holy cross hospital newapproachcomprehensive report ... · pdf...

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? Good –––

Overall summary

Holy Cross Hospital is operated by The Congregation ofthe Daughters of the Cross of Liège. The hospital has 40inpatient beds. Facilities include: 40 single bedroomswith ensuite and overhead hoists, an inpatientphysiotherapy gym and a separate Physiotherapy Centrefor outpatients, a hydrotherapy pool with hoist to assisttransfers, a sensory room, an activity room with a therapykitchen, a sensory garden, and a woodland trail. At thetime of inspection, the hospital was in the process ofbuilding an Education Centre.

The hospital provides support for patients with long-termconditions within the specialisms of: disorders ofconsciousness; postural and physical management;complex respiratory management; swallowing disordersand nutrition as well as providing assistive technology.

Physiotherapy services are provided to outpatients at theintegrated physiotherapy centre, as well as the gym andhydrotherapy pool.

HolyHoly CrCrossoss HospitHospitalalQuality Report

HaslemereSurreyGU27 1NQTel: 01428 643311www.holycross.org.ukebsite: www.holycross.org.uk

Date of inspection visit: 28 and 29 March 2017Date of publication: 26/06/2017

1 Holy Cross Hospital Quality Report 26/06/2017

We inspected this service using our comprehensiveinspection methodology. We carried out an announcedinspection on 28 and 29 March 2017.

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.

We rated this hospital as outstanding overall. We ratedsafe, effective and well led as good and responsivenessand caring as outstanding.

We found areas of outstanding practice:

• Patients were truly respected and valued asindividuals an there was an emphasis on providing acare setting that patients could consider theirhome.There was an embedded culture of caringamongst all staff and we saw many examples of staffgoing the ‘extra mile’ to meet the needs of patients inways that took account of their personal preferences.This included personal, cultural, social and religiousneeds.

• The hospital was at the forefront of care for peoplewith long-term conditions. There was holisticapproach to assessing, planning and delivering careand treatment to people who use services. The safeuse of innovative and pioneering approaches to careand how it is delivered were actively encouraged.New evidence-based techniques and technologieswere used to support the delivery of high qualitycare. Staff from the hospital had been invited toco-write Royal College of Physicians (RCP) guidelinesregarding pain as well as to set up a patient group aspart of a centre of excellence.

• When patients needed acute hospital care, therewere arrangements for staff from Holy Cross Hospitalto support patients in this environment, and also tosupport other professional staff in meeting thecomplex, individual needs of patients. Patients werewelcomed when they returned.

• Services were tailored to meet the needs ofindividual patients whose needs and preferences arecentral to the planning and delivery of tailoredservices. The services were flexible, provided choiceand ensured continuity of care. There wereopportunities for patients and those close to them toexperience a range of environments. There was awoodland trail outside the hospital that waswheelchair friendly and provided views over thecountryside, a sensory garden included a fishpondwith waterfall, plants of varying colour and scent anda terrace. Patients also had access to a holidaycottage in Selsey.

• The hospital had established “Special InterestGroups” covering a range of clinical areas such asinfection prevention and control to ensure bestpractice and guidance was reviewed, considered,disseminated and managed throughout the hospital.

We found other areas of good practice.

• People were protected from avoidable harm andabuse.

• There were systems to report and investigateincidents, to control the spread of infection, tomanage medicines in line with legislation andcurrent guidelines and to report and investigatesuspected abuse.

• There were sufficient numbers of staff with thenecessary qualifications, skills and experience tomeet patient’ complex needs.

• The leadership, governance and culture promotedthe delivery of high quality person-centred care.

However, we also found the following issues that theservice provider needs to improve. The hospital should:

• Expand information on duty of candour in theincident policy to indicate the practical applicationof candour as a point of reference for all staff.

• Have an auditable target in place for mandatorytraining completion.

• Follow through the chain of disposal external to thehospital for assurance at least annually.

Summary of findings


• Document a rolling schedule of plannedpreventative maintenance for equipment used toenable easy reference.

• Conduct additional resuscitation scenario training.

• Establish key performance indicators within thepathology service level agreement setting outreporting.

• Review its arrangements for advanced care planning.

• Review the use of syringe drivers to support patientson an end of life pathway and to provide medicationwhere appropriate.

• Ensure all staff have an annual appraisal.

• Ensure all staff know how to access professionaltranslation services.

• Devise a risk register that is prioritised and gives themanagement team assurance of safety across theorganisation.

Professor Ted baker

Deputy Chief Inspector of Hospitals

Summary of findings


Our judgements about each of the main services

Service Rating Summary of each main service

Long termconditions

Outstanding –

Patients were protected from avoidable harm andabuse as there were systems to report and investigatesafety incidents and learn from them. The hospital wasvisibly clean and well maintained and the risk ofinfection was controlled. Medicines were managed inline with current best practice and legislation. Therewere sufficient numbers of staff with the right skills tomeet the needs of patients. The multi-disciplinaryteam worked effectively together. Care was deliveredin line with national and international guidelines andpractice was actively monitored and reviewed. Therewere arrangements to ensure patients’ nutritionalneeds were met and any pain they experienced wasmanaged. Where patients lacked capacity to consent,staff acted in accordance with the Mental Capacity Act2005. We saw outstanding examples of care beingorganised and delivered with compassion. There was afocus on protecting rights and dignity of patients andthose close to them and they were fully involved indecisions about care. Patients’ individual needs andpreferences were central to the planning and deliveryof tailored services. Services were provided to supportthe holistic needs of patients. There were processes toreceive, review and learn from feedback includingcomplaints. The hospital had a clear set of values wellunderstood and demonstrated by staff, who showedhigh levels of satisfaction with their work.

Summary of findings


Contents

PageSummary of this inspectionBackground to Holy Cross Hospital 7

Our inspection team 7

Why we carried out this inspection 7

How we carried out this inspection 7

Information about Holy Cross Hospital 8

The five questions we ask about services and what we found 9

Detailed findings from this inspectionOverview of ratings 12

Outstanding practice 36

Areas for improvement 36

Summary of findings


Holy Cross Hospital

Services we looked at:Long term conditions

HolyCrossHospital

Outstanding –


Background to Holy Cross Hospital

Holy Cross Hospital is one of the works of the charity, TheCongregation of the Daughters of the Cross of Liege.

In 1917, the Congregation relocated a sanatorium fromRamsgate, Kent to Haslemere, Surrey. From the 1950’sonward, the sanatorium was adapted to undertake arange of medical and surgical work, mostly throughcontractual arrangements with NHS bodies. By the 1980’sthe hospital focussed on the treatment and care ofseverely physically disabled adults. In 1992 a new hospitalwas built by the Congregation to provide specificallydesigned facilities to manage patients with complexneurological disorders.

The hospital has admitted patients requiring specialisedrespiratory support for tracheostomy and ventilatormanagement since the 1980’s and in 2009 they added a

new building, the Physiotherapy Centre, to providehydrotherapy for in and outpatients. At the time ofinspection, the charity was funding a new EducationCentre to support staff learning and development.

On the ground floor of the hospital there is a ward with 20beds, all in single rooms with ensuite toilet facilities, thereis also the reception, chapel, quiet room and offices andthe hydrotherapy suite. On the first floor, there is anotherward of 20 beds in single rooms with ensuite toilets, aswell as an inpatient physiotherapy gym, living room,sensory technology room and an outpatientphysiotherapy gym and consulting room.

The hospital is registered to provide the followingregulated activities:

• Diagnostic and screening procedures

• Treatment of disease, disorder or injury

Our inspection team

The team that inspected the service was comprised of aCQC Inspection Manager, Shaun Marten, two CQC

inspectors and four specialist advisors with expertise inadult safeguarding, rehabilitation, hospital managementand cardiac rehabilitation.The inspection team wasoverseen by Alan Thorne, Head of Hospital Inspection.

Why we carried out this inspection

We carried out this inspection as part of our plannedprogramme of comprehensive inspections.

How we carried out this inspection

During the inspection, we visited all areas of the hospitaland observed the environment and care delivery. Wespoke with 30 staff including; registered nurses, healthcare assistants, activity coordinators, volunteers, medicalstaff, therapists and senior managers. We spoke with sixpatients and four relatives. We also received 17 ‘tell us

about your care’ comment cards which patients hadcompleted prior to our inspection. During our inspection,we reviewed 19 sets of patient records and looked at awide range of documents relevant to the running of theservice, including staff employment files, policies,meeting minutes and audit results.

Summaryofthisinspection

Summary of this inspection


Information about Holy Cross Hospital

Holy Cross Hospital is operated by The Congregation ofthe Daughters of the Cross of Liège and is a privatehospital in Haslemere, Surrey. The hospital primarilyserves the communities in the South East of England. Italso accepts patient referrals from outside this area. It is avery specialist service providing long-term support andrehabilitation services to people with extremely complexneeds, including those with total dependence onmechanical ventilation.

There were no special reviews or investigations of thehospital ongoing by the CQC at any time during the 12months before this inspection.

The most recent inspection of the hospital took place inFebruary 2014, which found the hospital was meeting allstandards of quality and safety it was inspected against.

The inspection in March 2017 was the first inspectionunder CQC’s new methodology.

Activity

The hospital provided care to 40 patients at the time ofinspection of whom eight were aged over 65. No childrenor young people were treated. The unit received 13referrals for admission between October 2015 andSeptember 2016. All patients were NHS funded throughthe Continuing Health Care scheme. NHS continuinghealthcare is a free package of care for people who havesignificant ongoing healthcare needs arranged andfunded by the NHS.

Most patients using the outpatient physiotherapy servicewere self-funding, and the service was restricted toadults.

Staffing

At the time of inspection the therapy team consisted of;5.5 whole time equivalent (WTE) physiotherapists, 1.4WTE occupational therapists (OT) and 0.2 WTE speechand language therapists (SALT).

There were 78 WTE nursing staff which comprisedregistered nurses (27.6) and health care assistants.Patients were under the care of a consultant inrehabilitation medicine, who was employed via a servicelevel agreement (SLA). A local GP practice providedday-to-day medical care at all times via another SLA.Specialist therapists, such as a neuropsychologist, werealso employed under similar agreements.

Track record on safety (October 2015 and September2016);

• No reported never events

• No reported serious incidents

• There were no incidences of hospital acquiredMeticillin-resistant Staphylococcus aureus (MRSA),hospital acquired Meticillin-sensitive staphylococcusaureus (MSSA), hospital acquired Clostridium difficile(C.diff), or hospital acquired E-Coli

• No hospital acquired venous thrombo-embolism(VTE) were reported

• Four expected, and no unexpected deaths reported

• There were six complaints made to the hospital.




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:

• There were clearly defined systems to report, investigate andlearn from incidents and when things went wrong.

• There were sufficient numbers of staff with the necessary skills,experience and qualifications to meet patients’ needs. Theywere supported by a programme of mandatory training in keysafety areas.

• There were systems and processes for recognising andreporting potential abuse, for preventing and controllinginfection and for managing medicines. These were wellunderstood and implemented by staff.

• Risks to patients were well understood, and there werearrangements to assess and mitigate clinical risks for individualpatients.

• Patient records reflected a multi-disciplinary approach to carewith individual outcome goals that were regularly reviewed.

However

• There was limited information about duty of candour in theincident policy.

• There were no targets set for mandatory training completion.• An audit of waste disposal external to the hospital was not

completed.• Resuscitation scenarios were not carried out separate to

training scenarios.• The pathology agreement did not include timeframes for when

results will be returned to the hospital.

Good –––

Are services effective?We rated effective as good because:

• The continuing development of staff skills, and competenceand knowledge was recognised as being integral to ensuringhigh quality care. Staff were supported to acquire new skills andshare best practice. This was shown in the development anduse of Special Interest Groups (SIG).

• Teams were committed to working collaboratively bothinternally and externally.

• Consent practices and records were actively monitored andreviewed to improve how people are involved in makingdecisions about their care and treatment.

Good –––




• There were arrangements to ensure patients’ pain wasmanaged and controlled, and that their nutritional needs weremet.

However:

• Appraisal rates were low and there was no target for staffcompletion.

Are services caring?We rated caring as outstanding because:

• Feedback from patients, those who are close to them andstakeholders was continually and overwhelmingly positiveabout the way staff treated people.

• There was a strong, person-centered culture amongst staff. Staffwere highly motivated and inspired to offer care that was kindand promoted dignity. Relationships between people who usedthe service, those close to them and staff were strong, caringand supportive. These relationships were highly valued by staffand promoted by leaders. Staff recognised and respectedpatients’ needs and took personal, cultural, social and religiousneeds into account.

• Patients were active partners in their care. Staff empoweredpatients to have a voice and to realise their potential. Patientpreferences and needs were reflected in how care wasdelivered. For example; the use of patient history andphotographs when planning patient shopping trips and patientinvolvement in goal setting meetings.

• Patients’ emotional and social needs were highly valued bystaff and were embedded in their care and treatment.

Outstanding –

Are services responsive?We rated responsive as outstanding because:

• Patients’ individual needs and preferences were central to theplanning and delivery of tailored services. Services wereprovided to support the holistic needs of patients. For example;the sensory room, activity room and the availability andfrequency of visits to the holiday cottage in Selsey.

• The involvement of other organisations and the localcommunity was integral to how services were planned andensured that services met patient’s needs. For example; thePhysiotherapy Centre outpatient unit provided a service to thelocal community.

• There were innovative approaches to providing integratedperson-centered pathways of care that involved other serviceproviders.

Outstanding –




• There was a clear process to review complaints and how theywere managed and responded to, and improvements weremade as a result. The hospital received very few complaintsand worked with patients and their families to resolve issuesbefore they developed.

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

• There was clear understanding of values and they were wellembedded and demonstrated in staff’s daily work with bothpatients and their families. There was a common focus acrossall staff groups on providing high quality care.

• There was a robust governance framework and annual planthat detailed clear reporting lines and areas of responsibilitywith structured meetings. All members of the multi-disciplinaryteam (MDT) were seen to be actively engaged in the governanceof the organisation.

• There were high levels of satisfaction across all staff groups.Staff were proud of the hospital, of the service provided, andspoke of a supportive and visible management team. There wasa high level of staff engagement and staff were involved inplanning major and minor developments in the service.

• There were systems for gathering feedback from patients andtheir families, gathering their views on delivery of care and allfuture developments.

However

• Departmental risk assessments need to be organised into a riskregister that is prioritised and gives the management teamassurance of safety across the organisation.

Good –––




Overview of ratings

Our ratings for this location are:

Safe Effective Caring Responsive Well-led Overall

Long term conditions Good Good Good

Overall Good Good Good

Notes

Detailed findings from this inspection


Safe Good –––

Effective Good –––

Caring Outstanding –

Responsive Outstanding –

Well-led Good –––

Are long term conditions safe?

Good –––

We rated safe as good.

Incidents and safety monitoring

• The hospital did not report any never events in theperiod October 2015 to September 2016. Never eventsare serious patient safety incidents that should nothappen if healthcare providers follow nationalguidance on how to prevent them. Each never eventtype has the potential to cause serious patient harmor death but neither need have happened for anincident to be a never event.

• There were four expected deaths during the reportingperiod (October 2015 to September 2016) and noserious injuries. There were 87 incidents in the reportingperiod comprising 13 clinical incidents, 35 health andsafety, 24 equipment, seven information governance,four security and four ‘other’ incidents. The report wesaw categorised whether the incidents were ofmoderate or low harm. This suggested a good reportingculture at the hospital.

• The hospital monitored safety incidents such aspressure ulcers, falls, urinary tract infections (UTI) andhospital acquired venous thromboembolism (VTE)and had registered to submit data to the NHS safetythermometer - a point of care survey conducted oneday a month. There were no falls or VTE’s, onepressure ulcer, and 19 UTI’s reported during October2015 to September 2016.

• The hospital does not hold mortality or morbidityreview meetings. Clinical Incidents were discussed atClinical Governance and Health and Safety meetings.A summary review of the four deaths was reviewedduring the inspection and showed us that thesedeaths were expected.

• The hospital policy stated that incidents should bereported through the hospital reporting system whichwas paper based. The director of nursing (DON) thenentered this data onto an electronic system whichshowed actions taken and severity including whetherany injury was sustained. All the staff we spoke with toldus they were encouraged to report incidents.

• Staff described the process for reporting incidents andtold us they received feedback, which was shared atreport handover and by email. We also saw incidentswere included on weekly briefing sheets, and these alsoshowed learning. Staff in all departments told usfollowing any incidents and investigations, theoutcomes would be discussed at their meetings andminutes were shared with all staff. However, there wasno assurance that all staff read the minutes of meetings.

• We saw root cause analysis (RCA) investigations werecompleted as part of the investigation of incidents. Wesaw reviewed three and saw they were completedappropriately on a standardised template. A completedpatient related incidents action plan showed whenincidents were discussed at the multidisciplinary team(MDT) meeting and whether the patient was informed ofthe outcome.

• Reviewing incidents was seen to be a standard agendaitem at the quarterly clinical governance committeemeeting. We were told and saw evidence of discussion

Longtermconditions

Long term conditions

Outstanding –


of incidents and planned actions. We saw a clinicalgovernance report, including incidents and learning wascirculated to the medical advisory committee (MAC) andwas noted within their minutes.

Duty of Candour

• The duty of candour is a regulatory duty that relates toopenness and transparency and requires providers ofhealth and social care services to notify patients (orother relevant persons) of certain ‘notifiable safetyincidents’ and provide reasonable support to thatperson’.”

• The hospital had an incident policy that referenced dutyof candour but did not detail how the decision to applyduty of candour should be made. This meant not allstaff had a point of reference regarding the practicalapplication of the duty of candour.

• We asked staff about their understanding of duty ofcandour and they were able to give examples of howthis could be applied. They spoke about being openand honest with patients and families.

• There was mandatory duty of candour training for allstaff that 79% had completed.

Mandatory Training

• We were told that training at the hospital was broadlyclassified into induction, mandatory andrecommended training. Mandatory training wasmonitored and all staff were expected to complete iton an annual basis.

• We were shown the training plan for all staff whichshowed the mandatory training that should becompleted by staff depending on their role. Trainingfor clinical staff was seen to include basic life support,a respiratory workshop, mentorship, mental capacityact (MCA) and deprivation of liberty safeguards (DOLS),information management, conflict management,complaints, and compliments. There was alsostatutory training in fire and health and safety.

• The most recent training report showed percentagecompletion rates varied from 58% to 100%, but thetarget for compliance with mandatory training wasunclear. A target for completion would help themanagement team manage performance in this areaeffectively.

• Much of the training was delivered face to face but thehospital had recently implemented an E-learningpackage for staff training and four topics were beingoffered to staff with a plan to increase this taking intoaccount feedback from staff.

• A learning development administrator had beenappointed recently and part of their role was tomaintain the database of completed training and toencourage staff to complete their mandatory training.

• Staff told us that that they had good access tomandatory training and had protected time in order tocomplete it.

Safeguarding

• The hospital had an adult safeguarding policy. Hardcopies of the policies and all information sheets werefound on the ward area which meant staff had accessto this information at all times. The policy includeddetails of what action should be taken whensuspecting a safeguarding concern. There werecontact details of relevant authorities to contact andclear guidance on who to contact outside of officehours.

• A safeguarding flowchart gave clear guidance onaction to be taken in the event of actual or suspectedabuse. In addition, there was a protection of childrenpolicy that contained relevant detailed information ofwhat action to take and how to report any concerns; itwas noted that the hospital is currently not admittingchildren or young persons as patients.

• There were three designated safeguarding officeradults trained to level three in line with best practice

• The hospital training report showed that 100% of allstaff had undergone basic safeguarding training and97% clinical staff had undergone enhancedsafeguarding training.

• Staff who participated in the focus group and wardstaff demonstrated good knowledge andunderstanding of safeguarding vulnerable adults. Theywere aware of the process for reporting any concernsand could locate the policy easily for further guidance.

Longtermconditions


Outstanding –


• The hospital showed us that they have a system inplace to monitor disclosure and barring service (DBS)checks that are made for all staff being employed.These were seen to be up to date at the time ofinspection.

• We did not see records for PREVENT training or anyawareness of understanding and reporting femalegenital mutilation (FGM). This should be considered aspart of the safeguarding policy in accordance withnational guidance.

• The hospital showed us that they were completing asafeguarding audit using the tool from the SurreySafeguarding Board and this demonstrated a robustprocess for monitoring safeguarding concerns.

Infection control and hygiene

• We saw an infection prevention and control (IPC)policy was that was readily available to staff. Infectionprevention and control training was mandatory andincluded in the induction programme and 82% of staffwere up to date with this training. We were told thetarget is for all staff to have completed this training.

• Before inspection, we requested data about hospitalacquired infection that had occurred between October2015 and September 2016. We were told there was noscreening data for Clostridium difficile (C.diff),Meticillin –susceptible staphylococcus aureus (MSSA)and Meticillin resistant staphylococcus aureus (MRSA).However, on the day of inspection there was a patientwith suspected C.diff who was being nursed withappropriate infection control measures.

• The hospital monitored infection rates and hadcomparison data for five years. We saw that for theperiod January 2016 to December 2016 there were 64reported infections, which included 29 chestinfections, 13 urinary tract infections and 22 other.This number of infections is within expected rangegiven the complexity and physical vulnerability of thepatients. Data showed that in ten months of the year2016 there were fewer infections than the precedingyear.

• The hospital has an anti-microbial policy that statesthe rationale for prescribing, in addition we saw thatreference was made to the ‘Guidance for themanagement of infection’, which was a formulary forprescribing which was available on the ward areas

• If advice was required from a microbiologist, there wasa service level agreement. We reviewed this and saw itwas with a local NHS trust hospital and contact couldbe made at any time.

• The director of nursing was the lead for IPC and wesaw a completed plan for the two monthly meetingswhich covered incident reporting, surveillance, audit,training and the development of protocols.

• We were shown information about the IPC specialinterest group that comprised of clinical teammembers with a special interest in this area ofpractice. We saw evidence of a report the groupsubmitted to the clinical governance committee.

• There was an annual plan for IPC and this reviewedthe previous year’s infection rate, compared rate andsite of infection for the past five years and reflectedobjectives achieved. This document is completed bythe director of nursing and submitted to the seniormanagement team and medical advisory committee(MAC).

• The hospital completed a patient -led assessment of thecare environment (PLACE), this is a system for assessingthe quality of the patient environment. Patientrepresentatives go into hospitals to assess how theenvironment supports patients’ privacy and dignity,food, cleanliness and general building maintenance. Inthe PLACE audit, 2016 The Holy Cross Hospital scored99.75% for cleanliness and 97% in relation to thegeneral building maintenance of the hospital, which wasmuch better than the national average of 93%. We saw areport on PLACE findings and actions to be taken waspresented to the management team.

• Areas we visited around the hospital were tidy andvisibly clean. We saw weekly departmental cleaningchecklists were completed in all areas.

• Domestic waste bins were available and contained noinappropriate items. When asked, staff were able to

Longtermconditions


Outstanding –


describe appropriate segregation of waste. This was inline with the Department of Health (DH) TechnicalMemorandum (HTM) 07-01, control of substancehazardous to Health and Safety at Work regulations.

• In patients’ rooms we saw that there were individuallaundry bins with appropriate separation of items.Double bagging was observed for contaminatedlaundry. Each patient had an individual slide sheetthat was used for manual handling manoeuvres. Weobserved that patient slings were initialled withpatient details.

• Patient rooms were dust free and all fabrics in the roomwere wipeable in line with hospital building note (HBN)00/09. The flooring was laminate with coved edges inline with HBN 00/10 part A (flooring).

• There were good processes in place for sharpsmanagement which complied with Health and Safety(Sharp Instruments in Healthcare) regulations 2013.Sharps bins were clearly labelled with the temporaryclosure in place and tagged to ensure appropriatedisposal.

• We were shown that the hospital had a contract with acertified company for waste management. Howeverthere was no follow through process. It is arequirement for the customer to follow through thechain of disposal for assurance at least annually.

• HTM 00-09 building note 3.42 states, “the locationshould provide clinical hand-wash basins and ensurethat they were all readily available and convenient foruse”’. We saw that there were hand basins availablewithin the ward corridor and in the therapy rooms.

• We saw hand-sanitising gel was available at point ofcare in and outside patient rooms. This was in line withepic3: ‘National Evidence-Based Guidelines forPreventing Healthcare-Associated Infections in NHSHospitals in England’ (epic3) and HTM 00-09. We sawstaff using hand sanitizer when entering and exitingclinical areas.

• We reviewed a hand hygiene audit that was completedusing direct observation and questioning of the staff.There was overall compliance of 96%. Areas ofnoncompliance were stated and recommendationsmade to address issues had been completed.

• On the ward we observed all nursing staff to be barebelow the elbow in line with best practice. Personalprotective equipment (PPE) such as disposable gloves,aprons and protective eyewear were readily available inall areas. We observed staff using PPE appropriately.One relative commented that staff always washed theirhands and used aprons when delivering care.

• We were shown an audit of clinical PPE. The audit wasundertaken to assess practice in 19 areas related tothe appropriate use of PPE in line with hospital policy.The methods included direct observation andquestioning staff. The compliance rate of 98% notedthat some staff were reluctant to use eye protectionwhen there was a risk of splashing. Recommendationsto improve practice were included in the audit.

• HTM 00-09 section 3.133 for furnishings states: “softfurnishings (for example seating) used within allpatient areas should be chosen for ease of cleaningand compatibility with detergents and disinfectants.They should be covered in a material that isimpermeable, preferably seam free or heat sealed”. Wenoted that all furnishings and chairs within the areaused for activities was compliant with thisrequirement.

• The patients are supported with specialist wheelchairsand we saw that these are subject to a daily cleaningregime and were wipeable and compatible with HTM00/09.

• All curtains within the patient area were labelled andchanged every six months.

• There was evidence of an up to date standard ofoperational practice for cleaning with a plannedschedule in place. Cleaning staff were allocated tenrooms each and were encouraged to have ownershipof these areas.

• There were systems to ensure the safety of the watersupply. We saw that legionella risk assessments werecompleted annually and this was last done in March2016. All taps are checked twice a year in line withguidance and we saw that six monthly water testingwas done to check for pseudomonas.

• The hydrotherapy department was seen to be purposebuilt and was visibly clean and tidy. We were told thatthe maintenance team manage the pool and wereshown daily water checks of pH, chlorine, water and

Longtermconditions


Outstanding –


air temperature. The results showed these to be withinexpected ranges. An up to date hydrotherapy manualcontained a current operating procedure for poolmaintenance. This meant that staff were aware ofprocesses and procedures in the management of thepool.

Environment and equipment

• We observed that the environment was generally in agood and tidy condition and corridors were kept freeof clutter. The hospital is currently undergoing internaland external building works and we observed yellowwarning notices were clearly displayed where workwas being undertaken.

• The hospital showed us the process they had in placefor regular equipment service checks from mainlyexternal sources. The list was in the process of beingcompleted with agreements in place for allequipment. The manager in charge was able to tell usthe process and company responsible but was yet tocomplete a database containing a rolling schedule sothere was assurance that planned preventativemaintenance would routinely take place. After ourinspection the provider advised us that they hadexpanded the database to capture the due date ofnext service.

• We saw that all equipment within the two gym areasand the hydrotherapy area had been serviced andtested, indicated by a label with the date tested. Thisprovided a visual check that that they had beenexamined and were safe to use.

• The hospital has a medical devices committee whichthe director of nursing led and which was responsiblefor the safe management of equipment at thehospital. We were told that training of staff in the useof patient equipment is also managed by this group.

• The hospital had two tamper-proof resuscitationtrolleys, one located on the first floor close to the wardarea and a second trolley located in the hydrotherapypool area. Both had weekly checks that werecomplete. When asked staff knew the location of thetrolleys and had access to the equipment.

• The hospital was undergoing a process of havingpiped oxygen installed for patient rooms. At the time

of inspection there were cylinders of oxygen keptwithin the patient rooms and in the corridors for easyaccess. We checked eight cylinders and they were allin date and safely stored.

• A number of patients were supported by the use of aventilator, the records for ventilator checks were keptin a file on the ward. They were recorded as per roomnumber, dated, timed and signed for. All equipment inthe patient’s room had dates showing when they werelast serviced. We saw records that showed patientswere checked every 15 minutes as well as the formalchecks of the ventilator settings twice per day. Anotherspecialised NHS unit working within a serviceagreement visited the hospital every three months tocomplete a service of the ventilators and we sawrecords of this.

• For ventilators we saw blue stickers with serialnumbers were put in the patient’s notes which wereinitialled and dated. Oxygen cylinders were checkedonce per day with the amount of oxygen left beingrecorded, signed and dated. In the clean room therewere spare ventilators all marked as clean.

• We saw records that showed there was a monthly siteinspection, including a check on lift function and panicalarms.

Medicines

• The hospital had a policy for the administration ofmedicines. The purpose of the policy was to makesuitable arrangements for the recording, safekeeping,handling and disposal of drugs. We were told that noprivate prescriptions were kept on site.

• The hospital did not have an onsite pharmacydepartment. We saw there was a contract for pharmacyservices with a third party for sourcing, delivery andmanagement of medicines. This meant that there wereadequate stocks of medicines to meet patients’ needs.The pharmacy service also provided an out of hour’sservice to ensure medicines were always available ifneeded urgently.

• We were shown how medicines are ordered by thenurses electronically, the pharmacist visited onceevery two weeks. We noted patient medication chartswere reviewed and stock checks were completed

Longtermconditions


Outstanding –


• Disposal of medicines were managed by the supplyingpharmacy. We saw an audit trail of containers beingchecked, secured and collected with the processbeing checked and signed by two nurses.

• Storage of medicines was appropriate. On the wards,all medicines were stored securely in the treatmentroom. All cupboards containing medicines werelocked and the keys were seen to be kept by the nursein charge. On checking the medicines cupboards allmedicines were in date with evidence of good stockrotation.

• All medicines including patients’ own medicines werekept in the treatment room enabling the visitingpharmacist to check any medicines to be dispensed.

• Robust procedures were in place for monitoring andrecording of ambient room temperatures where themedicines are stored and showed that storagetemperatures were appropriate.

• We saw that medicines were stored in dedicatedmedication fridges where applicable. Fridgetemperature monitoring was done daily and whenasked, staff knew what to do if the temperatures werefound to be outside the recommended range. Wechecked a fridge and all medicines were in date andappropriately stored.

• We looked at controlled drugs (CDs) which aremedicines liable to be misused and requiring specialmanagement in wards. We found that the medicineswere kept securely with controlled drugs (CDs) storedin suitable cupboards with records maintained. TheCD cupboards were locked with restricted access. Wechecked order records, CD registers and found theseto be in order. We saw that CDs were audited threetimes per month with no discrepancies noted.

• The director of nursing is the Controlled DrugsAccountable Officer (CDAO) for the location and is notinvolved in the administration of medicines. Theyattended the local intelligence network (LIN)pharmacy governance meeting; minutes of onemeeting were seen to include reporting a relevant CDincident at the hospital.

• The hospital showed us a standard operatingprocedure for the management of controlled drugsdated February 2017. It was signed by the author anda signature list of those required to work within theprotocol showing they had read the document.

• We reviewed five medication charts. We found them tobe legible and completed appropriately. Patientallergies were clearly noted on the chart. Reasonswere stated for any medicines not administered andany errors were crossed through and signed. We sawthat within the drug chart file there was informationabout the drug, mode of action and side effects as aprompt for nursing staff. The charts demonstrated thatprescribing was in line with national guidance.

• Guidelines had been developed setting out howmedicines can be administered through feeding linesstating the first line of choice and second, theseguidelines were readily available to the nursing staff.

• Where appropriate, the patient was included in theadministration of medicines and we observed apatient double-checking their medication with thenurse.

• When completing the administration of medicines thenurse wore a red tabard indicating that she should notbe disturbed. We observed that during medicineadministration patients were appropriately identified.We saw that no medicines were left at the bedsidewhich complied with ‘Standards for medicinesmanagement’ issued by the Nursing and Midwiferycouncil (NMC).

• Any medication errors were put onto the liveelectronic pharmacy system by the pharmacist andwe observed that senior nurses on the ward recordeda response directly onto this system showing whatactions were taken and lessons learnt. We saw that thehospital had a policy outlining action to be taken inthe event of any medication errors with the first actionbeing the nurse writing a reflective review of theincident. There was a clear escalation of actions to betaken if the error was repeated or of a more seriousnature.

• We saw that the live electronic pharmacy system wasa valuable resource of information includingmedication alerts and up to date information; for

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example the ‘Guidelines for the Administration ofMedication to Patients with Enteral Feeding Tubes orSwallowing Difficulties’, that set out how to managepercutaneous endoscopic gastrostomy(PEG) feeding.

• We were told that all nursing staff must complete themedicine management e-learning programme andsaw that 88% of staff had completed with only threestaff members yet to undertake it.

• We noted that the hospital planned to introduce amedicine management special interest group whichwill report through to the clinical governancecommittee.

Records

• We saw that patient’s records were multidisciplinaryas doctors, nurses and therapists contributed to asingle document. We saw that daily entries were madefrom the MDT. This ensured that relevant informationwas not omitted and that the entry was easy to followand understand.

• We looked at 10 sets of patient records across the twoward areas and we saw notes were well completedand easy to navigate. The notes were comprehensive,contemporaneous and reflected the care andtreatment patients received. They were generallycompliant with guidance issued by the GeneralMedical Council (GMC) and the Nursing and MidwiferyCouncil (NMC), the professional regulatory bodies fordoctors and nurses. Patient records were readilyaccessible to those who needed them.

• The British Society of Rehabilitation Medicine (BSRM)recommends standards of best practice for care forpatients with a complex neurological disability. Eachpatient should have a timed set of outcome goals thatinvolve their family and is coordinated by the MDT. Thegoals should be reviewed at a frequency appropriateto the patient’s management and be combined withappropriate outcome measures. We saw evidence inthe notes of short and long-term goal setting from theMDT ward round and following the six to eight weeklyMDT meeting when staff discussed the treatmentgoals with patient and relatives.

• Patient records contained information about thecorrect patient hoist to be used and there were photos

within the records that showed correct patientpositioning in the bed and wheelchair. This enabledthe staff to be safe in their moving and handling andpositioning of the patient.

• The hospital had an up to date health record andinformation governance policy. We saw that 91% of allstaff had completed information governance training.

• We saw that a care plan audit was completed annuallywith a clear rationale and the results showed that 94%of notes were compliant with standards set. Two mainareas of noncompliance were identified and an actionplan was put in place.

• Patient records were seen to be stored securely atward level and MDT notes were stored in a securedcupboard in an office secured with a keypad. Archivednotes are kept on site in a secured cupboard withlimited access.

• The hospital told us they are looking at identifying acustomised electronic patient record system they feltwould improve accuracy, sharing and accessibility.

Responding to patient risk

• We saw that patients were risk-assessed usingnationally validated tools. For example, the risk ofmalnutrition was assessed using the MalnutritionUniversal Screening Tools (MUST) tool and the risk ofpressure damage was assessed using the Waterlowscoring tool. We saw that patient risk assessmentswere completed dated and signed.

• We saw in patients records that the risk of patientsdeveloping venous thromboembolism (VTE) wasassessed on admission and reviewed by the MDT onthe ward round, and assessment and treatment wasdocumented.

• Staff we spoke to were aware of the national earlywarning scoring (NEWS) based on a simple scoringsystem in which a score is allocated to physiologicalmeasurements (for example blood pressure andpulse). This scoring system enabled staff to identifypatients who were becoming increasingly unwell. Wesaw information in the ward area informing staff aboutNEWS scoring and all patient records using NEWS wereseen to be completed appropriately

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• The hospital told us that between October 2015 andSeptember 2016 a total number of three patients weretransferred to another health care provider. Patientsrequiring intra venous antibiotics are admitted directlyinto the local trust intensive therapy unit (ITU) and hadhappened twice in the past year. Once treatment wascomplete patients returned to the hospital.

• We were told that all staff were trained in basic lifesupport and the use of an automated externaldefibrillator (AED) and senior clinical staff hadenhanced life support training, which includedscenario training. There are three advanced lifesupport trained staff. However there are no scenariosconducted at other times to test staff on theirresponses to an emergency and this should beundertaken.

• Pathology services were provided to the hospital bythe local trust. We were told that results could take aslong as a week to be returned and this might present apotential risk for patient safety in the case ofabnormalities needing urgent attention. Thearrangement with the trust should be reviewed withtimeframes put in place for results to be returned tothe hospital.

Nurse staffing

• Nurse staffing levels adhered to the recommendationsas defined by national guidelines including the BritishSociety of Rehabilitation Medicine (BRSM), theNational Service Frameworks for Long termConditions, the Royal College of Physicians Guidelineson Rehabilitation Following Acquired Brain Injury andthe Royal College of Physicians Guidelines onProlonged Disorders of Consciousness. Theseguidelines for establishment and daily staffing areused in conjunction with the safer nursing care tool(SNCT) endorsed by National Institute for Health andCare Excellence (NICE).

• We were told that the nursing staff establishment werereviewed annually and this was corroborated in thedocument submitted by the director of nursing ‘Toolsto calculate safe nursing staffing levels at Holy CrossHospital’, which showed calculation of current staffingestablishment.

• We reviewed the current duty rotas for March 2017,which showed the actual number of staff working,matched the agreed number of staff on the rota.

• We looked back over a four-week period fromFebruary 2017 to March 2017 and saw the weekly fillrates for day shifts ranged from 109% to 90%. For nightshifts for the same period the weekly fill rate was 97%or above. We saw that human resources (HR)department monitored fill rates. This meant overallstaffing levels generally matched agreedestablishment.

• Staff told us that enough staff were on duty unlessthere was sickness and that managers tried to fillthose vacant shifts. The hospital had a number of banknurses employed who filled shifts on a planned or adhoc basis. We were told that most of those nurses onthe bank are previous contracted employees who alsocompleted mandatory training and clinicalcompetencies to ensure they could meet the complexneeds of the patients.

• On occasions agency staff were used. We sawdocuments that showed the human resources (HR)department monitored this usage, ensured staff thatwere used had completed an induction, competencyassessments and had signed an awareness checklist.Regular feedback about their staff was given to theagency.

• We were told that there are currently 5.7 whole timeequivalent (WTE) trained nurse vacancies. To addressrecruitment difficulties there has been recruitment ofnurses from overseas. Two nurses we met told us theywere ‘well supported’ through their induction andhave stayed employed at the hospital beyond a twoyear period.

• Medical staff and patient’s relatives we asked told usthey felt there were enough nursing staff on duty.

• The hospital took student nurses from the localuniversity for their clinical placements, but these staffwere supernumerary to agreed staffing requirements.

Therapist Staffing

• The hospital had a therapy team that includedphysiotherapists. We reviewed the current serviceagreements for the occupational therapists (OT),speech and language therapists (SALT), specialist

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dietitians and clinical neurophysiologists. There wasevidence that these were reviewed bi-annually andthat all checks including proof of identification, DBS,details of professional registration and personalindemnity were complete.

• We were told that the hospital took into account twosets of guidelines to ensure safe staffing. The RoyalCollege of Physicians Rehabilitation followingAcquired Brain Injury, 2003 and the British Society ofRehabilitation medicine ‘SpecialisedNeuro-rehabilitation Service Standards’ 2015. We sawthat the hospital were meeting these standards usingcontracted and bank staff. There was no use of agencystaff and no vacancies.

Medical staffing

• Patients care was overseen by a consultant inRehabilitation Medicine employed through a serviceagreement, which we saw. He made weekly visits andwas available at any time for phone advice. Staffconfirmed that the consultant always responded torequests for assistance. In his absence one of theGeneral Practitioners (GPs) would cover and this wasconfirmed by the GP and the nursing staff.

• There was a service level agreement, which we saw,with a local GP practice, which provided weekday dailydoctor visits and a twenty-four hour on call serviceprovided by a pool of seven doctors who are allfamiliar with the hospital’s patients. The doctorsattend in the capacity of visiting physicians and arenot necessarily the patients’ registered GPs. Thepractice has been providing this service for 23 years.

• Ward rounds were done every weekday and we sawthere was an escalation plan for emergencies. We sawthe visiting physicians visiting patients on both days ofour inspection.

• There was an informal arrangement with the localtrust hospital for patients to be admitted directly tothe intensive therapy unit if required. Medical staff hadaccess to a specialist tertiary NHS service if supportwas required in managing patients using withventilator.

Anticipation and planning for potential risks

• The hospital provided us with a copy of their riskmanagement policy, this included a section on

responding to emergencies. In the case of emergencythe senior staff on duty were directed to refer to thebusiness continuity and critical incident plan. Thisplan was seen to detail what would be seen as a threatto the business and contained action plans for a rangeof scenarios. We saw records that showed desktopexercises with different scenarios were carried out bythe senior team every three months.

• The hospital had its own generator in the case ofelectrical shutdown and we saw that weekly checkswere made of fuel and oil to ensure it was ready forimmediate use.

• The hospital also provided us with a separate firepolicy. We saw records of weekly fire alarms and firedrills. We were told that the hospital did a drill usingsilent alarms with the night staff. The latest fire riskassessment was completed within the last six monthsand the next fire department visit was scheduledwithin the next month. A register of visitors was kept atmain reception and would be used to account foreveryone in the event of a fire. At ward report, we sawa member of staff was allocated as fire warden for thatshift.

• The hospital had put in place individual evacuationplans for immobile patients and we saw twoexamples, these were complete with stated processand equipment needed. When asked, staff knewwhere to find and gave examples of equipmentneeded for specific patients.

• Therapy staff told us they practised a hydrotherapyemergency evacuation procedure three times a yearand we saw records this was done on at least twooccasions with a report produced of who was present,timings and training carried out.

Are long term conditions effective?(for example, treatment is effective)

Good –––

Evidence-based care and treatment

• We found care and treatment was delivered inaccordance with national and international guidanceand best practice.

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• We checked ten hospital policies, and all relevantclinical policies were in date. We noted the hospital’spolicy frameworks were based on, and referencednational guidance and best practice. We sawexamples of guidance from National Institute forHealth and Care Excellence (NICE) beingimplemented.

• The hospital took part in the antimicrobialstewardship as part of the Antimicrobial PrescribingStewardship (APS) competencies developed by theAdvisory Committee on Antimicrobial Resistance andHealthcare Associated Infection (ARHAI) and PublicHealth England (PHE). The antimicrobial stewardshipis a coordinated program that promotes theappropriate use of antimicrobials (includingantibiotics), improves patient outcomes, reducesmicrobial resistance, and decreases the spread ofinfections caused by multidrug-resistant organisms.

• Patients were assessed for venous thromboembolism(VTE) (formation of blood clots in the vein) as part ofthe admissions process. After patients had beenadmitted, regular review of VTE was a part of themultidisciplinary team (MDT) review. This was in linewith NICE guidance CG 92 and CG 144.

• Patients with spasticity (a state of increased tone of amuscle; for example, spasticity of the legs has anincrease in tone of the leg muscles so they feel tightand rigid and the knee jerk reflex is exaggerated) weresupported with their condition using a combination ofspasticity medication, hydrotherapy and Botox, to aidthe relaxation of muscles and reduce pain. This was inline with the 2009 national guidelines ‘Spasticity inadults: management using botulinum toxin’.

• Staff could refer to the hospitals Palliative Care ClinicalGuidelines regarding advice for palliative carepatients. The guidelines included informationregarding symptom management as well as palliativecare recommendations as detailed by NICE. Staff knewwhere to find the guidelines and when to seekassistance from senior staff and outside supportagencies.

• Advanced care planning is recommended as animportant aspect of holistic care planning by the endof life care strategy. However, we found very few

patients had advanced care plans in place. Staffadvised us this went against the ethos ofrehabilitation. However, putting advanced care plansinto place is considered best practice.

Patient outcomes

• We saw goals set for therapy for example when apatient was having hydrotherapy treatment. We sawthere were patient screening and assessment formswhich contained the goals of the therapy.

• We saw an auditing plan that listed upcoming auditsand included details of the responsible person. Topicsincluded; catheter management, tracheostomymanagement, positioning and splinting, use of beds/mattresses/bed rails and care plans, which checkedstaff understanding as well as documentationstandards.

• Audit results showed year on year the number ofreported pressure ulcers was significantly less thanother hospitals of this size. When we spoke to staffthey advised us this was due to the MDT approach topositioning and that patients were checked on every15 minutes. Therefore poor positioning was monitoredand quickly rectified.

• On admission, patient outcomes were measured usinga number of recognised tools. These were thenregularly monitored by the MDT and care plans wereamended accordingly. A few examples of the toolsused at the hospital included; the Wessex Head InjuryMatrix (WHIM), a scale to assess and monitor patientrecovery after severe head injury, the Coma RecoveryScale Revised (CRS-R), is used to assess patients with adisorder of consciousness, commonly coma. It may beused to differentiate between vegetative state (VS) andminimally conscious state (MCS). Modified AshworthScale (MAS), measures resistance during passivesoft-tissue stretching and is used as a simple measureof spasticity, Berg balance scale (BBS), clinical test of aperson's static and balance abilities and FunctionalIndependence Measure/Functional AssessmentMeasure (FIM/ FAM), used for measuring disability. Thenature of patients comorbidities meant a lot ofpatients were at the hospital for the long term,although it is important to regularly review patientabilities, there was not necessarily improvedoutcomes for many years.

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• The hospital had acquired equipment to support thedetection of early secondary conditions. For example,a bladder scanner was used to support detection ofurinary tract infections as well as early signs of urineretention. We were given two examples where thisequipment had supported the care and treatment ofpatients. The hospital also had a blood gas analyser(which measured the acidity and levels of oxygen andcarbon dioxide in the blood. This test is used to checkhow well your lungs are able to move oxygen into theblood and remove carbon dioxide) that was used toprovide quick results regarding blood gases andelectrolytes. We were provided with examples wherethe testing had been used to wean a patient off atracheostomy (an incision in the windpipe made torelieve an obstruction to breathing).

• Guidance from the British Medical Association (BMA),the Resuscitation Council (RC) and the Royal Collegeof Nursing (RCN) ‘Decisions relating tocardiopulmonary resuscitation’ states “Performanceof CPR and the appropriateness and effectiveness ofdecisions about CPR should be the subject ofcontinuous clinical audit.” We reviewed the result ofan audit dated March 2017 which demonstrated theoverall level of compliance with the providers policywas 100%. There were a validDNACPR decisions recorded and these were reviewedevery two years. The last CPR attempt was made in2014 and the audit demonstrated it was appropriate.

• The hospital had a list of patients that were Do NotAttempt Cardiopulmonary Resuscitation (DNACPR).Staff we spoke with did not know where this list waskept, however staff knew which patients were forDNACPR, which we confirmed via care plans and theDNACPR form.

Nutrition and hydration

• The majority of patients were fed using enteralfeeding, (a way of delivering nutrition directly to yourstomach or small intestine). However, several patientswere fed orally or a combination of both whilst beingweaned off the enteral feed. We saw nutrition careplans were developed in conjunction with anutritionist and speech and language therapist (SALT)and reviewed monthly.

• Staff were only able to support the feeding of patientsif they had completed nutrition and dysphagiatraining. We checked the staff files of staff seensupporting patients to eat and found they hadcompleted this training. We viewed five patientrecords and saw that all had completed MalnutritionUniversal Screening Tools (MUST). MUST is a five-stepscreening tool to identify adults, who aremalnourished, at risk of malnutrition, or obese. Thesewere reviewed monthly as part of the care plan review.

• The dietitian visited the hospital twice a month andworked with the dietitian from the referring hospital tounderstand requirements before discharge. They thenreviewed patients two weeks after admission andmonthly from then on. NICE states reviewing of dietmust be at least three monthly, therefore the hospitalwas more than meeting this requirement. Staffadvised us they were able to contact the dietitiananytime if they had concerns.

• Patient records we reviewed showed staff monitoredpatient input and output. Staff knew when and towhom to escalate if a patients output was low.

• Information regarding the consistency of food anddrink was documented in patients’ care plans as wellas the hospital kitchen. The dietician, lead nurse andSpeech and Language therapist were all involved anda weekly updated list forwarded to all theprofessionals by the Speech And Language Therapist(SALT). We saw evidence of this communication.

• However, food was transferred to a preparation roomwhere information such as; a list of patients who wereable to support themselves, a list of patients whorequired soft/pureed food, number of scoops ofthickener required etc. was not available. When weasked staff about this, they advised us they knew eachpatients nutritional requirements. An easyreference list could be useful to reference whensupporting new members of staff.

• The hospitals in-house patients survey 2017 showed93% of respondents felt food portions were sufficientfor them, 93% of respondents felt the food and drinkwas of a quality they would expect and 85% ofrespondents reported that food arrived at anappropriate temperature.

Pain relief

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• Patients in need of palliative care were supported by amultidisciplinary team (MDT) to manage pain. Aconsultant in rehabilitation medicine was present atweekly ward rounds and supported the review of painmedication. Staff could access support and advicefrom the local Macmillan team, there was 24-hoursupport from the therapy team who assisted patientswith pain through posture management andhydrotherapy. Staff used the World HealthOrganisation (WHO) Analgesic Ladder (2015) to assessthe pain needs of palliative care patients.

• At the time of inspection, the majority of patients wereprescribed regular analgesia (pain relief) such asparacetamol. If patients required further pain relief,staff used a visual analogue score (a measurementinstrument used to review levels of pain by assessingsubjective characteristics that cannot be directlymeasured) if the patient was able to verbalise. If apatient was unable to verbalise, staff reviewed levelsof agitation, sitting duration in wheelchair, time spentin a splint etcetera. We saw care plans whichconfirmed health care assistants (HCAs) checkedpatients every 15 minutes. If during a check a patientappeared or advised they were in pain, staff escalatedthe issue to a nurse.

• The hospital held a two-day workshop in conjunctionwith Know Pain, to look at managing long-term pain inpatients. The workshop included looking at;discussing pain with patients, looking at evidencebased theories of pain and practical implementation.

• The hospital was developing a specialst pain scale inconjunction with the University of Liege in Belgium foruse with patients with profound neurologicalimpairment.

• Staff did not have the training skills to use a syringedriver (a small infusion pump used to graduallyadminister small amounts of fluid, with or withoutmedication). When we spoke to staff about this, theysaid the Macmillan team supported the use of syringedrivers and therefore they did not need to use them.However, we saw patient notes that suggested use of asyringe driver would have been beneficial insupporting patients ‘care.

Competent staff

• The Nursing and Midwifery Council (NMC) and HealthProfessions Council (HCPC) requires nurses and alliedhealth professionals to maintain registration withthem in order to ensure standards of practice. At HolyCross Hospital, the management team had checkedthe registrations of nurses, therapists and other alliedhealthcare professionals using an electronic systemthat was demonstrated to us. Within the last 12months, 100% of applicable staff has theirregistrations checked. Therefore, the hospital could beassured their staff met NMC standards.

• We reviewed the service level agreements held bysome therapy staff. We noted they contained checks ofthe practitioner’s qualifications and registration statusthat were current.

• Staff were supported with revalidation by the Directorof Nursing and had access to support informationregarding how to complete the revalidation processand how to provide examples of best practice.

• Staff within the MDT had specialist skills including;advanced respiratory management, botulinum toxininjection therapy (Botox), as well as 24-hour posturemanagement, spasticity management and respiratorymanagement. Ward staff used them as a source ofinformation and stated the knowledge within the MDTwas a “useful resource”.

• All staff received training to keep them up-to-date indevelopments including attendance at the nationaldisorders of consciousness conference hosted by thehospital, brain injury and objective assessment ofdisorders of consciousness, respiratory management,nutrition and dysphagia, care planning, 24 hourposture management and splinting.

• Special interest groups had been developed by thehospital and were made up of clinical team memberswith a special interest in the area concerned. Thepurpose of the groups was to promote best practicebased on recent developments and evidence.Members of the group supported staff in other clinicalteams through coaching and as a point of contact foradvice. Areas covered by the special interest groupsincluded; respiratory management, dysphagia andnutrition, posture and positioning, tissue viability andwound management, continence, disorder ofconsciousness and end of life care.

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• There was a competence framework for registerednurses and health care assistants. Senior nursesassessed the competences of nursing staff relevant totheir role and responsibilities. All staff files wereviewed had completed competency frameworks.

• New members of staff underwent a two weekinduction period and were expected to demonstratecompetences in several key areas relevant to their role,for example, manual handling, knowledge of patientsand administration of medication. Reviews wereundertaken after one and three months with the latterfocusing on personal development. Competenceswere assessed on completion of induction. At the timeof inspection, 100% of staff had received an induction.

• Senior clinical staff received clinical supervision froman external supervisor on a two monthly basis. Seniorstaff provided clinical supervision to junior staff on atwo monthly basis. Supervision consisted of one toone’s or groups where the group was formed of staffon a similar grade.

• The hospitals in-house patient survey 2017 showed96% of respondents always or mostly had trust andconfidence in the staff looking after them. Thisindicated good, trustful working relationshipsbetween staff, patients and their families.

• Between October 2015 and September 2016, 48.4% ofnurses, 86% of therapists and 80.6% of HCA’s receivedan appraisal. Therefore, there were reducedassurances that nurses at the hospital hadopportunities to discuss professional developmentand working practices with senior members of staff.We saw records during the our inspection visit whichshowed the appraisal rates for nurses had improved to79%.

Multidisciplinary working and coordinated carepathways

• Each patient had a member of the MDT allocated tothem as their key worker. The key worker role includedbeing a point of contact across systems, ensuring careplans were adhered to and being an ambassador onbehalf of the patient. One member of staff describedthe role as “How can I make this patient’s life better.”

• There was a weekly ward round every Tuesday onalternate wards. We observed a ward round and notedthere was input from the whole MDT includingtherapists. Each patient was spoken to individually todiscuss any issues and review pain.

• Patient handover was at 1.30pm which included allstaff. Handover was used as an opportunity to assessthe patient’s day. Nurses or care assistants managingthe care of the patient discussed the care given thatmorning and any issues or concerns. Any specialistreferrals were discussed as well as family issues andany activities the patient had been involved in.Changes in skin condition were mentioned and anyimpact this would have for planned activities the nextday. The handover was also an opportunity for theSister to discuss any training or learnings fromincidents.

• After six weeks of being at the hospital, patientsreceived a full MDT meeting that included family. Afterthis time the MDT set up goal setting meetings everysix to eight weeks. The purpose of the meetings was tosupport patients regarding changing priorities andensure the whole team had up to date informationregarding a patient and that aims were shared acrossteams.

• There were quarterly meetings with the Macmillanteam to discuss patients on an end of life carepathway and review any changes to policy andplanning. This gave staff the opportunity to keepcurrent with best practices.

Access to information

• Staff we spoke with knew where they could access thepolicies and gave us examples of when they wouldrefer to them.

• Turnaround times of blood tests was about a week.However, we could not find any evidence that thisdelay effected patient safety or the hospitals ability torespond to patient need.

• All external information, for example informationbeing sent to a GP, was reviewed by the informationgovernance lead to ensure it met standards of theData Protection Act 1998 and was sent via securemethods.

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Consent, Mental Capacity Act, and Deprivation ofLiberty Safeguards

• We viewed the hospitals consent policy, whichreferenced all relevant legislation such as; NICE‘Guidance on informed consent’, the Mental CapacityAct 2005 ‘Code of practice’, General Medical Council‘Guidance on consent’ and the Nursing and MidwiferyCouncil ‘Code of professional conduct’. The policyprovided information on the five core principlesregarding capacity, where to get support regardingmaking best interest decisions, advice on when toseek consent, what documentation was required bylaw, as well as information to support staff when apatient refused treatment. All staff knew the contentsof the policy as well as how to access it.

• We checked five patient records and noted allcontained relevant consent forms. Where there was aDeprivation of Liberty Safeguard (DoLS) in place, careplans included a best interest statement, a signedstandard authorisation with an upcoming review dateand all documentation referenced the Mental CapacityAct 2005 (MCA). DoLS provides protection forvulnerable people who are accommodated inhospitals or care homes who lack the capacity toconsent to the care or treatment they need.

• Staff knew their responsibilities under the MCA andDoLS to make best interest decisions for patients whowere unable to give consent. Best interest decisionswere made by an MDT where applicable and includedinput from families. We saw staff refer to ‘Getting toknow me’ forms when making day-to-day best interestdecisions. For example, staff used photographs todress and style a patient in order that they presentedin the same style as they preferred before their injury.

• We saw that the hospital had guidelines in place forthe covert administration of medicines and stated thatpatient consent was essential but recognised thatwhere best interest decisions were necessary thiswould be made by the multi-disciplinary teamincluding pharmacist, medical and nursing staff.

• At the time of inspection staff completion rates forMCA/DoLS training was 91%. Therefore, there wasassurance staff knew the legal processes forsupporting a patient who lacked capacity and theirresponsibilities regarding best interest decisions.

• Staff used communication equipment in the sensoryroom to support patients with difficulty in verbalisingtheir choices to ensure patients were able to consentthemselves rather than have a best interest decisionmade for them. Therefore, staff were using allavailable resources to ensure patients had theopportunity to consent, rather than solely relying onstaff making best interest decisions.

Are long term conditions caring?

Outstanding –

Compassionate care

• Patients were truly respected and valued as individuals.All staff were passionate about their roles and were verydedicated to making sure patients received the bestpatient centred care possible.

• Feedback from patients and those close to them wascontinually positive and care received exceeded theirexpectations. We reviewed results from the hospitalsmost recent patient experience surveys and found thefeedback was very positive and the ratings were high.For example, the 2017 survey showed 96% ofrespondents always or mostly felt that all staff had ashared understanding of their needs and 96% ofrespondents felt that they are always treated withrespect and dignity. In addition, the hospital provided uswith the results of the annual patient survey 2017 basedon an NHS standard survey. There was a 60% return ratewith 20% completed by patients, 76% by relatives and4% by others. Overall, the responses showed 92% of allrespondents rated the hospital at the top of thefour-point scale and 84% gave the highest rating for careand attention provided by nurses and carers while theremainder gave a score of three.

• CQC received numerous comments from families thatoverwhelmingly described the caring andcompassionate attitude of the staff. For example, a fewcomments stated; “The care, respect andunderstanding my daughter and us as a family receiveis absolutely second to none.” “Wonderful place,wonderful people, great care!!” and “After 40 years [ofour son being in care], Holy Cross is the best hospitalfor patient care and attention. Staff treat him withdignity.”

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• During inspection, we spoke with six patients who alldescribed staff in a positive, empathetic light. Forexample, comments included “Staff are lovely”, “Reallynice and polite” and “I would not have got where I amwithout the support of all the staff here, they arewonderful, I cannot fault them. They have supportedme throughout my journey and really took time tounderstand my worries and concerns.”

• The hospitals ‘operational standards’ detailed thestandards staff were expected to work towards. Thestandards included ensuring patients’ privacy,confidentiality of information and working withintegrity. These standards were displayed throughoutthe hospital in order that patients and families knewthe standards they could expect from staff. We saw allstaff adhering to these standards during care andtreatment of patients and interactions with families.Staff knew the standards and understood theimportance of holistic care.

• We observed patients were always treated withdignity, respect and kindness during all interactionswith all staff, and relationships were characterisedbetween staff, patients and those close to them asstrong and caring. For example, we observed staffalways knocked on patients’ doors before entering.

• Patients and staff provided us with numerousexamples of where staff had gone “Above andbeyond”. For example, a patient who had beentransferred to an acute hospital found theenvironment very distressing and hospital staff foundit difficult to communicate with them. Therefore, stafffrom Holy Cross Hospital visited the patient every day,assisted with personal care, ensuring the patient waslooked after by people they knew and supportedhospital staff to communicate and understand howbest to communicate with the patient. One patienttold us that if you had been away from the hospital fora period of time, staff put up welcome home banners,had a tea party with you on your arrival and a memberof staff was allocated to ensure you “Settled backhome ok.”

Understanding and involvement of patients andthose close to them

• Patient’s individual preferences and needs werealways reflected in how care was planned and

delivered, we saw staff support patients to make ownchoices on clothes, hairstyles, weekly shopping,visitors and others. Patients were supported to choosetheir own food on advice of dietician and speech andlanguage therapist (SALT), select preferable socialoutings (for example, theatre and seaside trips) orarrange own outings (for example, home visits). Wherepatients lacked capacity, staff used photos andinformation garnered from patients ‘Getting to knowme’ forms to inform them of the preferred style of thepatient and support which items they bought duringshopping trips.

• Staff explained to patients what they were going to dobefore proceeding and spoke in non-medical jargon.Staff gave patients choices as much as possible, weobserved a staff member supporting a patient to eat.They asked the patient what aspect of the meal theywould like to eat next, for example, potato, beef orbroccoli. We also saw staff adapting the environmentto support patient choices, for example a patientwished to be positioned on their left so they could seethe door whilst waiting for visitors, however in themeantime he also wanted to watch television.Therefore, staff arranged the bed in order that thepatient could see both.

• Patients were considered active partners in their care.Patients and their families were fully involved in thegoal setting process and their wishes and opinions areembedded in the goals set. Patients were alsoinvolved in the risk based care planning process,which enabled them to be in control of theirmanagement plan. Families were supported whenthey wanted to get involved with day-to-day careneeds such as support with eating. One familycommented, “We are pleased we have the opportunityto help with some of his care without compromisinghospital controls.”

• Patients with capacity were fully involved in theirtreatment and care planning, for example, they hadthe option to attend goal-setting meetings. A patientwe spoke with said this enabled them to be confidentin taking control of their own health. We also sawevidence of patient involvement in thedecision-making process regarding transfer to acutehospital, palliative care and DNACPR requests.

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• It was clear when speaking to staff and patients thatpatients were fully supported to be empowered and totake charge of their health when at all possible.Patients and families told us staff focused on thepatients’ needs. All parties felt involved in discussionsabout care and treatment options and told us theywere confident asking questions.

• Families of patients who lacked capacity wereprovided with a ‘Life story post injury book’ in order tocompile their relatives’ life stories after their injury aswell as a ‘Getting to know me’ form which detailedinterests and preferences which staff used to supportcare and activity planning. Families were also fullyinvolved in patient care and treatment and wereinvited to attend regular family meetings where care,treatment and progress were discussed. Families alsocontributed to the relatives’ weekly activity timetableswhich we saw minutes of. Families we spoke with saidthey appreciated this and it also ensured activitiesthey knew their family member would enjoy weretaking place.

Emotional support

• Patients’ emotional and social needs were highlyvalued by staff. Staff showed a great understanding ofthe impact the condition and treatment had onpatients and this was embedded in their care using amultidisciplinary approach. For example, staffsupported patients and their families in the firstinstance, however referrals to other services such ascounselling services and chaplaincy, could be made iffurther specialised support was needed. We saw staffhad good relationships with patients and families andfamilies told us they felt confident in asking staff forsupport from external agencies when they felt it wasneeded. For example, a clinical neuropsychologistregularly attended the hospital and was available toassist patients, families and staff.

• Patients in need of palliative care receivedpsychological support from the clinicalneuropsychologist and other local counsellingservices from outside the hospital, such as Macmillan.

• Patients were supported when they needed to betransferred into an acute setting. For example, staff

visited an anxious patient daily when they were inhospital in order to provide assurance, communicatemore effectively and ensure the patient had regularcontact with someone they knew.

Are long term conditions responsive topeople’s needs?(for example, to feedback?)

Outstanding –

We rated responsive as outstanding.

Planning and delivering services which meetpeople’s needs

• Services were tailored to meet the needs of individualpatients, people with neurological conditions moregenerally and the local community. They wereplanned to deliver maximum flexibility and choice.

• If families and friends wished to stay overnight in thelocal area, staff were able to arrange accommodationat the convent or families could stay in the homes of‘Friends of the Holy Cross’ who lived in Haslemere andthe local area. Families we spoke with said this wasgreatly appreciated, especially during times when apatient was in ill health.

• Visiting times at the hospital were 10am to 8.30pmdaily. This gave flexibility to patients’ friends andfamilies, and families we spoke with appreciated thisas many of them visited daily. Therefore, they couldwork visits around their home life.

• The outpatient Physiotherapy Centre providedphysiotherapy support and classes which members ofthe public could access directly or be referred.Patients received an initial assessment and could thenaccess either 1:1 treatment such as acupuncture orjoin one of the exercise classes such as pilates orhydrotherapy. This showed the hospital provided aservice that would otherwise not be available to thelocal community.

• The environment had been planned and adapted tosupport the needs of patients and encourageparticipation in everyday life at the hospital. Patientswere empowered to get as involved as they wished

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regardless of level of disability and the environmentsupported this. For example, corridors and doors werewide enough that patients who were bed bound couldattend activities in the activity room. There was anethos of patient ownership regarding theenvironment, as all art displayed within the hospitalhad been painted by patients. In addition, patientbedrooms were personalised as much as possible. Amember of staff said, “This is their home.”

• The hospital held regular stroke meetings in theactivities room for members of the public to use as ameans of support and have regular contact with otherpeople who had either suffered a stroke themselves,or had a family member who had a stroke.

Meeting needs of different people

• There was a proactive approach to understanding theneeds of patients. The hospital participated innational and international research studies designedto improve the understanding of the needs of peoplewith acquired brain injuries, and to developtechniques and strategies to meet those needs. Themanagement team told us they were proud of theirdevelopments in learning and development and in thelast year have put on a national conference relevant totheir specialist field of care, which was attended byinternal and external delegates.

• There were innovative approaches to providingpatient centred care. We found numerous examples ofwhere the hospital had utilised state of the arttechnology as well as using simple activities and theenvironment to best meet the needs of patients andprovide a living environment that was “Not just ahospital, it is their [patients] home.”

• The St Anne’s sensory room was an example of howthe hospital and staff supported and empoweredpatients with very little mobility to interact with theirenvironment, other people and make their choicesand opinions known. The room included a ‘magiccarpet’ that used eye gaze software (using thedirection of a person's gaze to detect the point onwhich a person's eyes are focused) to enable patientsto play games and interact with projected pictures.The room also had optobeam technology wherepatients with limited mobility could interact withbeams of light that triggered reactions on a projected

animation. Staff used this technology to communicatewith patients. Patients could answer yes and noquestions by responding in one of two ways. Thisempowered patients with even the most limitedcommunication skills to let their opinions be heard.

• The activity room was big enough that it could beeasily divided into several areas in order thatnumerous activities could take place at the same time.Activities were usually divided into two with one areafocusing on more sensory activities and another formore mobile/active patients. We saw patients joiningin a singing session in the morning and watching a filmthey had chosen in the afternoon. As well as one toone sessions where books were read and jigsawpuzzles completed.

• The activity room included a therapy kitchen, whichalthough not in use during the inspection, patientsadvised us they enjoyed using the facility and it madethem feel “More like normal.” It also supportedpatients to live more independently and prepare forwhen they moved back into the community.

• A chapel was open 24 hours a day, seven days a week.It was available for use by patients, families and staff.We were advised people from any religiousbackground could use the chapel. However as this wasa Christian institution the chapel displayed Christiansymbols, therefore people who wanted a differentquiet environment could use other rooms such as thesensory room.

• There was a sensory garden that included a fishpondwith waterfall, plants of varying colour and scent and aterrace. Staff advised us the garden was planned to bestimulating to all five senses and patients said it was acalm area to relax in and appreciated theenvironment.

• Although the hospital provided rehabilitation facilities,staff understood some patients would be at thehospital for a significant period of time and the socialimpact this would have. Therefore, safe environmentshad been created away from the hospital itself. Forexample, there was a woodland trail outside thehospital that was wheelchair friendly and provided

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views over the countryside. Patients and family wespoke with said they appreciated having somewherequiet they could spend time together that was nearmedical assistance if it was needed.

• Patients also had access to a holiday cottage in Selsey.Trips were regularly organised and gave patients asafe, adapted environment to see family and friendsaway from the hospital. One patient advised us theyliked the cottage as it was easier for their family totravel to Selsey than to Haslemere. We were impressedwith the regularity of these trips considering thelogistics needed to undertake them. When we spoketo staff about this they understood the benefit to thepatients and were “Happy we can support them in thisway.”

• There were in-house facilities that enabled patients tohave regular visits from a hairdresser. This supportedpatients to have a sense of self, take pride in theirappearance and take part in everyday activities.

• The hydrotherapy pool was commissioned whenanother local hydrotherapy pool closed down and thehospital recognised there was a need for this servicenot only for their own patients but also for those thatwanted the service within the local community. Thepatients’ group, which was made up of patients’relatives requested that the opening hours of the poolbe increased at weekends. This was being consideredat the time of our inspection.

• Occupational therapists assessed patients’ needs andprovided equipment in order to empower patientsand support independence. For example, we sawadapted cutlery to support patients to feedthemselves, there were numerous types of call bell inorder that patients could seek assistance whenrequired. Television remotes were also adapted sopatients could change the channel independentlywithout the need to ask for assistance.

• Staff had access to registered translation services tosupport understanding in patients whose firstlanguage was not English, not all staff knew thisservice was available, however at the time ofinspection there were no patients who could not

speak English. Other staff advised us they would usepatients’ family to convey information; however, this isnot best practice as there is no assurance ofunderstanding.

• Two nurses from the hospital had completed aEuropean Palliative Care (EPC) course. The aim of thecourse was to support pain management as well asbuild relationships with outside agencies such ashospices. The nurses worked with the Macmillan teamto compile end of life care plans and were available asa resource for other staff.

• Staff, patient and the public could access informationregarding the hospital through various newslettersincluding; Friends of Holy Cross newsletter and a HolyCross Centenary newsletter that provided updates onSt Hugh’s, a new education centre being built on site.These were available on the hospital website.

• The website also provided information regarding whatfamilies and patients due for admission could expecton the day of admission, including details of anyassessments, care planning and rehabilitation plans,as well as plans for meeting the clinical team. Familieswe spoke with advised us this was helpful inalleviating fears in the run up to admittance.

• In outpatients and the physiotherapy centre we foundinformation leaflets for a variety of different ailmentsthat were from recognised institutions such as ArthritisResearch UK. We checked 10 different leaflets and allwere in date. Therefore patients could be assured theinformation they received was current and from areliable source.

Timely care and treatment

• There were arrangements to ensure patients couldaccess services that could meet their complex needsin a reasonable period. A pre admission assessmentwas completed by senior clinicians in order to identifyclinical needs and risks, and to ensure the MDT couldmeet patient’s needs. The findings from the preadmission assessment were shared with themulti-disciplinary team and the consultant inrehabilitation medicine before a final decision onadmission was made. The patient and their familywere encouraged to visit the hospital before finalisingtheir decision. If all parties agreed, the patient wasthen placed on the waiting list. In the event there was

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no likely prospect of bed becoming available for morethan three months, all parties were advised whichallowed alternative options to be pursued. At the timeof inspection, there were two patients currently on thehospital waiting list.

• The multidisciplinary team including doctors, nurses,speech and language therapists (SALT), occupationaltherapists (OT), physiotherapists (PT), psychologistsand dieticians assessed patients prior to admission.On admission, a comprehensive assessment wascarried out to identify problems and list rehabilitationgoals.

• Discharge planning was carried out in consultationwith the patient and the family. Before discharge theMDT compiled a report of patient’s needs andidentified a suitable discharge destination, forexample family home or care home. The therapy MDTassessed home environments and ensured allnecessary equipment was in place, they also workedwith community services to ensure care packageswere ready for discharge home. For example, the teamworked with care agencies and social services in orderto provide a seamless service from an acute tocommunity setting.

Learning from complaints and concerns

• Information on how to complain was easily availableon the hospital website. The complaints policy andprocedures were also detailed in the patients’ guidefolder and copies were available in reception andoutpatients. Patients we spoke with knew how tocomplain and advised staff were very good atresolving any issues they had.

• Hospital staff aimed to resolve concerns before theybecame formal complaints, this reflected the smallnumber of complaints received at the hospital andshows the strong working relationships between staff,patients and their families. Managers practised anopen door policy and were frequently around thehospital and available for informal discussion withpatients and families. The director of nursing madedaily visits to every patient to check there were noissues or concerns.

• The management team had clearly defined rolesregarding who had responsibility for handling andresponding to complaints.

• From October 2015 to September 2016, there were sixwritten complaints at the hospital; however, thesewere not formal complaints. All received a fullresponse within 20 days as detailed in the hospitalscomplaints policy.

• The hospital maintained a register of complimentsand complaints received as well as any actions takenand the outcome. The management team compiledthe information into an annual report which wasforwarded to the relevant NHS body and to the CareQuality Commission. All new entries in the registerwere reported to the MAC for review, comment and ifnecessary implementation of new practices.

• From the six complaints there were no discerniblethemes, although the management team activelyreviewed complaints and made amendmentsaccordingly. For example, one patient complainedabout being cold, therefore a contractor was called toinvestigate and a fault was found and corrected. Inanother example, staff breaks had been spread out inorder that requests for assistance could be respondedto more effectively.

• The hospitals in-house patient survey 2017 showed96% of respondents always or mostly felt that theirconcerns or complaints were addressed andresponded to by staff. A family member advised us“[Staff] listen to any concerns we have and respondappropriately.”

Are long term conditions well-led?

Good –––

We rated well-led as good.

Leadership and culture

• The hospital achieved the Investors in People award in2016 for the sixth consecutive time. This nationalaward was in recognition of the hospital developed,supported and motivated staff.

• The structure of the management of the hospitalconsisted of a chief executive who was answerable tothe trustees of the hospital. There were departmentaldirectors for clinical services, nursing, finance,

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information services, human resources and generalmanagement. Once a month the whole team mettogether as heads of departments. The managementteam reported to the trustees every six weeks.

• The chief executive described inter- professionalrelationships at the hospital as ‘excellent’ asmanagement and staff all know each other.

• The human resources manager was the nominatedspeak up guardian. Staff said they were aware ofwhistleblowing policy but felt able to speak directly tocolleagues if there were any issues to be addressed.We saw records that showed staff had approached thespeak up guardian when there were concerns and thatappropriate support was given. This demonstratedthat there was an open culture and staff told us theyfelt supported when they raised concerns.

• Staff described the hospital as being well organisedwith good support from the management team.

• Staff talked about ‘knowing each other well andworking together as a team’, Staff told us they feltvalued. One staff member said they were able to work,flexible hours, ‘liked the calmness, was able to delivercare properly and did not have to cut corners’, hadregular breaks and did not feel stressed or underpressure. All staff commented on the productiveworking together of the multi-disciplinary team.

• Staff told us they feel that they make a difference totheir patients, A member of the cleaning staff told usthey understood the importance of their role, aspatients were ‘vulnerable to infection’. Thisdemonstrated that there was a shared purposethroughout the workforce.

• We saw an example of where conduct had fallenbelow accepted professional standards had beenmanaged appropriately and robustly. This showed thehospital management team did not tolerateunacceptable conduct.

Vision and strategy

• The hospital told us the values of the hospital weredeveloped by the religious order that first establishedthe hospital and this has been passed on over theyears as an enduring mission statement to servepeople who are sick or suffering and their families.Staff we spoke with were very positive about this

approach and talked about their ability to make adifference to the patients. They spoke of the religiousfounding of the hospital and the beliefs in ‘doing whatwas best for the patient’. We observed that staff werecaring and compassionate and made constantreference to patient’s and family members as theyplanned and delivered care

• The strategy of the hospital was to “be a centre ofexcellence for people with disabilities resulting fromneurological injury or illness and meeting the needsand expectations of patients and their relatives”. TheClinical Outcomes report 2016 described the hospitalplan to be the improvement of hospital services,increasing knowledge, skills and efficiency.

Governance

• There was a governance framework in the hospitalthat gave assurance about the quality and safety ofservices. The hospital held meetings through whichgovernance issues were addressed, the meetingsincluded the Medical Advisory Committee (MAC),clinical governance meetings and monthly heads ofdepartment meetings.

• We saw that the hospital had a robust clinicalgovernance framework document that detailed allreporting lines and who held professionalresponsibility for decision making at different levels ofthe organisation. In addition to this, there was aclinical governance annual plan for the year, whichincluded an audit programme, measurements ofeffectiveness, risk management, staffing, a learningand development and service plan.

• There were eight special interest groups forming partof the governance framework covering areas ofpotential risk and development such as infectionprevention and control, posture management andtissue viability and wound management. Thesegroups had a planned set of objectives and reportedthrough to the senior management team. Teams areto be added as a need is identified. We saw thatmedicine management is soon to be added.

• The MAC had representation from the GP’s whoprovided cover for the hospital, the consultant inrehabilitation medicine and the senior hospital team.The hospital provided terms of reference for the group.

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We saw minutes of the meeting which showed it metquarterly. The directors of nursing and clinical servicesproduced a governance report that was reviewed anddiscussed at this forum.

• The hospital provided us with a risk managementpolicy which showed the categories under which riskswere assessed and saw that risk is a standard agendaitem on the governance meeting agenda.

• Each ward sister or department lead monitored risk intheir own department. On the ward, we sawcompleted risk assessments for the environment andequipment. We were told that staff are getting moretraining on completion of risk assessments. However,the risk register is a list of assessments with links tosupporting policies. There was no clear risk ratingbased on likelihood of occurrence and severity ofoutcome, or priority for each risk. Mitigating actionswere to be found in the supporting policies and werenot individualised to the specific risk identified. Therewas no system for escalating risks based on their riskrating from a local to hospital wide risk register. Thismeant there was no assurance that the seniormanagement team had awareness of key risks acrossthe hospital. This was discussed with themanagement team at the time of inspection.

• Medicine management was seen to be a standingagenda item at the MAC and governance meeting.Medicine and healthcare products regulatory agency(MHRA) alerts and the NICE guidelines are available onthe live pharmacy system. Meeting minutes wereviewed showed these were regularly reviewed andcirculated. When managing medicine errors, there wasclear evidence that appropriate procedures werefollowed when necessary.

• There was a wide range of audits carried out in thehospital and there was evidence that these werereviewed within the governance meetings. There was aregular audit plan for the hospital and we saw theywere up to date with the plan.

• On checking personnel files, it was found there wereincomplete work histories for staff required in line withschedule 3 of “The Health and Social Care Act 2008(Regulated Activities) Regulations 2014. Informationrequired in respect of Persons Employed or Appointedfor the purposes of a Regulated Activity”. However, this

was discussed with the management team and thenext day the files had been updated and the processof obtaining the information had been adapted toensure all requirements of schedule 3 were met.

Engagement and involvement

• We saw minutes of the monthly patients’ forum fromSeptember 2016 to December 2016. Patients used theforum to put forward ideas regarding upcomingactivities. Staff also used the forum as an opportunityto update patients and families regarding ongoingdevelopments at the hospital such as building workfor the new education centre.

• Staff described the hospital as a happy place to work.Ideas could be put forward and staff felt they would belistened to and suggestions will be acted on. Theywere encouraged to look outside of the organisationto source relevant information and to comparepractice.

• One manager spoke about the importance ofengaging staff at induction and how this wasreinforced in the delivery of clinical outcomes. Wewere told that at the start of projects, a consultationletter would be sent to staff and relatives to engageand involve them. We saw the letter that was sentabout the capital project to install piped oxygen andsuction to patient rooms. The letter invited stafffeedback on this project.

• Staff spoke positively about the continueddevelopment of the hospital including the building ofa learning centre and felt they had been consulted andkept involved with this project. They said they werepleased that this building would be open to externalorganisations.

• We saw examples that showed families were activelyconsulted and involved in their relatives care and withdevelopment of services at the hospital. The patientsgroup for relatives was a meeting used to discuss anyhospital wide concerns, clinical representativesattended the meeting and minutes are taken.In themeeting minutes an example of how this group caninfluence care was seen as relatives had asked for anincrease in the number of hydrotherapy sessions andwe were told this was now being considered.

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• The hospital supplied minutes from the monthlypatient forum group which was attended by patients,relatives, staff and volunteers which showeddiscussion about daily and weekly activities for thepatients and families.

• We were told that the hospital was in the process ofinstalling piped oxygen and suction to each patientroom. We saw that staff had been emailed and askedfor their comments on this project before it wasstarted and staff feedback was shared with therelevant managers. In addition, there was a letter to allpatients and relatives detailing plans of the project,the benefits of the piped oxygen and suction weregiven and level of disruption anticipated. The letterasked for feedback and comments. This demonstratedgenuine engagement with patients and those close tothem.

• The monthly hospital newsletter included informationon the upcoming plans including the current buildingwork. The newsletter gave details of the ‘you say’sessions. The head of department meeting minutessupplied showed feedback from these sessions beingdiscussed.

• The hospital management team spoke positivelyabout the support they received from volunteers whobelonged to the Friends of Holy Cross. During ourinspection we spoke to volunteers who wereoverwhelmingly positive about their contribution andinvolvement at the hospital and told us how muchthey enjoy being part of the volunteer team. We sawthe hospital clinical report acknowledged thevolunteers contribution to the hospital and saw therewere regular committees meetings and an annualgeneral meeting.

• We saw the Queen’s Award for Voluntary Servicesdisplayed near the activity room. The Queen’s Award isthe highest award given to volunteer groups acrossthe UK. In order to be eligible volunteers must providea service and meet a need for people living in the localcommunity, be supported, recognised and respectedby the local community and the people who benefitfrom it and be run locally. Volunteers were rightfullyvery proud they had received this award.

Continuous improvement

• The hospital was at the forefront of disorder ofconsciousness medicine and held a conference onmultidisciplinary management of people with adisorder of consciousness every two years. Thehospital clinical and management team invitedclinical and academic experts to attend and provideinformation and learning on both medical theory andthe practicalities of implementing practice.

• The hospital was at the forefront of practice in that itwas developing pathways for other institutions to use.For example, staff from the hospital had been invitedto co-write Royal College of Physicians guidelinesregarding physical management as well as set up apatient group as part of an excellence centre. TheNational Skills Academy for Health is developing anetwork of Excellence Centres across England to bringtogether employers from the NHS, independent andvoluntary sectors to coordinate and implement highquality skills programmes.

• The director of clinical services had received ascholarship to work with a hospital attached toHarvard Medical School to look into long-term acutecare in minimally conscious patients. Thisdemonstrated that clinical leads were at the forefrontof care for specialisms within the hospital.

• The hospital was working with global leaders in thetreatment of disorder of consciousness patients suchas, Northwick Park Hospital, Cambridge Coma Centre,the Royal Hospital for Neurodisability and KeeleUniversity to develop disorder of consciousnesspathways.

• We saw examples of staff being encouraged todevelop their knowledge in the specialty and topublicise their achievements. The hospital hosted atwo-day national conference and told us that they sawthis as an opportunity to strengthen networks withclinicians, academics and researchers.

• We saw there was active service evaluation andresearch activities undertaken by one of the seniormanagers with publication expected this year. Thehospital was actively involved in the development ofgood practice treatment guidelines for themultidisciplinary team.

• To support the opening of the new educational suitewhich we saw was under development we saw there

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are plans for an inaugural event to host a ‘supportingfamilies of people with severe and complex braininjuries: What can professionals do’. We were told theaim was to share experience and discuss what trainingis required.

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Outstanding practice

• People were truly respected and valued asindividuals and were empowered as partners in theircare. There was an emphasis on providing a caresetting that patients could consider theirhome.There was an embedded culture of caringamongst all staff and we saw many examples of staffgoing the ‘extra mile’. Services were planned anddelivered to afford maximum flexibility and choicefor patients and those close to them.

• The hospital was at the forefront of care for peoplewith long-term conditions and disorder ofconsciousness medicine. Staff from the hospital hadbeen invited to co-write Royal College of Physiciansguidelines regarding pain as well as set up a patientgroup as part of an excellence centre. The hospitalwas developing a specialist pain scale in conjunctionwith the University of Liege in Belgium The hospitalhosted a national conference on multidisciplinarymanagement of people with a disorder ofconsciousness twice a year.

• When patients needed acute hospital care, therewere arrangements for staff from Holy Cross Hospitalto support patients in this environment, and also tosupport other professional staff in meeting thecomplex, individual needs of patients. Patients werewelcomed when they returned.

• The hospital was using cutting-edge technologies toimprove care of patients. The St Anne’s sensory roomhad a ‘magic carpet’ that used eye gaze software(using the direction of a person's gaze to detect thepoint on which a person's eyes are focused) toenable patients to play games and interact withprojected pictures. The room also had optobeamtechnology where patients with limited mobilitycould interact with beams of light that triggeredreactions on a projected animation.

• There were opportunities for patients and thoseclose to them to experience a range of environments.If patients wanted to get away from the hospitalenvironment there was a woodland trail outside thehospital that was wheelchair friendly and providedviews over the countryside. A senses gardenincluded a fishpond with waterfall, plants of varyingcolour and scent and a terrace. Patients also hadaccess to a holiday cottage in Selsey.

• The hospital had established “Special InterestGroups” covering a range of clinical areas such asinfection prevention and control to ensure bestpractice and guidance was reviewed, considered,disseminated and managed throughout the hospital.

Areas for improvement

Action the provider SHOULD take to improve

• The hospital should expand information on duty ofcandour in the incident policy to indicate thepractical application of candour as a point ofreference for all staff

• The hospital should have a target in place formandatory training completion

• The hospital should follow through the chain ofdisposal external to the hospital for assurance atleast annually.

• The hospital should document its rolling schedule ofplanned preventative maintenance for equipmentused to enable easy reference.

• The hospital should conduct additional resuscitationscenario training, this tests staff on their responses toan emergency.

• The hospital should establish key performanceindicators within the pathology service levelagreement setting out reporting.

• The hospital should review its arrangements foradvanced care planning.

Outstandingpracticeandareasforimprovement

Outstanding practice and areasfor improvement


• The hospital should review the use of syringe driversto support patients on an end of life pathway and toprovide medication where appropriate.

• The hospital should ensure all staff have an annualappraisal.

• The hospital should ensure all staff know how toaccess professional translation services.

• The hospital should devise a risk register that isprioritised and gives the management teamassurance of safety across the organisation.

Outstandingpracticeandareasforimprovement

Outstanding practice and areasfor improvement


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