Chartwell Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

The service was responsive in making changes following discussion with the inspection team around concerns. Patients told us they felt safe and supported in the environment. Managers shared learning with their staff about lessons learned following incidents. Leaders had made improvements to the environment to ensure it was safe for patient use.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We spoke with patients who told us they felt well informed about their care and treatment and were involved in the decision making about their treatment.

Managers shared learning with their staff about lessons learned following incidents in daily huddles and to consultants via email every 3 months or sooner if urgent. Staff received feedback from investigations of incidents. Staff knew what incidents to report and how to report them. Staff told us about the electronic incident reporting function and the process of investigating incidents. Staff told us team meetings were held regularly and managers shared learning following incidents. Staff understood the duty of candour and could give examples of what that meant in practice. However, training records illustrated the service did not provide duty of candour mandatory training.

The service had an incident policy and staff we spoke with knew about this policy. We saw the duty of candour policy was two years old at the time of inspection. The service provided a revised version of the policy during the data request stage.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We spoke with patients on the two days of our inspection who collectively told us they knew who to contact and how to raise concerns if they did not feel safe, or if they had concerns about the safety of other people. Patients told us they felt safe and supported in the environment.

We were told the provider of the service would complete the recruitment process. The interviews and onboarding process was completed by the service. The service completed Disclosure and Barring Service (DBS) checks at the beginning of new starters employment and obtained updates during their employment. Managers would check staff members had the required competencies to complete their role. Managers ensured staff completed their mandatory training and were alerted to update training in advance of its expiration. Managers would hold yearly appraisals. Staff knew how to make a safeguarding referral and who to inform if they had concerns. Nursing staff received training specific for their role on how to recognise and report abuse. Following our inspection, we were provided an updated training matrix which showed staff completed online training on safeguarding adults and children level 2 as part of their mandatory training. The hospital dashboard showed that all nursing staff were up to date with safeguarding training. The service did not have access to mental health liaison and specialist mental health support. The clinical services manager was trained to safeguarding level 4 and was the lead for the service.

The service made sure new starters completed Disclosure and Barring Service (DBS) checks before they started in role. We saw the safeguarding policy which was in date and had been ratified. The policy made reference to who the referral should be made to and the telephone numbers and emergency duty team. The service had a chaperone policy which was in date and had been ratified. The policy discusses how to safeguard the dignity, rights, safety and wellbeing of patients, consultants and staff throughout consultation, examination and treatment of care.

We spoke with patients who told us they were involved with the decision making about their treatment. Patients knew who to contact if things went wrong. Patients felt informed about the treatment they were going to have or had received.

The service had risk assessment processes in place. An exclusion criteria was used to help ensure the service treated patients who were suitable for the level of care available and we were told the service only treated patients that were in good health.

The service used paper patient notes which were then scanned and electronically saved. The paper notes were filed for a period of time. The service had an Early Warning Scores (EWS) Policy which had been ratified. The policy stated the service would audit the completed patients’ observations and subsequent EWS’s with the use of the audit tool. The policy indicated that observations will be reviewed bi-monthly, and the results reported at the Endoscopy Users Group (EUG) meeting. However, in reviewing the EUG minutes of meeting, we could not see this was discussed. The service had a deteriorating patient policy, but this specifically referred to MRI patients and not the whole hospital. We discussed this with management and they were in the process of formulating a policy for deteriorating patients for the rest of the hospital. The service does not provide out of hours endoscopy cover for emergencies, and patients experiencing complications after their procedure are advised to seek treatment at NHS hospitals. We saw the policy for the safe transfer of patients which was attached to the resuscitation trolley in the recovery room. This policy was out of date and valid until September 2019. Also attached to the resuscitation trolley was the emergency event with possible transfer from the endoscopy unit standard operating procedure (SOP). This SOP was out of date and due to be reviewed on 31 March 2021. Following the assessment the service provided an up to date version of the emergency transfer of patients policy.

Patients told us the patient waiting room was spacious and patients were able to follow the signs to get to where they needed to be. Patients told us the service had suitable facilities.

The registered manager identified the building reconstruction as one of the top three risks for the service. Following a flood in 2022, the service had made improvements to the building however still required some changes to be made. We were told one of the top priorities was to fix the boiler so the premises could have heating. At present the service had thermostatic taps and used electric heaters for heating. We could not see any action plan to fix the boiler.

We saw that facilities and equipment within the endoscopy suite were well-maintained. The service had enough equipment to deliver safe and effective care. We saw the decontamination process and saw all facilities and equipment were clean. We found that cupboards on the ground floor containing electrical components labelled “fire door keep locked” were unlocked. We reported this, and the doors were subsequently locked. We observed the same issue on the first floor; again, we reported it, and the doors were locked. Handwashing facilities were adequate throughout the service. Coffee facilities were out of order, and no other refreshments were available for patients. The COSHH cupboard was securely locked and properly stocked.

We saw monthly cleaning audits for the endoscopy unit January 2024 to July 2024 which were all 100%. The service completed regular audits for the resuscitation trolley including auditing the top of the trolley. We saw audits from January 2024 to July 2024. However, staff did not complete daily checks of the resuscitation trolley equipment every day. We saw that the resuscitation trolley was only checked on the days the service had an endoscopy patient list.

Staff told us there was poor skill mix and poor staff retention. Staff told us there was poor morale amongst the team. Staff did not know who the new clinical lead was or what their role at the service would be. We spoke with leaders about their staffing. We were told many staff members left the hospital after the decision by the ICB to suspend activity for a period of time in 2023. The hospital had 22 members of staff in 2023 and currently had 14 members of staff. Due to the decrease number of patients since the suspension in 2023 there were no plans for the recruitment and retention of staff.

The service had enough medical staff to keep patients safe. We saw that most of the bank staff were previously employed by the service in a substantive role. The service had consultants working under practising privileges in endoscopy. We saw staff working well in their teams however there was no integration between staff in the endoscopy unit and diagnostic imaging.

Staff for outpatients and endoscopy were managed by the same clinical manager. All staff had received a full induction and understood the service. All new staff were supervised and required to complete competencies before they were able to work independently. Bank staff were required to complete an induction process, clinical competencies and mandatory training. We saw records showing bank staff had completed competencies and mandatory training. Bank staff we spoke with told us they had completed an induction programme and we saw evidence of this on the electronic system.

Patients told us they thought the environment was clean and they were happy with the facilities.

Leaders told us they had a contract with an external company to provide cleaning services twice a year. The legal contract for this service was requested but not provided. We were told at the data request stage the service do not have a contract with the external company and use this service as and when they require. The last deep clean for the service was completed in May 2024. We spoke with staff who told us the service had a cleaner. The cleaner worked at the premises from early hours in the morning until 10.30/11am. We saw cleaning charts in the reception toilets that showed the cleaners signature at 4.30am. Staff told us when the cleaner was off on annual leave or sick, they would be required to clean. We were told the heating system was still not working from the previous inspection. The senior leaders told us there were plans to fix this. We saw the action plan for the estates rectification plan however there was no mention of the heating system being repaired.

The reception area and communal areas were visibly clean. Hand washing facilities were available in clinical areas. Reception staff ensured patients and visitors used sanitising gel on arrival. Staff were ‘bare below the elbow’ and adhered to infection control precautions throughout our inspection, such as hand washing and using hand sanitisers. Clinical waste was stored in a secure compound next to the building. The service had a clinical waste collection service level agreement which was signed in 2019 and agreed for a 24 month period. The service told us this was a rolling contract but we did not see any evidence of this. We saw all sharps bins were dated and secure. The sharps bin in the recovery area which was secured to the wall was dated 02/2024 but was half full. The hospital had suffered a severe flood in April 2021 and the diagnostic imaging department was badly affected, however we could see there had been some improvement in the environment. The environment and equipment were visibly clean. Staff cleaned equipment after patient contact. Cleaning records were up-to-date and demonstrated that all areas were cleaned regularly. The centre had undertaken legionella and fire risk assessments. Records showed action plans had been completed to mitigate the risks identified. Water outlets and sinks were flushed to reduce the risk of legionella build-up in line with Health and Safety Executive (HSE) guidance.

The service completed temperature audits. We saw audits for the last 6 months which were completed however the service did not complete any audits on days they did not have an endoscopy list. Following the inspection, we saw cleaning audits for the last six months for the endoscopy unit which had an overall score of 100%. We were provided with the latest audit for the endoscope washer which on average passed with 99.2% Infection control policy was in date and had been ratified. However, the scope of the policy indicates the infection control arrangements must be approved and assessed by the infection control advisor and other relevant staff. However, we were not told or had any knowledge of who the infection control advisor was. The policy also had links to websites that did not work and showed an error page when following the link. We saw the lone worker policy which was in date and had been ratified. The policy stated wherever possible, the service will ensure that the norm should be that staff do not work alone. However, we were aware that the cleaner had been working at very early hours of the day at the service on their own. We had not seen any risk assessments or any implementation of a safe system to ensure the safety of the member of staff. The service had an inhouse decontamination unit. This unit had separate dirty and clean rooms for endoscope decontamination and storage and there was flow of dirty to clean instrumentation within the decontamination area to minimise cross contamination during the decontamination process. We saw that staff used a daily checklist for decontamination equipment. There was protective equipment available to staff working within decontamination. We saw that staff were wearing this during our inspection.

People’s medical history including currently prescribed medicines were reviewed on referral to the service. This ensured that the service was able to meet people’s individual needs prior to accepting them for referral to the service. People were provided with easy to read and understand information about their medicines and were guided through the process by knowledgeable staff. People’s capacity and consent was reviewed on entry to the service however there had been occasions where a person’s right to refuse certain medicines had not been fully considered by the team providing the care. The service had taken steps to ensure this would not occur again.

Staff were suitably trained to administer medicines throughout the organisation. Staff underwent routine competency checks and learning to manage and maintain their skills. Staff were in the process of being upskilled to undertake screening of people’s healthcare records and authorise them for treatment, however at the time of the inspection this could only be conducted by one person. Staff conducted a daily huddle where they could discuss about that day’s patients list and any learning or concerns that should be reviewed by the service.

Medicines were stored safely and secure. This included controlled drug which also had regular checks completed when the clinics were open. We observed that each area where medical or diagnostic procedures took place had access to appropriate resus equipment and emergency medicines. However, we did see that oxygen cylinders were not always secured appropriately and there weren’t always warning notices on the doors to rooms where medical gases were being stored. We raised this at the time of the inspection and the provider has since taken steps to rectify this.

The provider had medicines management policies and procedures in place. They worked alongside their supplying pharmacy to ensure medicines were stored safely and processes were followed. However, physical health checks required in the providers own policy following administration of sedative medicines were not always being recorded when the person was in the recovery area following a procedure. This places them at increased risk of avoidable harm of the side effects of prescribed medicines.