Alexandra Private 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

At our last inspection, the service was in breach of regulation due to us finding out of date equipment and an inadequate process for reporting incidents. We found leaders made improvements since this inspection including implementation of a robust process for reporting and investigating incidents, and ensuring that all equipment on the ward and in theatre was present and within date. As a result, the service is no longer in breach of this regulation and at this inspection, the rating for this key question has changed to Good.

Staff recorded patient care consistently using a patient pathway booklet, ensuring treatment plans were accessible and up to date. Staff had access to postoperative monitoring procedures, including escalation protocols and a formal agreement with a local NHS hospital for emergency transfers.

Safeguarding processes were robust, with an adult safeguarding policy that included guidance for concerns involving children.

The hospital environment was clean, well-maintained, and compliant with Control of Substances Hazardous to Health (COSHH) regulations. Safety checks confirmed all resuscitation and airway equipment was in date and properly maintained.

Staff received appropriate role-specific training, including structured inductions and annual appraisals. Agency staff provided evidence of mandatory training. Staffing levels met national guidance, with a safe dual-role policy for scrub nurses.

Staff had access to infection control policies.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. Leaders listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service had a clear process for reporting incidents, which staff were aware of. Incidents were reported using an incident report tracker that was reviewed regularly by the management team. As part of the inspection, we examined the tracker and noted that one incident had been reported since our last inspection. There had been no serious incidents. Documentation within the tracker evidenced that each incident had been appropriately investigated, with lessons learned and proportionate actions taken to reduce future risk. Feedback from these incidents was shared with staff at team meetings. Staff meetings were used as an opportunity to deliver group training sessions on subjects such as duty of candour and sepsis awareness.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Leaders made sure there was continuity of care, including when people moved between different services.

There was a clear process in place for documenting the patient pathway within patient medical records. A patient pathway booklet was actively in use. This enabled clinicians to track the patient journey throughout the course of treatment, ensuring that care plans were consistently recorded and readily accessible.

The provider had a policy in place outlining the procedures for monitoring patients following surgery, including specific guidance on when and how to escalate care appropriately. In the event of patient deterioration, there was a clearly defined escalation pathway which included an agreement with a local NHS hospital to transfer patients who required urgent medical intervention.

We scored the service as 3. The evidence showed a good standard.Leaders provided staff with training and access to up to date policies to ensure patients at risk of abuse could be protected.

The service had an up-to-date safeguarding adults policy in place. As individuals under the age of 18 were not permitted on the premises, a separate safeguarding children policy was not required. However, the existing adult safeguarding policy included guidance on how to raise concerns regarding children, ensuring appropriate procedures were available if needed.

All staff were required to be trained to level in 4 safeguarding adults and children. As part of this inspection, staff training records were reviewed which confirmed that all staff were fully compliant with the required safeguarding training standards.

We scored the service as 3. The evidence showed a good standard. The service worked with patients to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Patients were actively engaged in discussions regarding the risks and benefits associated with their planned surgical procedures.

The service used consent forms which could be customised to reflect risks of the specific surgery being undertaken and the patient’s comorbidities. This was in addition to appropriate risk assessments which were completed during the pre operative risk assessment. This enabled surgeons to document all relevant risks tailored to the individual patient and procedure.

Leaders informed us that discussions regarding the risks associated with surgery are held during the initial consultation with all patients. They explained that when the potential risks outweigh the expected benefits, this is clearly communicated to the patient and where appropriate, staff were confident in making the decision to decline surgery. In cases where the surgical risk was deemed too high, alternative treatment options were considered.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Since our previous inspection, leaders had undertaken a project to remove all unnecessary equipment and clutterfrom the hospital, and the hospital was observed to be clean, tidy and well organised.

Patient rooms were clean and tidy. At our last inspection it was noted that all emergency pull cords in patient bathrooms were tied up and not easily accessible in an emergency, during this inspection all emergency pull cords were free hanging.

Staff stored hazardous chemicals in accordance with Control of Substances Hazardous to Health (COSHH) regulations.

All consumable stock was stored off the floor on racks and when we checked expiry dates, all equipment was in date. Following our previous inspection where out of date equipment was identified, managers had developed a medical items register which was used to complete monthly checks of all areas of the hospital and ensure that consumable stock was being used before its date of expiry. This allowed staff to monitor equipment more effectively and keep record of when expiry dates were approaching.

Staff had immediate access to resuscitation trolleys in both the ward and theatre areas, with a difficult airway trolley located in the theatre. Staff undertook regular safety checks. All equipment and consumables within the trolleys were found to be in date and appropriately maintained.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

All staff directly employed by the hospital received annual appraisals to support their professional development. Appraisals were not conducted for staff that were not directly employed by the service. However, leaders were actively involved in the appraisal processes of surgeons and anaesthetists who also held roles in other healthcare organisations. This collaborative approach helped ensure oversight of clinical performance across settings.

Staff received appropriate training relevant to their roles, including a structured induction programme for new starters. Leaders maintained oversight of training compliance through regular monitoring. All agency staff were required to submit evidence of up-to-date mandatory training completed through their primary employer, ensuring consistent standards across the workforce.

Current staff levels were in line with national guidance. There were times when the scrub nurse would work in a dual role and support as a surgical first assistant. The service had a safe staffing dual role policy in place which was in line with the Perioperative Care Collaborative position statement and ensured that all staff were aware of the expectations and scope of their role.

The service used a small, consistent group of bank staff who had worked together for a considerable amount of time. Although bank staff made up most of the workforce, this did not impact patient safety, as the team was well-established and familiar with working collaboratively.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service had infection prevention and control and hand hygiene policies in place. All staff had completed level one and two infection prevention and control training.

Bathroom facilities and clinical areas were visibly clean, tidy, and free from clutter. Regular routine cleaning was carried out, and an external agency was contracted to perform deep cleans following surgical procedures. Hand sanitiser was readily available in all patient rooms and at ward entrances to support effective hand hygiene.

Although staff practice could not be observed during this inspection due to the service being closed to patients on the day, hand hygiene audit records since the previous inspection were reviewed. These demonstrated 100% compliance, with only one exception where a staff member was noted to be wearing nail polish in theatre.

Cleaning audits over the same period also showed full compliance with the expected cleanliness standards.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met patients’ needs, capacities and preferences. They involved patients in planning, including when changes happen.

Medicines were stored securely and in accordance with guidance from the Medicines and Healthcare Products Regulatory Agency (MHRA). The service had appropriate processes in place for the safe management of medicines.

Staff completed regular audits of medicines, during our previous inspection we found medicines which were out of date during this inspection all medicines were in date. We saw evidence that regular temperature monitoring of the rooms where medicines were stored was completed.

Controlled drugs were stored in a secure location that had been approved by the Home Office. Staff undertook regular stock checks to ensure accurate record-keeping and accountability.

The service had a policy in place for transferring controlled medicines to the theatre area, we reviewed the controlled drugs log on the ward and in theatre which showed that the medicines were being transferred in line with this policy,

Staff had access to an emergency drug box on the ward, which was locked away and appropriately sealed and in date.