At ASET Hospital, we value the role of CQC in maintaining the safest and highest standards of healthcare in UK. This mirrors ASET Hospital’s ethos of excellent, compassionate care. CQC visits act as a tool of communication and a pathway for improvement. These visits are conducted to assess several aspects of a hospital; facilities, staff and services provided.
In December 2022, our hospital had its CQC inspection when ASET staff welcomed and helped the CQC inspection team to conduct their work.
“Could I take this opportunity to thank you once again for the arrangements that you made to help organise the inspection and for the cooperation that we experienced from you and your staff” – CQC inspection team, Dec 22.
Following the inspection, we received the CQC report, which includes assessment of different services provided by ASET Hospital. The report praised the hospital for some outstanding and good services but at the same time advised the hospital with some improvements in few areas and services. The hospital immediately implemented the changes advised by the CQC team.
Summary of the report
Outstanding practice
The following outstanding practice:
The service had a designated emotional well-being practitioner who was closely involved in providing tailored support for individual patients, working together with nursing and consultant staff in the service. This support available included psychological assessment, stress management techniques if required on the day of surgery and a well-being follow up appointment. This staff member was also the patient coordinator and chaperone; patients we spoke with spoke highly of their very positive experience of patient care in receiving this service.
GOOD service
We rated the service as good because of the following:
Evidence-based care and treatment
The service provided care and treatment based on national guidance and evidence-based practice. Managers checked to make sure staff followed guidance. The service met cosmetic surgery standards published by the Royal College of Surgeons.
Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
Emotional support
Staff provided emotional support to patients, families and carers to minimise their distress. They understood patients’ personal, cultural and religious needs.
Understanding and involvement of patients and those close to them
Staff supported patients, families and carers to understand their condition and make decisions about their care and treatment.
Service delivery to meet the needs of local people.
The service planned and provided care in a way that met the needs of local people and the communities served. It also worked with others in local organisations to plan care.
Access and flow
People could access the service when they needed it and received the right care.
Patient outcomes
Staff monitored the effectiveness of care and treatment. They used the findings to make improvements and achieved good outcomes for patients.
Competent staff
The service made sure staff were competent for their roles. Managers appraised staff’s work performance and provided support and development.
Nurse and support staffing
The service had enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Leaders regularly reviewed and adjusted staffing levels and skill mix, and gave bank and agency staff an induction.
Medical staffing
The service had enough medical staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Leaders regularly reviewed and adjusted staffing levels and skill mix and gave locum staff a full induction.
Multidisciplinary working
Doctors, nurses and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care.
Seven-day services
The service was available seven days a week to support timely patient care.
Health promotion
Staff gave patients practical support and advice to lead healthier lives.
Incidents
Staff knew what to do if an incident occurred. Staff understood the duty of candour.
Consent, Mental Capacity Act and Deprivation of Liberty Safeguards
Staff supported patients to make informed decisions about their care and treatment. They followed national guidance and ensured that patients gave consent in a two-stage process with a cooling-off period of at least 14 days between stages. They understood how to support patients.
Leadership
Leaders had the skills and abilities to run the service. They mostly understood and managed the priorities and issues the service faced. They were visible and approachable in the service for patients and staff. They supported staff to develop their skills and take on more senior roles.
Advice to improve
Staff training
“Not all staff had completed training on how to recognise and report abuse and compliance with safeguarding training was low. Staff had an understanding of how to protect patients from abuse and a basic awareness of safeguarding procedures in the service. Staff knew how to make a safeguarding referral and who to inform if they had concerns. They explained they would discuss the case with the registered manager who was also the designated safeguarding lead for the service. The registered manager had completed level three safeguarding training.”
ASET hospital’s are experienced well-trained staff who have worked in NHS and other hospital before they joined ASET. They have completed their safeguarding in their previous jobs. The staff records have been updated and training completed.
Cleanliness, infection control and hygiene
“The service mainly controlled infection risk well, however the air filter in one of the theatres was visibly dusty. The service used systems to identify and prevent surgical site infections. Staff mainly used equipment and control measures to protect patients, themselves and others from infection. They kept the premises visibly clean. We inspected a sample of patient rooms and en-suite bathrooms and found them to be visibly clean. Patients we spoke with were satisfied with the level of cleanliness of their patient rooms.”
The air filter was in the unused part of the hospital which has been upgraded in the same week of inspection. See attached photos
Environment and equipment
“The design, maintenance and use of facilities, premises and equipment mainly kept people safe, however one of the clinical rooms had damp on the wall. Staff mainly managed clinical waste well. Staff were trained to use equipment. The service had damp in one of their theatre rooms which if used could cause a risk of infection for patients. Leaders told us that the damp treatment had been cancelled due to the inspection. They explained that the clinical room had not been used since the damp had been identified.”
The damp was in a decommissioned room, out of use for weeks prior to the visit. This room was part of the hospital expansion which happened in the same inspection week. That room has been upgraded to a local anaesthetic operating theatre. See photos
Meeting people’s individual needs
“The service mostly took account of patients’ individual needs and preferences. Staff made some reasonable adjustments to help patients access services, although there were limited arrangements for patients who required support from an interpreter or for communication needs. There was a system for referring patients for psychological assessment before starting treatment, if necessary.”
The hospital had a comprehensive interpreter and communication service in place. However, CQC advised to add clearer notification at the hospital reception and website which has been immediately done.
Learning from complaints and concerns
“It was not always easy for people to raise concerns about care received. The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff.”
The CQC report proved that ASET hospital takes any complaint or concern seriously. The hospital placed the complaint/feedback form on the hospital website. However, the advice from CQC is to place the complaint policy/form at the hospital reception which has been immediately done.
Vision and Strategy
“The service had key objectives for what it wanted to achieve. However, there was limited development of a strategy to turn this into action. The vision and strategy were not always focused on sustainability of services and staff did not always have a clear understanding of future plans for the services.”
ASET hospital has shown steady stable expansion. This is mirrored by continuous recruitment of new staff which need time to grasp the hospital future plans and long-term vision. However, all staff, senior and new, understand the fundamental aim of the whole service as confirmed by CQC :
“Staff we spoke with had a general awareness of providing a patient-centred approach to care as the service’s key aim.”
In response to CQC advice, the hospital has enhanced its staff communication tools and increased the frequency of staff regular meetings.
Culture
“Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service did not always promote equality and diversity in daily work although staff had opportunities for career development. The service had an open culture where patients, their families and staff could raise concerns without fear.”
ASET hospital is proud with the culture we created for patients and staff since we started. However, the CQC advice was related to updating the staff records on Equality and Diversity training which has been done.
Out of date Medicine
“The hand sanitiser bottles in the reception area were passed their expiry date.”
The only medicine CQC report referred to was a hand sanitiser displayed in the reception area. This was due to human error by a member of staff who didn’t check the expiry date which was just passed.
Within days from the publication of CQC report, ASET hospital communicated with the CQC team and implanted their advice and recommendation. A full action plan have been submitted to CQC and we are expected further engagement or re-visit from the CQC soon.
We welcome you to read the full CQC report – Which can be found by clicking here