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Inspection Summary


Overall summary & rating

Good

Updated 11 November 2016

We carried out a comprehensive inspection of BMI Mount Alvernia Hospital on the 19, 20 and 26 July 2016 as part of our national programme to inspect and rate all independent hospitals. We inspected the core services of surgical services, medical services, out-patient and diagnostic imaging services as these incorporated the activity undertaken by the provider, BMI Healthcare Limited at this location.

We rated all four core services as good overall.

Are services safe at this hospital/service

Incidents were reported, investigated and learning evidenced. Reports were communicated to all staff.

Patients were cared for in a visibly clean environment that was well maintained. There were arrangements to prevent the spread of infection and compliance with these was monitored. There were no outbreaks of serious infection reported.

There were processes for assessing and responding to patient risk. The service had enough staff with the skills and experience to care for the number of patients and their level of need. The majority of staff had completed the provider’s mandatory training programme. Staff were aware of their responsibilities with regard to the protection of people in vulnerable circumstances.

There were adequate supplies of appropriate equipment that was properly maintained to deliver care and treatment and staff were competent in its use. Staff demonstrated good medicines storage, management and administration.

There was room for improvement with safety in surgery where we found that the side of the patient due to be operated on was not always clearly or accurately documented on daily operating lists. We also found that staff did not consistently adhere to the World Health Organisation Safe Surgery checklist.

We also found not all staff had not attended major incident or business continuity training.

Are services effective at this hospital/service

We found care and treatment reflected current national guidance. There were formal systems in place for collecting comparative data regarding patient outcomes.

Staff worked with other health professionals in and out of the hospital to provide services for patients. Patients were cared for by staff who had undergone specialist training for the role and who had their competency reviewed.

There were arrangements that enabled patients to access advice and support seven days a week, 24 hours per day. There was comprehensive assessment of patient needs. This included clinical needs, physical health, nutrition and hydration needs. Patients received adequate pain relief.

Patients provided informed, written consent before commencing their treatment. Where patients lacked capacity to make decisions, staff were able to explain what steps to take to ensure relevant legal requirements were met.

There was a proactive audit programme that included national, corporate, hospital and departmental audits. Results were shared throughout the hospital and collated to identify themes.

Are services caring at this hospital/service

Staff provided sensitive, caring and individualised personal care to patients. Staff supported patients to cope emotionally with their care and treatment as needed.

Patients commented positively about the care provided from all staff they interacted with. Staff treated patients courteously and with respect. Patients felt well informed and involved in their procedures and care, including their care after discharge.

Patients and their relatives were involved in their care and were given adequate information about their diagnosis and treatment. Families were encouraged to participate in the personal care of their relatives with support from staff.

We observed patients treated with compassion, care and dignity. Patient feedback was positive and staff demonstrated commitment to continuous improvement.

Are services responsive at this hospital/service

There were a variety of mechanisms to provide psychological support to patients and their supporters. This range of service meant that each patient could access a service that was relevant to their particular needs. For example those with spiritual needs, those requiring bariatric equipment, patients whose first language was not English, or support for people living with dementia or learning disabilities.

The services were delivered in a way that met the needs of the local population and allowed patients to access care and treatment when they needed it. Waiting times, delays and cancellations were minimal and well managed. Patients told us staff were responsive to their needs.

Complaints management was a priority in the hospital. The process was transparent and open with learning communicated across the hospital.

Are services well led at this hospital/service

There were clear organisational structures and roles and responsibilities. The senior management team were highly visible and accessible across the hospital. Staff described an open culture and said managers were approachable at all times.

Staff spoke highly about their departmental managers and the support they provided to them and patients. All staff said managers supported them to report concerns and their managers would act on them. They told us their managers regularly updated them on issues that affected the separate departments and the whole hospital.

There were good governance, risk and quality systems and processes that staff understood. The committee structure supported this with reports disseminated and discussed appropriately. Staff from all departments had a clear ambition for their services and were aware of the vision of their departments.

Staff asked patients to complete satisfaction surveys on the quality of care and service provided. Departments used the results of the survey to improve services. The hospital had a risk register which was reviewed at the governance committee meetings. However, the risk register was not divided into separate departments.

The management team had an understanding of the Workforce Race Equality Standard (WRES) as there is a national requirement to produce key data relating to race quality in the workplace. BMI had started to collect data nationally which they currently held, for example the numbers of staff from black and ethnic minority groups. The management team was in the process of implementing reporting processes to capture the data to enable them to fully comply with WRES reporting requirements.

However there were areas of where the provider needs to make improvements.

The provider must:

  • Ensure that staff are trained to the appropriate level for safeguarding children. Children attend the hospital as patients and visitors.

The provider should:

  • Provide each individual department with a separate and relevant risk register.
  • Enable all staff to attend major incident or business continuity training and attend simulation exercises.
  • The outpatient department should adequately risk assess environment and equipment.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 11 November 2016

Incidents were reported, investigated and learning evidenced. Reports were communicated to all staff.

Patients were cared for in a visibly clean environment that was well maintained. There were arrangements to prevent the spread of infection and compliance with these was monitored. There were no outbreaks of serious infection reported.

There were processes for assessing and responding to patient risk. The service had enough staff with the skills and experience to care for the number of patients and their level of need.

The majority of staff had completed the provider’s mandatory training programme. Staff were aware of their responsibilities with regard to the protection of people in vulnerable circumstances.

There were adequate supplies of appropriate equipment that was properly maintained to deliver care and treatment and staff were competent in its use. Staff demonstrated good medicines storage, management and administration.

There was room for improvement with safety in surgery where we found that the side of the patient due to be operated on was not always clearly or accurately documented on daily operating lists. We also found that staff did not consistently adhere to the World Health Organisation Safe Surgery checklist.

We also found that staff had not attended major incident or business continuity training, or attended any simulation exercises.

Effective

Good

Updated 11 November 2016

We found care and treatment reflected current national guidance. There were formal systems in place for collecting comparative data regarding patient outcomes.

Staff worked with other health professionals in and out of the hospital to provide services for patients. Patients were cared for by staff who had undergone specialist training for the role and who had their competency reviewed.

There were arrangements that enabled patients to access advice and support seven days a week, 24 hours per day.

There was comprehensive assessment of patient needs. This included clinical needs, physical health, nutrition and hydration needs. Patients received adequate pain relief.

Patients provided informed, written consent before commencing their treatment. Where patients lacked capacity to make decisions, staff were able to explain what steps to take to ensure relevant legal requirements were met.

There was a proactive audit programme that included national, corporate, hospital and departmental audits. Results were shared throughout the hospital and collated to identify themes.

Caring

Good

Updated 11 November 2016

Staff provided sensitive, caring and individualised personal care to patients. Staff supported patients to cope emotionally with their care and treatment as needed.

Patients commented positively about the care provided from all staff they interacted with. Staff treated patients courteously and with respect. Patients felt well informed and involved in their procedures and care, including their care after discharge.

Patients and their relatives were involved in their care and were given adequate information about their diagnosis and treatment. Families were encouraged to participate in the personal care of their relatives with support from staff.

We observed patients treated with compassion, care and dignity. Patient feedback was positive and staff demonstrated commitment to continuous improvement.

Responsive

Good

Updated 11 November 2016

There were a variety of mechanisms to provide psychological support to patients and their supporters. This range of service meant that each patient could access a service that was relevant to their particular needs. For example those with spiritual needs, those requiring bariatric equipment, patients whose first language was not English, or support for people living with dementia or learning disabilities.

The services were delivered in a way that met the needs of the local population and allowed patients to access care and treatment when they needed it.

Waiting times, delays and cancellations were minimal and well managed. Patients told us staff were responsive to their needs.

Complaints management was a priority in the hospital. The process was transparent and open with learning communicated across the hospital.

Well-led

Good

Updated 11 November 2016

There were clear organisational structures and roles and responsibilities. The senior management team were highly visible and accessible across the hospital. Staff described an open culture and said managers were approachable at all times.

Staff spoke highly about their departmental managers and the support they provided to them and patients. All staff said managers supported them to report concerns and their managers would act on them. They told us their managers regularly updated them on issues that affected the separate departments and the whole hospital.

There were good governance, risk and quality systems and processes that staff understood. The committee structure supported this with reports disseminated and discussed appropriately. Staff from all departments had a clear ambition for their services and were aware of the vision of their departments.

Staff asked patients to complete satisfaction surveys on the quality of care and service provided. Departments used the results of the survey to improve services. The hospital had a risk register which was reviewed at the governance committee meetings.

However,

the risk register was not divided into separate departments.

The management team had an understanding of the Workforce Race Equality Standard (WRES) as there is a national requirement to produce key data relating to race quality in the workplace. BMI had started to collect data nationally which they currently held, for example the numbers of staff from black and ethnic minority groups. The management team was in the process of implementing reporting processes to capture the data to enable them to fully comply with WRES reporting requirements.

Checks on specific services

Medical care (including older people’s care)

Good

Updated 11 November 2016

We found the medical services at BMI Mount Alvernia to be good. This was because:

  • The hospital had systems and processes in place to keep patients free from harm.
  • Infection prevention and control practices were in line with national guidelines.
  • Areas we visited were visibly clean, tidy and fit for purpose. The environment was light, airy and comfortable. The oncology unit was awarded the Macmillan Quality Environment Mark, which identifies and recognises cancer environments that provide high levels of support and care for people affected by cancer. It had been developed in partnership with patients living with cancer and the Department of Health. It is a core component of the English Cancer Reform Strategy.
  • The hospital provided end of life care training and had an on going education programme which was attended by staff.
  • The palliative care team worked with ward staff to provide holistic (the treating the whole of something and not just a part) care for patients with palliative and end of life care needs in line with national guidance. This meant a multidisciplinary approach was maintained.
  • Staff kept medical records accurately and securely in line with the Data Protection Act 1998.
  • Medicines were stored in locked cupboards and administration was in line with relevant legislation.
  • The endoscopic services demonstrated compliance with British Society of Gastroenterology (BSG) guidelines. The service was working toward Joint Advisory Group (JAG) on gastrointestinal (GI) endoscopy accreditation incorporating the endoscopy global rating scale, which is the quality improvement and assessment tool for the GI endoscopy service.
  • Oncology services demonstrated compliance with National Institute for Health and Care Excellence (NICE) guidelines.
  • The medical services had an appropriate level of competent staff.
  • Staff completed appraisals regularly and managers encouraged them to develop their skills further.
  • Staff interacted with patients in a kind and caring manner. Patients told us they felt relaxed when having their treatment.
  • The hospital and its staff recognised that provision of high quality, compassionate end of life care to its patients was the responsibility of all clinical staff that looked after patients at the end of life.
  • Staff at the hospital provided focused care for dying and deceased patients and their relatives. The hospital had an end of life care link person. Facilities were provided for relatives and the patient’s cultural, religious and spiritual needs were respected.
  • Managers were visible, approachable and effective. This had resulted in a well-led service that had a clear vision and strategy to provide a streamlined service for medical and end of life care patients.
  • The hospital had a clinical governance committee and medical advisory committee (MAC) both responsible for ensuring there were robust systems and processes in place in relation to governance and assurance.

However

  • The safeguarding lead was not trained to level 3 for safeguarding children as per national guidelines.
  • Staff had not attended major incident or business continuity training, or attended any simulation exercises.
  • The risk register was hospital wide and not divided into separate departments.

Surgery

Good

Updated 11 November 2016

We rated the surgical services at Mount Alvernia Hospital as good because:

  • The hospital had good systems and processes in place to keep patients free from harm. There was a good track record on safety.
  • Staff understood the incident reporting process and their responsibilities to report, investigate and learn.
  • There were processes for assessing and responding to patient risk and safe protocols for patient transfer. There was a comprehensive assessment of patient needs. There were sufficient skilled and experienced staff to care for patients.
  • The hospital worked to current national guidance. The hospital participated in national audits and had a proactive programme of hospital and departmental audits. Results and recommendations were shared throughout the hospital with change and learning evidenced.
  • Patients were treated with compassion, care and dignity. They were well supported and provided with good information.
  • Services were provided to meet the needs of the local population and allow access to care and treatment. There were minimal delays or cancellations for treatment and these were well managed.
  • Complaints were investigated and discussed openly with staff.
  • The organisational and committee structures supported good governance systems and processes. Staff described an open culture within the hospital and were clear on roles and responsibilities.
  • The hospital collected patient feedback and demonstrated ongoing work by all staff towards continuous improvement in the patient experience.

However:

  • The safeguarding lead was not trained to level 3 for safeguarding children as per national guidelines.
  • The side of the patient due to be operated on was not always clearly or accurately documented on daily operating lists.
  • Staff had not attended major incident or business continuity training, or attended any simulation exercises.
  • The risk register was not compiled so that department risks could be identified.

End of life care

Updated 20 February 2015

Palliative and end of life care specialist input was via the Palliative Care medical consultants and the Palliative Care nurse. The end of life care delivered was a consultant led service with the Palliative care consultants reviewing patients daily as well as being contactable by telephone if staff required support. Out of hours and over the weekend the Palliative Care consultants provided on –call cover and undertook any reviews necessary. This meant that patients had access to specialist advice 24/7.

The care people receive at end of life was a whole team approach with the ward nursing and medical staff and the palliative care team all working together to deliver holistic care. Medicines were provided in line with the Adult Palliative Care Guidance 2nd edition 2006. The choice of medications at the end of life had been aligned to local community guidelines to support safe and consistent practice between care providers. A fast track process is in place to support patient’s wishes and preferences to achieve their Preferred Place of Care.(PPC)

The nursing staff we spoke to on the wards had not received end of life training and no end of life care link nurses were present on the wards. At the time of the inspection BMI Mount Alvernia did not have an end of life pathway to support staff to identify and care for people at the end of life. End of life patients were placed on the generic medical pathway with specialist input from the palliative care consultants and nurse.

Leadership of the specialist palliative care team was good and quality and patient experience was seen as a priority.

Outpatients

Good

Updated 11 November 2016

We found the outpatient and diagnostic imaging services at BMI Mount Alvernia to be good. This was because:

  • The hospital had good systems and process in place to keep patients from harm.

  • A wide variety of modern equipment was available for staff to deliver a range of services and examinations.

  • Staff managed medicines in line with best practice and stored them securely.

  • The hospital had a comprehensive audit programme in place to monitor services and identify areas for improvement.

  • The outpatient and diagnostic imaging departments had sufficient numbers of appropriately trained competent staff to provide their services.

  • Staff dealt with patients in a kind, caring and considerate manner. Patients were happy with the care they received.

  • The hospital was responsive to the needs of the local populations. Appointments could be accessed in a timely manner and at a variety of times throughout the day.

  • Results of investigations were available quickly and double checked by members of staff.

  • Managers were visible, approachable and effective.

  • The hospital had a clinical governance committee and medical advisory committee both responsible for ensuring there were robust systems and processes in place in relation to governance and assurance.

However:

  • Children attended the outpatient department, but neither the safeguarding lead nor any staff had attended level three safeguarding children training as per national guidelines.

  • The assessment and response to risk was not managed consistently throughout outpatient and diagnostic imaging services.