Pinehill awarded GOOD in their recent CQC Inspection

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Pinehill awarded GOOD in their recent CQC Inspection

Pinehill CQC

Pinehill hospital had their comprehensive inspection on December 4th & 5th 2018. The CQC rating improved with Pinehill being rated as "GOOD" overall.

During the inspection the CQC found some good areas of practice including;

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had completed safeguarding adult and children’s training.
  • The hospital managed patient safety incidents well. All staff recognised incidents and reported them appropriately. Managers investigated incidents thoroughly and shared lessons learned with teams throughout the hospital. When things went wrong, staff apologised and gave patients honest information and suitable support. There was good awareness of Duty of Candour and this was applied appropriately. There was a culture of openness and honesty at all levels.
  • Staff generally kept appropriate records of patients’ care and treatment. Records were clear, up-to-date and easily available to all staff providing care.
  • Services in the hospital provided care and treatment based on national guidance and evidence of its effectiveness.
  • Staff gave patients enough food and drink to meet their needs and improve their health. The service made adjustments for patients’ religious, cultural and other preferences.
  • The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.
  • The service had enough medical and allied health professional staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment all the time.
  • Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. They followed hospital policy and procedures when a patient could not give consent. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.
  • There was good multidisciplinary working across the hospital. Staff in different teams worked together to benefit patients. Doctors, nurses and other healthcare professionals, supported each other to provide good care.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. Patients were treated with dignity, respect and kindness during all interactions with staff.
  • Staff provided emotional support to patients to minimise their distress.
  • Staff involved patients and those close to them in decisions about their care and treatment. They were communicated with and received information in a way that they could understand.
  • Hospital services were planned and developed to meet the needs of the local population for both private and NHS patients.
  • The service had suitable premises and equipment. Hospital premises were clean, well maintained, and suitable equipped. There was an equipment replacement programme to ensure that all large items of equipment were replaced when they became outdated.
  • The hospital took account of patients’ individual needs. Reasonable adjustments were made for patients who had additional or complex needs.
  • People could access services when they needed it. Waiting times from referral to treatment for surgical procedures, and arrangements to treat and discharge patients, were in line with good practice. There was an emphasis on the importance of flexibility, choice and continuity of care across the hospital. Services were delivered at times that were suitable for patients through the provision of out of hours services, and the use of additional clinics and appointments to meet areas of high demand.
  • The hospital treated concerns and complaints seriously. Managers investigated them thoroughly and made responses within agreed timescales. There was an appropriate escalation process for complaints when patients were not satisfied with the outcome of a complaints investigation. Lessons were learned from complaints and were shared widely with all staff.
  • Managers at all levels in the hospital had the right skills and abilities to run services and provide high-quality sustainable care. There were named and experienced heads of department for each area. Each service lead was passionate about the service they led and worked well with the team of staff in their department.
  • The hospital had a vision for what it wanted to achieve and workable plans to turn it into action. The hospital set a five-year strategy and vision from 2018 to 2021. All staff we spoke with were aware of the vision for the hospital, and understood their role in achieving it.
  • Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
  • The service systematically improved service quality and safeguarded high standards of care by creating an environment for excellent clinical care to flourish.
  • The service had good systems to identify risks, plan to eliminate or reduce them, and cope with both the expected and unexpected.
  • Information needed to deliver effective care and treatment was available to relevant staff in a timely and accessible way.
  • The service engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.
  • The service was committed to improving services by learning from when things went well or wrong, promoting training and innovation.

Karen Doyle, Head of Clinical Services said, ‘I am very proud of the hard work being done by the entire hospital team. This has been demonstrated in the improved result of our CQC inspection achieving a good overall rating from requires improvement when last inspected. I am confident the team will continue to develop and promote positive change in the services being delivered’.


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