You are here

Inspection Summary

Overall summary & rating


Updated 17 August 2018

West Midlands Hospital is operated by Ramsay Health Care UK Operations Limited. The hospital has 34 beds with en-suite facilities. Facilities include two operating theatres and an endoscopy room, and a three bay recovery area. One theatre had laminar flow ventilation system. Outpatient and diagnostic services were available including six consulting rooms and x-ray. MRI and CT scans were provided by Ramsay Diagnostics UK and therefore these facilities were not inspected. An offsite hydrotherapy pool is available for patients requiring this as part of the physiotherapy services.

The hospital provides surgery, and outpatients and diagnostic imaging. We inspected both core services.

We inspected this service using our focussed inspection methodology which meant we followed up on issues and concerns raised at the last inspection. We carried out the inspection on 31 May 2018.

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.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

This inspection was conducted as a follow up inspection to identify changes made after the previous inspection completed in 2015. During the previous inspection we found the following concerns:

  • Outpatient records were removed from site resulting in hospital staff not having access to contemporaneous notes.
  • Medicines were not consistently stored and managed as per national guidelines. In addition, some medicine errors were not reported appropriately.
  • The World Health Organisation (WHO) safer surgery checklist was not consistently completed for interventional radiology; and there was no regular audit to monitor the completion of WHO checklists within theatres.
  • The external multi-disciplinary approach to managing patients with cancer required improvement.
  • Consultants held practising privileges which were reviewed by the hospital every five years rather than every two years.
  • The nurse competency assessment process was informal and required improvement.
  • The equipment register did not include all staff who used this.

Following this inspection, we rated this hospital as good overall.

  • We found that medicines were managed and stored appropriately. The hospital had improved the amount of pharmacy support provided by the local trust since the previous inspection. We found a pharmacist attended West Midlands Hospital three times per week to check medicine stock and management; and held a weekly meeting with the resident medical officer (RMO) to review medicine requirements.
  • We found the World Health Organisation (WHO) checklist was consistently completed; and was audited to ensure compliance. In particular, the imaging service had introduced a modified World Health Organisation (WHO) safer surgery checklist for patients undergoing specific procedures, for example ultrasound guided injections.
  • We saw consultants’ practising privileges were reviewed yearly at Medical Advisory Committee meetings.
  • The management of patients with cancer through external multidisciplinary team meetings had been formalised with the local NHS trust.
  • We found that patient records were kept securely on site.
  • During our inspection we found that staff competencies, including nurses, were well recorded and up to date.
  • Medical and non-medical equipment was well maintained and serviced in line with manufactures requirements. This was well managed by the operations and facilities department.

However, we found that record keeping required improvement. Improvements were needed to ensure medical staff maintained accurate and up to date records about patient care.

  • Medical records for outpatient clinics were incomplete and lacked detail. We found three out of 14 records looked at had no outpatient documentation within them.
  • We found psychological assessments on patients undergoing cosmetic surgery were not documented fully within patient records. Therefore, we could not gain assurance consultants completed these fully.
  • We looked at an inpatient record for a patient who had deteriorated post-surgery and required an additional night at the hospital. We found that consultant updates; and a review by the resident medical officer had not been documented within the patient record. The management team took immediate action in response to this during our inspection and both the consultant and the RMO were made aware that, on that occasion, there was a lack of documentation.

Heidi Smoult

Deputy Chief Inspector of Hospitals

Inspection areas


Requires improvement

Updated 17 August 2018

Are services safe?

We rated safe as requires improvement because:

  • As reported within the overall summary, we found patient records did not consistently contain accurate and up to date medical entries. However, we saw entries made by nurses and allied health professionals were to a satisfactory standard.
  • We found infection control risks across outpatients and diagnostic imaging. Carpeted flooring was in place in rooms used to change dressings and perform internal ultrasounds. We requested the cleaning policy which indicated for bodily fluid spillages; clinical staff should follow the infection and prevention control policy for cleaning this. Housekeeping staff could complete their normal clean following this. Therefore, the infection control risks were mitigated. The hospital was undergoing extensive re-decoration and plans were in place to replace the carpeted flooring post inspection.
  • Incident reporting and sharing of learning was not consistent across outpatients. We found examples where staff had not reported incidents and learning had not been shared. However, we found that within the surgery department including theatres and the ward; incidents were reported and investigated; with lessons learnt consistently disseminated to staff.

However, we also found:

  • Mandatory training compliance within outpatients and surgery met targets.
  • Safeguarding knowledge and training was good. Systems were in place to ensure patients were protected from abuse.
  • Staffing across the hospital met the needs of the service, including nursing, medical and allied health professionals (such as radiographers and physiotherapists).
  • Medicine management throughout the hospital was good. This was an improvement from the previous CQC inspection in 2015.



Updated 17 August 2018

We rated effective as good because:

  • The imaging service had introduced a modified World Health Organisation (WHO) safer surgery checklist for patients undergoing specific procedures, for example ultrasound guided injections.

  • Fasting guidelines given to patients due to undergo surgery adhered to National Institute for Health and Care Excellence (NICE) guidelines.

  • We saw staff were assessed as competent to undertake their roles within the hospital.

  • We found staff had knowledge around capacity and the Mental Capacity Act 2005. Staff asked were aware of their requirements to raise concerns around capacity and the ability to consent for treatment.

  • Multidisciplinary work was evident across the hospital; staff worked with different teams and liaised with each other in order to achieve a high standard of care for patients.

However, we also found:

  • Appraisal rates across theatres required improvement. At the time of the inspection, 83% of staff had received an appraisal. However, it was noted that appraisal rates for ward staff were much higher than the rates for theatre staff.



Updated 17 August 2018

Are services caring?

We rated caring as good because:

  • All patients undertaking intimate examinations were accompanied by a chaperone to ensure their privacy and dignity needs were met. Staff were respectful of patients and knocked on doors prior to entering patient rooms.
  • Staff involved family members in consultations and decisions where the patient wished this to happen. Staff answered patients’ questions about their care and treatment. Patients told us that they were given time to consider their choice to undertake treatment prior to consenting for this.
  • We observed a caring approach from staff who sought to ensure the patient was comfortable at all times throughout appointments and procedures.



Updated 17 August 2018

We rated responsive as good because:

  • Services were planned with the needs of the local population in mind. The hospital opened six days per week and flexibility around appointment days and times was offered.

  • Staff could access information leaflets in multiple languages, and print these directly from their internal intranet. Staff told us that they could access interpreters for both spoken and signed languages. Interpreters could be accessed via telephone and in person depending on the needs of the patients.

  • Patient complaints and concerns were dealt with appropriately; and improvements were made following these.

However, we also saw areas in which the hospital could improve:

  • Storage within the physiotherapy department was limited. The physiotherapy room was small and contained a lot of equipment. Staff told us they felt this hindered their ability to undertake full physiotherapy sessions. In addition, physiotherapy patients had no specific waiting room. Instead; chairs were set out along a corridor.



Updated 17 August 2018

We rated well-led as good because:

  • During our inspection, we observed a culture of openness, transparency and support. Staff were encouraged to report incidents, raise new ideas and initiatives and to work towards continued professional development.

  • Staff reported that heads of department and senior leadership were visible and supportive.

  • Risks to each core service were noted on departmental risk registers; these were assessed and where required escalated to a hospital risk register which was reviewed through clinical governance meetings.

Checks on specific services

Outpatients and diagnostic imaging


Updated 17 August 2018

A range of specialist consultants undertook consultations on an outpatient basis.

Outpatient facilities also included a physiotherapy department who provided post surgery rehabilitation in addition to sports injury clinics, pain management clinics and acupuncture. An offsite hydrotherapy pool was available for patient use.

The diagnostic facilities included an x-Ray department offering a range of screening and x-Ray procedures, including: on site plain x-ray and ultrasound. A mobile magnetic resonance imaging (MRI) scanner and a computerised tomography (CT) scanner also came to the hospital; however these were offered under a different provider therefore were not included within this inspection.



Updated 17 August 2018

Surgery was the main activity of the hospital. Where our findings on surgery also apply to other services, we do not repeat the information but cross-refer to the surgery section.

Surgical specialties at the hospital also included orthopaedics, gynaecology, ear, nose and throat, ophthalmology, general surgery and urological procedures.

The hospital undertook cosmetic surgery including breast enlargements, abdominoplasty, liposuction and facial surgery.