The Care Quality Commission
  • Hospital
  • Independent hospital

Alexandra Private Hospital

Overall: Inadequate read more about inspection ratings

Off Basil Close, Chesterfield, Derbyshire, S41 7SL (01246) 558387

Provided and run by:
Alexandra Health Care Limited

All Inspections

22/06/2023

During an inspection looking at part of the service

Alexandra Private Hospital is an independent hospital which provides cosmetic surgery to self-funding patients.

We carried out an unannounced focused inspection to follow up on concerns we found at our last inspection in February and March 2023, when we rated the cosmetic surgery core service overall as inadequate.

As a result of the March 2023 inspection the provider were imposed with the below conditions:

The provider is not to undertake any of the following regulated activities:

  • Treatment of disease, disorder, or injury
  • Surgical procedures
  • Diagnostic and screening procedures

We only inspected some of the key questions of safe and well led as this is where the breaches of regulation were found from our previous inspection and the reasons behind the section 31 conditions, latest report was published in June 2023.

We did not inspect the safe and well led key questions in full; instead, we focused on the key lines of enquiry where serious concerns had been previously identified to see if improvement had been made.

We did not collate enough evidence to re -rate the service as we only looked at areas based around the conditions imposed. We inspected this service to determine if the service had made improvements and if the conditions imposed could be uplifted, allowing the service to re-open.

22 February and 7 March 2023

During an inspection looking at part of the service

Alexandra Private Hospital is an independent hospital which provides cosmetic surgery to self-funding patients.

We carried out an unannounced focused inspection to follow up on concerns we found at our last inspection when we rated the cosmetic surgery core service overall as inadequate.

We only inspected the key questions of safe, effective, and well led as this is where the breaches of regulation were found for our previous inspection, published on 7 December 2022. We did not inspect the safe, effective, and well led key questions in full; instead, we focused on the key lines of enquiry where serious concerns had been previously identified to see if improvement had been made.

We collated enough evidence to rate both safe and well led key questions.

We did not rate the effective key question as we did not collect sufficient evidence to rate this key question.

We did not inspect the service for the caring and responsive key questions during this inspection.

Our rating of this location stayed the same. We rated it as inadequate because:

  • The service did not have oversight if staff were compliant with mandatory training and competence requirements for their roles. Staff did not have adequate training on how to recognise and report abuse. The service did not control infection risk well. Equipment and premises were not visibly clean. Staff used out-of-date products to wash their hands. Staff did not monitor the effectiveness of infection prevention and control measures. The design, maintenance and use of facilities, premises and equipment were not sufficient to keep patients safe. Staff did not always complete risk assessments for each patient. Staff did not identify or quickly act upon patients at risk of deterioration. The service could not evidence that patients knew who to contact to discuss complications or concerns following their surgery. Staff did not keep detailed records of patients’ care and treatment. Records were not comprehensively and consistently completed and did not follow best practice guidance. The service did not consistently use systems and processes to safely manage medicines.
  • The service did not monitor the effectiveness of care and treatment. Therefore, they did not use findings to make required improvements to the service to ensure patients received safe care.
  • Leaders did not have the necessary skills and abilities to run the service in relation to governance and managing performance and risk. They did not understand or effectively manage all the priorities and issues the service faced. They were not always visible and approachable in the service for patients and staff. They did not always support staff to develop their skills. Leaders did not operate effective governance processes, throughout the service and with partner organisations. Some staff were not clear about their roles and accountabilities and some non-clinical staff were asked to work outside of their competency level. Staff did not have regular opportunities to meet, for example at team meetings, to discuss and learn from the performance of the service. Leaders and teams did not use systems to manage performance effectively. They did not identify or escalate relevant risks and issues and therefore were unable to identify actions to reduce their impact. The service did not collect enough data in easily accessible formats, to understand performance, make decisions and improvements. The information systems at the service did not always support the delivery of the business.

However:

  • Staff managed clinical waste well.
  • Controlled drugs were safely secured.
  • The service had a vision for what it wanted to achieve.

11 October 2022

During a routine inspection

Alexandra Private Hospital is an independent hospital which provides cosmetic surgery to self-funding patients. We carried out an unannounced comprehensive inspection of surgery services at this location on 11 October 2022.

This is the first time we have rated this service. We rated it as inadequate overall because:

  • We were not assured all staff had completed training in key skills. The service did not always control infection risk well. Equipment was not always regularly checked and maintained to keep patients safe from harm. Risk assessments were not always tailored to meet the needs of the patients using the service and did not routinely complete NEWS scores during the pre-operative assessment. Records were not always comprehensive and up to date. The service did not always use systems and processes to safely prescribe, administer, record and store medicines.
  • We were not assured managers monitored the effectiveness of the service and the outcomes of patient care and treatment.
  • Leaders did not always have the skills to identify whether they had appropriate governance to support processes and did not have effective processes. The service did not have an assured process to for managing performance in a timely way or to assess and monitor risks.
  • The service did not have a strategy for how the service planned to achieve the vision or measures to identify if the vision had been achieved.

However:

  • The service had enough staff to care for patients and keep them safe. Staff showed an understanding of how to protect patients from abuse. The service managed safety incidents appropriately and learned lessons from them.
  • Staff provided care and treatment in line with national guidance and legislation, and made sure staff were competent. Staff assessed patients pain and post-operative nausea and vomiting regularly. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. They followed the two-stage consent process.
  • Although we observed minimal patient and staff interaction, what we did observe indicated staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet patients’ individual needs and made it easy for people to give feedback.
  • Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and staff were committed to improving services continually.

23 January 2017

During an inspection looking at part of the service

Alexandra Private Hospital is operated by Alexandra Healthcare Limited. The hospital facilities include 21 individual rooms located over two floors, and two operating theatres. The hospital does not perform surgery every day; on average, there are four to five days per month when surgery takes place.

The hospital provides cosmetic surgery for self-funding patients. The hospital also offers cosmetic procedures such as dermal fillers and laser hair removal, ophthalmic treatments and cosmetic dentistry. We did not inspect these services.

We inspected cosmetic surgery using our comprehensive inspection methodology, on the 14 and 16 June 2016. This identified the provider was in breach of five regulations of the Health and Social Care Act 2008 (Regulated Activity) Regulations 2014. These were:

  • Regulation 12: Safe care and treatment
  • Regulation 17 Good governance
  • Regulation 13 Safeguarding service users from abuse and improper treatment
  • Regulation 19 Fit and proper persons employed
  • Regulation 15 Premises and equipment

The full report of this inspection can be found on the CQC website: https://www.cqc.org.uk/location/1-114136771

We carried out a focused inspection again on the 23 January 2017, to follow up our concerns.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

At this inspection we looked at the safe, effective and well led domains only.

We regulate cosmetic surgery services but we do not currently have a legal duty to rate them. We highlight good practice and issues that service providers need to improve and take regulatory action as necessary.

We found the following areas of good practice:

  • The hospital was visibly clean and tidy and processes were in place to ensure equipment was cleaned appropriately between use.
  • The provider had introduced a new policy relating to the use of using aseptic non-touch technique (ANTT), which is a standardised approach to performing procedures in order to reduce the risk of a healthcare associated infection (HCAI). Staff confirmed their knowledge and understanding of this.
  • The provider had introduced monitoring processes to ensure that consumables were in date.
  • Medicines were stored securely and in date, and the provider had introduced a new policy for the prescribing of antibiotics, which was in line with national guidance.
  • Records were kept securely.
  • The provider was working with the local acute NHS trust to formalise the existing agreement for a patient to be transferred to the local acute NHS hospital if their condition deteriorated, as required by the Independent Healthcare Advisory Services.
  • Staff used an early warning score (EWS) to identify a deteriorating patient. Early warning scores have been developed to enable early recognition of a patient’s worsening condition by prompting nursing staff to get a medical review at specific trigger points.
  • The provider was actively working to meet the requirements of the Review of the Regulation of Cosmetic Interventions (2013).

However, we also found the following issues that the service provider needs to improve:

  • Governance, risk management and quality measurement were not robust and we were not assured the provider was taking a proactive approach to continuous learning and improvement.
  • We did not see sufficient evidence to ensure us that all incidents were reported and lessons learnt and shared.
  • Not all policies reflected up to date guidance or reflected the needs of the organisation.
  • Disclosure and barring service (DBS) checks had not been completed for the staff member we identified at the inspection on the 14 and 16 June 2016.
  • Information advising patient about cosmetic surgery and having an anaesthetic was out of date.
  • There was no system to electronically record details of any implants used, which could be easily accessible in the case of a product recall.
  • Whilst the provider had incorporated the World Health Organisation (WHO) Surgical Safety Checklist into existing documentation that staff used in theatres not all elements of the WHO had been included. The WHO checklist is a set of safety checks, identified for improving performance at safety critical time points within the patient’s intraoperative care pathway. Staff did not undertake child safeguarding training. Whilst the hospital did not care for children, this did not mean that children did not visit the hospital. Therefore, staff should have children safeguarding training as outlined in the Royal College of Paediatric Health intercollegiate document: safeguarding children and young people (2014).
  • There was no clear guidance as to which risk assessments and screening were required preoperatively for patients. Staff did not assess patients for their risk of venous thromboembolism (VTE) or consider their psychological well-being preoperatively. Preoperative checks, such as MRSA risk and blood pressure recording undertaken by the registered nurse as part of the pre-operative screening process had not been recorded.
  • Fasting guidance for patients undergoing a general anaesthetic did not reflect current best practice.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with one requirement notice that affected the cosmetic surgery service. Details are at the end of the report.

Professor Sir Mike Richards

Chief Inspector of Hospitals

14 June 2016

During a routine inspection

The Alexandra Private Hospital is an independent cosmetic hospital, based in Chesterfield and is part of Alexandra Health Care Limited.

The Alexandra Private Hospital is registered to provide the following Regulated Activities:

  • Diagnostic and screening procedures.
  • Surgical procedures.
  • Treatment of disease, disorder or injury.

The hospital’s senior management team consists of the owner who is also the registered provider and a theatre manager.

Our inspection was part of our ongoing programme of comprehensive Independent Health Care inspections. We inspected the hospital on 14 June 2016 on an announced visit. During this visit, there were no patients and no surgery planned for the day. On 16 June 2016, we carried out an unannounced inspection of the hospital, when there were patients undergoing surgical procedures.

We inspected the core service of surgery, at the Alexandra Private Hospital, which also incorporated the consultations patients had with their surgeon prior to and after their operations.

Are services safe at this hospital/service

Systems in place were not consistently reliable in protecting people from the risk of healthcare associated infections. We found some out of date consumable items on the resuscitation trolley and within theatres. The arrangement for managing medicines was not robust. Some medicines were out of date and some medicines were left unattended. There was no process in place for monitoring the use of prescriptions and no protocols for antibiotics prescribing. Temperatures of the medicine fridge were above the recommended range. Records were not kept securely. The safeguarding policy lacked detail, did not reflect current best practice and the service was unsure as to what level of safeguarding training staff received. There were no robust processes in place to respond to and reduce patients’ risk. The use of an early warning score (EWS) to identify a deteriorating patient was inconsistent; however patients did receive regular monitoring following surgery. Although there was a procedure in place for a patient to be transferred to the local acute NHS hospital if their condition deteriorated there was no formal written agreement between the local NHS acute trust to admit patients as required by the Independent Healthcare Advisory Services (2015). There were no clear processes for assessing patients’ risk of developing venous thromboembolism (VTE), for identifying those patients who should be screened for MRSA, or for assessing the psychological well-being of patients prior to theatre.

However, all staff had attended mandatory training. Staffing levels, including resident medical officer cover (RMO) were planned, implemented and reviewed to ensure there were sufficient staff to provide safe care. There was clear patient exclusion criteria to identify those patients who would not be suitable for surgery, which meant patients who were potentially high risk were not admitted. The service reported no never events, no wound infections and no VTE incidents. During our inspection we observed an anaesthetist respond appropriately and efficiently to a potential risk to a patient.

Are services effective at this hospital/service

Policies referred to out of date material, or did not reflect current best practice. The service had not started to collect data for the submission to the Private Healthcare Information Network (PHIN); PHIN requires every private healthcare facility to collect a defined set of performance measures and to supply that data to PHIN. The service did not collect and report Q-PROMs from patients. Q-PROMS are patient report outcome measures, which describe the level of patient satisfaction with certain operations and is a recommendation from the Royal College of Surgeons (RCS). The service did not keep electronically the details of implants used. This is required to ensure information is easily accessible in the case of a product recall. However, the service did use a paper-based system that recorded details of all the equipment used during a patient’s operation. There was no robust system in place to ensure information was communicated with the patient’s GP.

However, patient pain was managed effectively. Staff worked well together with effective communication and partnership working between the different professional groups. There was a robust procedure in place to ensure patients were able to give an informed consent. The service had an audit programme in place.

Are services caring at this hospital/service

Without exception, patients told us they were treated with kindness and compassion by all staff. Patients spoke positively about the service and the care they had received. Patients were fully involved in their care and staff explained procedures to them, and provided emotional support.

Are services responsive at this hospital/service

The service arranged appointments and surgery times to meet the needs of individual patients. Patients were able to self-refer to the hospital or were referred from other independent cosmetic surgery services. There was a clear complaints policy, although patient information displayed regarding this was inaccurate. Written information for patients was out-of-date.

Are services well led at this hospital/service

There was no documented vision or strategy for the hospital, which had been shared with staff. Governance arrangements were not robust. Quality assurance systems and audits completed had not identified the issues found on our inspection. Whilst the service reported no incidents, we could not be assured whether this was because there were no incidents or there was a failure to report. Many policies and risk assessments did not reflect up-to-date practice or current guidance. Disclosure and barring service (DBS) checks had not been completed for one staff member and one doctor did not have evidence of indemnity insurance in their file. The hospital had not made arrangements to ensure they were meeting the recommendations from the Review of Regulation of Cosmetic Interventions (2013).

However, staff spoke very positively about the leadership of the service; staff felt engaged and enjoyed working at the hospital. The service sought feedback from all patients regarding the care they had received.

Our key findings were as follows:

  • Systems in place were not consistently reliable in protecting people from healthcare associated infections. We saw dust on equipment such as fans and dust in the corners of patients’ rooms. We saw debris had collected in the light fitting of theatre. There was inappropriate storage of items such as mop heads and linen. Decontamination procedures for equipment were ineffective and staff did not always adhere to recognised good practice procedures, such as using aseptic non-touch technique (ANTT), which is a standardised approach to performing procedures in order to reduce the risk of a healthcare acquired infection (HCAI).
  • Whilst the service reported no incidents, we could not be assured whether this was because there were no incidents or there was a failure to report.
  • The policy for reporting notifiable incidents to the CQC, referred to out of date legal regulations.
  • We found some out of date consumable items, some of these were on the resuscitation trolley.
  • The arrangement for managing medicines was not robust; some medicines were out of date and some medicines were left unattended. There was no process in place for monitoring the use of prescriptions and no protocols for antibiotics prescribing. Temperatures of the medicine fridge were above the recommended range.
  • Records were not kept securely and poor quality photocopied documentation was used.
  • The safeguarding policy lacked detail, did not reflect current best practice and the service was unsure as to what level of mandatory safeguarding training was provided.
  • There were no robust processes in place to respond to and reduce patients’ risk. The use of an early warning score (EWS) to identify a deteriorating patient was inconsistent, although patients were monitored regularly following surgery.
  • Although there was as procedure in place for a patient to be transferred to the local acute NHS hospital if their condition deteriorated there was no formal written agreement between the local NHS acute trust to admit patients, as required by the Independent Healthcare Advisory Services (2015).
  • Documentation that reflected The World Health Organisation (WHO) Surgical Safety checklist (2008) was under development, but this had not yet been implemented.
  • There was no clear guidance as to which risk assessments and screening were required preoperatively for patients. There was no clear guidance for assessing patients for their risk of developing venous thromboembolism (VTE), or identifying those patients who required screening for MRSA. There was no consistent assessment of the psychological well-being of patients prior to theatre.
  • There was no robust system in place to ensure information was communicated with the patient’s GP.
  • The service had not started to collect data for the submission to the Private Healthcare Information Network (PHIN), nor did it collect and report on Q-PROMs for all patients. Q-PROMS are patient report outcome measures, which describe the level of patient satisfaction with certain operations and is a recommendation from the Royal College of Surgeons (RCS)
  • The hospital had not made any arrangements to ensure that surgical cosmetic procedures were coded in accordance with SNOMED_CT. SNOMED_CT uses standardised codes to describe cosmetic surgical procedures, which can be used across electronic patient record systems.
  • There was no system to electronically record details of implants, which could be easily accessible in the case of a product recall.
  • Many policies and risk assessments did not reflect up-to-date practice or current guidance.
  • Disclosure and barring service (DBS) checks had not been completed for one staff member and one doctor did not have evidence of indemnity insurance in their file.
  • Written information for patients relating to having an anaesthetic was not current.
  • All staff had attended mandatory training.
  • Staffing levels and skill mix were planned, implemented and reviewed to ensure there were sufficient numbers of staff.
  • Staff spoke very positively about the leadership of the service; staff felt engaged and enjoyed working at the hospital.
  • We saw effective communication and partnership working between the different professional groups.
  • There was a clear patient exclusion criteria to identify those patients who would not be suitable for surgery.
  • The service reported no never events, no incidents, no wound infections and no VTE incidents.
  • We observed an operation, where the anaesthetist responded appropriately and efficiently to a potential risk
  • Without exception, patients told us they were treated with kindness and compassion by all staff. Patients spoke positively about the service and the care they had received. Patients were fully involved in their care and staff explained procedures to them.
  • Patient’s pain was managed effectively and staff provided emotional support.
  • Patients were able to self-refer to the hospital and the service arranged appointment and surgery times to meet the needs of the individual patient.
  • There was a robust procedure in place to ensure patients were able to give a fully informed consent.
  • The service had a clear complaints policy, and the service continually sought feedback from all patients regarding the care they had received.

There were areas where the provider needs to make improvements.

Importantly, the provider must:

  • Ensure systems and processes are in place to ensure people are protected from healthcare associated infections.
  • Ensure policy for reporting notifiable incidents in line with the CQC (Registration) Regulations 2009.
  • Ensure systems and processes are in place so that all incidents are reported and investigated.
  • Ensure learning from incidents is used to evaluate and improve practice.
  • Ensure processes are in place to guarantee that consumables are in date.
  • Ensure there is a safe process for the management of medicines.
  • Ensure safe storage of patients’ records.
  • Ensure that safeguarding policy is in line with current legislation and that staff receive mandatory safeguarding training at the correct level.
  • Finalise and implement new documentation that reflects the World Health Organisation (WHO) Surgical Safety Checklist.
  • Ensure there is a formal written agreement with the local NHS acute trust for the transfer of a deteriorating patient.
  • Improve compliance with the use of the early warning system (EWS).
  • Ensure there is clear guidance for which risk assessments and screening are required preoperatively for patients.
  • Ensure all policies reflect up-to-date guidance and that care provided reflects best practice.
  • Ensure the recommendations from the Review of the Regulation of Cosmetic Interventions (2013) are being met.
  • Ensure there are robust governance arrangements in place that include ensuring risk assessments reflect best practice and that there is a robust system for staff checks.
  • Ensure patient information is up-to-date and patients are signposted to information resources to help make an informed decision about their procedure as recommended by the Royal College of Surgeons Standards (2016).

In addition the provider should:

  • Consider providing clear guidance describing which operations need to be performed in the theatre with specialist ventilation.
  • Consider improving the quality of the documents used for patients’ records.
  • Consider the procedure for the nurse lead pre-operative clinic.
  • Consider developing a training needs analysis for all staff.
  • Consider how they meet the requirements of the Duty of Candour regulation.

Professor Sir Mike Richards

Chief Inspector of Hospitals

22 January 2014

During a routine inspection

During our visit to Alexandra Private Hospital we spoke with two patients who had recently had cosmetic surgery at the hospital. Both of the patients spoke very highly of the care and treatment they had received, commenting that the nursing staff were very attentive to their needs. We also saw positive feedback from patients who had received dental treatment at the hospital.

Care and treatment was planned and delivered in a way that ensured people's safety and welfare and there were arrangements in place to deal with foreseeable emergencies. Patients were being cared for in a clean, hygienic environment.

The provider worked in co-operation with others to ensure the safety and welfare of patients.

The provider had an effective system in place to regularly assess and monitor the quality of service that people receive. This included a number of quarterly audits used to monitor infection control, patient records and the results of patient questionnaires.

15 March 2013

During a routine inspection

Alexandra Private Hospital's dental surgery had recently begun to take enquiries and hold consultations with patients about proposed treatments. The provider planned to begin providing dental treatment for people in April 2013.

We saw that consent was sought before any procedure was undertaken and that people were given appropriate information and support before giving their agreement to proceed with treatment. One person told us, "I was fully informed about every aspect of my treatment. I was told that I will need to give my consent when I'm sure, and before anything is done."

We looked at records, policies and procedures and found that appropriate arrangements were in place for the planning and delivering people's treatment and care. We spoke with people who had attended a consultation and found that they were happy with the information and care they had received. One person we spoke with said, "I found everyone very professional indeed. Certainly the best dentist I have been to."

We saw that a complaints procedure was made available to anyone who received care

We looked at equipment found that it was appropriate for the treatments being planned. We also found that systems were in place to ensure that equipment and medical devices were safe for use.

We saw that procedures ensured that appropriately qualified and experienced staff were employed to provide people's treatment and care at the dental surgery.

15 March 2013

During a routine inspection

People we spoke with were happy with the treatment and care they received at Alexandra Private Hospital. One person told us, "Everything is excellent here. Cleanliness, staff, everything." Another person told us, "They are so professional. I would recommend the hospital to anyone."

We found that recruitment procedures, including for nursing and medical staff, ensured that suitably qualified and experienced people were employed to deliver people's treatment and care. We also found that people's care was assessed, planned and delivered in a way that protected their welfare and safety. People we spoke with said their privacy and dignity was respected by staff at the hospital.

We saw that people received information and were fully involved in their treatment and care. We also saw that people's consent was gained before they received any treatment.

We saw that suitable equipment was used at the hospital and that systems were in place to ensure that it was safe and used correctly.

We found that there was an effective system in place for people to make comments and complaints. If complaints were received they were dealt with appropriately by managers at the hospital.