplace.

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Engagement

• The service engaged well with patients to plan andmanage appropriate services.

• The services sought the views of patients and their nextof kin. Staff provided patients with comment cardsencouraging them to complete these following theirappointment. We were informed of changes that hadbeen made in response to feedback. For example,feedback about a cramped reception area led to arelocation of the reception providing a larger waitingroom with air conditioning to improve the environmentwhere patients were waiting.

• The hosting organisation carried out an annual patientsatisfactory survey, which included patients who hadattended for InHealth appointments. The hostingorganisation sent out 100 questionnaires of which 56were returned but it was not stated how many of thesewere patients who had attended for InHealth endoscopyprocedures.

Learning, continuous improvement and innovation

• The service was committed to improving servicesby learning from when things went well or wrong,promoting training, research and innovation.

• The clinic was exploring how they could extend theirservice. They were offering procedures to neighbouringclinical commissioning groups and NHS trusts.

• InHealth endoscopy units offered trans nasalOesphago-gastric-duodenoscopy (the scope is passedthrough the nose rather than through the mouth), whichimproved patient tolerance and comfort during theprocedure. It also gave patients the opportunity to talkand swallow more naturally, therefore helping to reduceanxiety levels.

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Areas for improvement

Action the provider MUST take to improve

• The service must ensure medicines are prescribed andadministered in line with national guidance andlegislation.

• The service must ensure patient paper-based recordsare disposed of securely.

• The service must review consent processes to ensurepatients’ understanding of risks are checked whenpatients bring in their signed consent forms.

• The service must ensure processes for obtainingconsent for patients living with dementia or other‘complicated consent’ are managed in line with theMental Capacity Act 2005.

Action the provider SHOULD take to improve

• The service should continue to review arrangements toincrease capacity to reduce waiting lists and to meetnational targets on referral to treatment times.

• The service should improve mandatory trainingcompliance and include regular training and updatesin mental capacity training.

• The service should consider the use of national earlywarning scores when recording patients’ vitalobservation.

• The service should review processes for the auditing ofWHO compliance and that actions identified fromdocumentation audits are followed through toimprove compliance.

• The service should improve use of results fromdocumentation audits to improve documentationcompliance.

• The service should review arrangements for ‘chooseand book’ facilities to improve the booking processand patient experience.

Outstandingpracticeandareasforimprovement

Outstanding practice and areasfor improvement


Action we have told the provider to takeThe table below shows the legal requirements that were not being met. The provider must send CQC a report that sayswhat action they are going to take to meet these requirements.

Regulated activity

Diagnostic and screening procedures Regulation 12 HSCA (RA) Regulations 2014 Safe care andtreatment

The endoscopists did not write prescription records thatcould be signed. The effect was that medicines were notactually prescribed.

The endoscopists did not sign for the medicines theyadministered.

Regulation 12 (2) (g) the proper and safe management ofmedicines

Regulated activity

Diagnostic and screening procedures Regulation 9 HSCA (RA) Regulations 2014 Person-centredcare

Although patients with complicated consenting (e.g.dementia) was on the list of exclusion criteria, weobserved a patient with a dementia diagnosis whounderwent an endoscopy procedure. There was noassessment of the patient’s mental capacity to consentand there was not a specific form (such as consent form4 or equivalent) used for this patient.

Consent processes were ambiguous. Risk associatedwith procedures were not always explained and staff didnot always check patients’ understanding of associatedrisks

Regulation 9 (3) (c)

Regulated activity

Regulation

Regulation

Regulation

This section is primarily information for the provider

Requirement noticesRequirementnotices


Diagnostic and screening procedures Regulation 17 HSCA (RA) Regulations 2014 Goodgovernance

Paper based patient records were not disposed ofsecurely.

Regulation 17 (2 ) (c)

This section is primarily information for the provider

Requirement noticesRequirementnotices


Documents

InHealth Endoscopy Unit - Cirencester Hospital … · 2020-02-04 · Ourjudgementsabouteachofthemainservices Service Rating Summaryofeachmainservice Endoscopy Good ––– Theserviceprovidesdiagnosticendoscopyforadults