• Text size
  • A
  • A
  • A
Helping you get the best out of local health and social care services
menu

CQC inspectors report on surgical services at Frimley Health NHS Foundation Trust

04/09/2018

The Care Quality Commission (CQC), the independent regulator of health and social care in England have released their reports about surgical services. The review was carried out following a number of never events. NHS Improvements says that never events are serious incidents that are entirely preventable because guidance or safety recommendations providing strong systemic protective barriers are available at a national level, and should have been implemented by all healthcare providers.

"At Frimley Park Hospital the key findings were;

  • The service developed and implemented local safety standards for invasive procedures,; however, not all staff were aware of these.
  • There was a culture of openness and honesty and service leads encouraged staff to challenge poor practice.
  • The service had a positive incident reporting culture, demonstrating, which showed that there was learning from incidents, and was shared learning and sharing both locally and across the trust.
  • Governance arrangements were clear and structured ensuring leaders and staff received information to enable them to challenge and improve performance.
  • Staff did not adhere to the trust's surgical site marking policy.
  • However, there were also areas of poor practice where the trust needs to make improvements.

The trust should:

  • Ensure there are clear guidelines on safe patient transfers and responsibilities during patient handovers from all wards to anaesthetic room or theatres. This should include patient safety checks and the patient's involvement.
  • Involve all departments in the development of local safety standards for invasive procedures.

At Wexham Park Hospital the key findings were;

  • Substances subject to Control of Substances Hazardous to Health (COSHH) legislation were not always stored securely. We found cleaning tablets stored in an unlocked utility room.
  • Access to medicines was not appropriately restricted on the surgical unit. We found prescription only medicines left unattended in an unlocked pharmacy room.
  • Accesses to various areas within the service were not appropriately restricted. Doors were left open and unlocked and there was no way of tracking the entering and exiting of visitors into the department.
  • Staff were knowledgeable about incident reporting and their responsibilities.
  • Lessons learned were communicated widely to support improvement within the service.
  • Governance arrangements were clear and structured ensuring leaders and staff received information to enable them to challenge and improve performance.

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

Importantly, the trust must:

  • The service must ensure there are appropriate systems of medicine management and that staff are of their responsibilities in relation to this.
  • The service must ensure safe and secure storage of substances subject to Control of Substances Hazardous to Health (COSHH) legislation.
  • The service must ensure the access to surgical areas is restricted to authorised persons.
  • The service must ensure the temperature of the blood fridge is checked and recorded regularly in line with national requirements.
  • The service must ensure all sections of the WHO surgical safety checklists are performed for every procedure undertaken.

In addition the trust should:

  • The service should ensure equipment including sterile supplies are stored safely and securely.
  • The service should ensure all policies are up to date.
  • The service should display stop before you block information in the anaesthetic room as a visual reminder for staff involved in anaesthetic procedures.
  • The service should ensure the environment is free from clutter."

The above has been taken from the reports included below.

The CQC press statement follows;

England's Chief Inspector of Hospitals has reported findings following an unannounced inspection of surgical services at Frimley Health NHS Foundation Trust.

A team of inspectors from the Care Quality Commission visited the Frimley Park Hospital and Wexham Park Hospital, Slough on 3 July in response to information of concern about the safety of the surgical services.

On the day of the inspection CQC passed on its initial findings to senior managers, and the trust leadership team took immediate action.

At Wexham Park Hospital, the inspection identified five areas for improvement, including:

  • There must be appropriate systems of medicine management and staff must be aware of their responsibilities in relation to this.
  • The service must ensure safe and secure storage of substances subject to Control of Substances Hazardous to Health (COSHH) legislation.
  • Access to surgical areas must be restricted to authorised persons.
  • The service must ensure the temperature of the blood fridge is checked and recorded regularly in line with national requirements.
  • The service must ensure all sections of the World Health Organisation surgical safety checklists are performed for every procedure undertaken

Overall, inspectors found service leads who included the various chiefs of services associated to surgery, theatre manager and the team leaders and practice educators were available, visible within the division, and approachable. Leadership of the service was good and there was good staff morale despite the run of never events. Staff told inspectors they felt supported by their leaders during this difficult period. They were able to access support such as retraining and one to one meetings when they required it.

The full report is available at: https://www.cqc.org.uk/provider/RDU

Catherine Campbell, Head of Hospital Inspection for the South East said:

"We took this unannounced, focussed inspection in response to a number of Never Events which had been raised by the trust.

"Most of the issues that we followed up were satisfactory. These related to governance arrangements, learning from incidents and the use of World Health Organisation surgical safety checklist. However at Wexham Park Hospital we did identify a number of safety issues relating to security, checking of equipment and medicines management.

"We have made it clear to the trust where it must take action to improve and have issued a requirement notice that identifies where these improvements are needed. We note that the trust has already provided assurance that it is addressing the issues raised at the time of inspection.

"We will continue to monitor those services and we will return in the near future to check progress."

Downloads

Frimley Park Hospital

Wexham Park Hospital

Recent

Social and Wellbeing Calander

Contact Us

There are lots of ways to contact us, you can write, email, phone, facebook, tweet or use the contact or speak out form(s) to email us.

Healthwatch WAM
20-21 Market Street
Bracknell
Berkshire
RG12 1JG

01753 851 725