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Inspection carried out on 31 May 2018

During a routine inspection

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 carried out on 1-2 December 2015

During a routine inspection

West Midlands Hospital, part of the Ramsay Health Care UK Operations Limited offers private hospital treatments, procedures, tests and scans to patients from Halesowen and surrounding areas. The hospital offers a range of surgical procedures, cancer care, rapid access to assessment and investigation and a physiotherapy service. Since September 2015, no children under 18 years received care and treatment at the Hospital.

Patients are admitted for elective surgery, day case surgery/treatment or outpatient care. There are no urgent admissions. Facilities include 34 beds each with ensuite facilities; 29 of which were available for use at the time of the inspection. There are three theatres and a three bay recovery area. There is no dedicated High Dependency Unit (HDU). There is an agreement in place with the local acute NHS trust to transfer patients, should their health deteriorate and they require specialist medical support. Staff were supported with medical input to stabilise patients prior to transfer. The hospital has outpatient facilities, and plans are underway to relocate the outpatient department to a separate site one mile from the main hospital. The hospital also offers services to NHS patients on behalf of the NHS through local contractual agreements and seventy-two percent of its activity is NHS funded care.

Prior to the CQC inspection visit, the CQC considered a range of quality indicators captured through our monitoring processes. In addition, we sought the views of a range partners and stakeholders. Key elements of this process were the focus groups we held with healthcare professionals and feedback from the public.

The inspection team make an evidence based judgment on five domains to ascertain if services are:

• Safe

• Effective

• Caring

• Responsive

• Well-led.

Our key findings were as follows:

West Midlands Hospital was selected for a comprehensive inspection as part of our independent healthcare inspection programme. The inspection was conducted using the Care Quality Commission’s Independent Health inspection methodology.

The inspection team included CQC inspectors, doctors, nurses and senior managers with experience of working in the independent healthcare sector. The inspection took place on 2 December 2015, with an unannounced visit on 12 December 2015. The inspection team looked at the following core services: surgery, and outpatient and diagnostic imaging services.

Are services safe at this hospital

  • Incident reporting was variable, the majority of incidents were reported and lessons learned shared among staff, however, medication errors were not routinely reported.

  • A Duty of Candour Policy was in place, however staff we spoke with were not fully aware of what it meant in practice and further training was required.

  • Staff were aware of their responsibility to safeguard adults and children.

  • The resident medical officer (RMO) was available 24 hours a day seven days per week.
  • Consultants were responsible for their patients throughout their inpatient and day case stay.

  • There were sufficient staff to meet people’s needs across surgery and outpatients and diagnostic services.

  • The 5 steps to safer surgery, World Health Organisation (WHO) surgical checklist was completed appropriately, however the document was retained in theatre for a period of time and not kept in patient’s records directly after completion.

  • Completion of the WHO safety checklist for interventional radiology needed to be improved to meet national standards and practiced consistently.

  • There was no process in place to assess and record ward nurses competencies at the hospital and the equipment register to record which staff are competent to use items of equipment was out of date and did not include night staff.

Are services effective at this hospital

  • Local policies and care pathways to treat patients followed national guidance. There was some participation with national audits and benchmarking clinical practice across Ramsay Health Care UK Operations Limited, however this was limited.

  • Staff understood their responsibilities relating to consent and were clear about their responsibilities under the Mental Capacity Act 2005.

  • Patient reported outcome measures (PROMs) data for knee replacements demonstrated the service had a better than average expected health gain for these procedures.
  • Readmission rates for surgery were ‘similar to expected’ compared to the other independent acute hospitals.

  • There was a robust process in place for checking staffs’ General Medical Council (GMC), Nursing and Midwifery Council and Allied Healthcare Professional registrations.

  • Consultant competencies were assured through the NHS annual appraisal, and the GMC revalidation process. They were also assured through the clinical review process which formed part of the biennial review. However, we saw the biennial review did not take place every two years but every five years. We were not confident a five yearly check was frequent enough to review consultants’ performance and practice. However, any trends or patterns relating to concerns with a consultant’s performance was discussed at the monthly MAC meeting.
  • Information confirmed 100% of consultants had an in-date appraisal (based on 15 months expiry) and had supplied in-date evidence of indemnity.
  • There was no process in place to assess and record ward nurses competencies at the hospital. The equipment register to record which staff were competent to use items of equipment was out of date and did not include night staff.

Are services caring

  • Staff were caring and compassionate and treated patients with dignity and respect.
  • For the NHS equivalent Friends and Family Tests, hospital scores for both privately funded and NHS funded patients showed the results of 98% of 59 respondents said they would recommend the hospital.
  • The 2015 patient led assessment of the care environment (PLACE) audit scored the hospital, 89.3% for privacy and dignity.

Are services responsive at this hospital

  • Patient operations and procedures were rarely cancelled.

    Care planning for patients with complex needs such as patients living with dementia or a learning disability was well managed from pre-admission to post-discharge.

    The complaints procedure was robust. The hospital had received 44 complaints in 2014, complaints had been investigated and supported by actions for improvement.

    The complaints leaflet which provided details relating to the Independent Healthcare Ombudsman was out-of-date and contained incorrect contact details.

  • Complaints were reviewed at the monthly heads of departments meeting, led by the Quality Improvement Lead, governance meetings and the medical advisory committee (MAC).

Are services well led at this hospital

  • Staff were aware of and understood the vision and values of the hospital.
  • The hospital did not routinely retain copies of patients’ records for all patients who attended the outpatients department. This is a legal requirement and failure to hold these records meant there was a breach of regulation 17- HSCA, 2008, (Regulated Activity) Good Governance of the Health and Social Care Act (2014)
  • Senior managers had not ensured the process underpinning the WHO check list for interventional radiology was completed in a consistent manner or audited.
  • Senior managers had not ensured there was a formal process in place to manage patients when consultants needed to cancel clinics at short notice.
  • The Hospital Risk Register did not provide an accurate comprehensive reflection of the key risks across Surgery or OPD services and senior managers did not have clear oversight of what risks should be included on the register.
  • There were missed opportunities to discuss and learn from incidents which demonstrated similar trends and not all consultants were aware of incidents which had been reported. For example, the hospital reported six surgical site infections (SSI) all relating to abdominal wounds. There was no route cause analysis (RCA) to look at common links and this was not discussed at the MAC. We saw this was a missed opportunity for the hospital to look at patterns and learn from SSI’s.
  • Governance arrangements were in place for teams and departments to discuss learning from complaints, incidents and audits. However, further work was required to review and disseminate lessons learned from medication incidents.
  • The senior management team conducted daily huddles to instantly communicate clinical and non-clinical issues.
  • There was a supportive and open culture and staff felt that department and senior managers were approachable and supportive. However, 57% of ward nurses and 50% of heads of department had not received recent performance appraisal.

We saw several areas of good practice including:

  • Endoscopy services had been accredited by Joint Advisory Group (JAG) for GI endoscopy in 2014.
  • A Quality Improvement Lead had recently been appointed to strengthen governance arrangements and was making good progress.

However, there were also areas of poor practice where the provider needs to make improvements.

Importantly, the provider must:

  • Ensure that hospital staff have access to all necessary information, including maintaining an accurate, complete and contemporaneous record on the hospital site in respect of each patient.

  • Ensure all medicines are handled and stored safely.

  • Ensure all medication errors including ‘missed doses’ are reported appropriately.

  • Ensure all medicines for general use are ordered and kept separately from individual patient medicines

    • Ensure the WHO check list for interventional radiology is competed appropriately for each procedure carried out and audited at regular intervals.

    • Improve external multidisciplinary team management of patients with cancer in accordance with NICE guidance.

    • Review the frequency of ‘Biennial reviews’ which the hospital is currently undertaking every five years.

    • Formalise the nursing competency assessment process.

    • Update the equipment register and include all staff who use equipment.

In addition the provider should:

  • Ensure there is a robust and formalised process in place for cover arrangements for consultants.

  • Ensure the completed 5 steps to safer surgery, (WHO) surgical checklist is promptly included within patient’s records.

  • Ensure Complaints leaflets contain correct information.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 27 February 2014

During a routine inspection

At this inspection visit we focused on the care and treatment patients received on the surgical ward. We spoke with the general manager, the matron, charge nurse, and two nurses. We spoke with nine of the twelve patients receiving treatment who told us they received excellent care. One patient said, “Everything right from the time of my appointment through to assessment and surgery has been organised and well planned”.

We saw care and treatment plans were in place and detailed patients’ needs and their proposed medical procedures. A patient told us, “I had many consultations and loads of written information, I was well prepared and the care is excellent”.

We found that people were confident about their follow up care. One person told us “I have to come back for some physiotherapy. She (physiotherapist) has given me leaflets in case there is anything I'm worried about and the phone number. Everyone has given me information and that suits me”.

Patients confirmed that they were regularly asked about the quality of the service they received. One patient told us, “From the reception desk through the whole procedure, everybody asks”. We saw that comments from people that had used the service were monitored and used to improve the service.

There were leaflets that explained how people could make a complaint in the reception area and in brochures in people's bedrooms. People told us they had no complaints about the care and treatment they received. One patient said, “I would go through the telephone system and ring them up and ask who to speak to if there was a problem”.

Inspection carried out on 5 February 2013

During a routine inspection

During our inspection we visited the medical ward, the physiotherapy department, X-Ray and theatre. We spoke with seven people who used the service and nine members of staff; the matron, theatre manager, ward manager, sister, infection control lead, human resources coordinator and three physiotherapists.

The people we spoke with from both the in patient and outpatient departments were very satisfied with the care and treatment they received. One patient told us, "I’m very impressed, I had all the information I needed prior to my treatment and I have been very well looked after since my operation”. Another patient told us, “I’ve been impressed with the high standards of care”. Patients felt well informed and involved in making decisions about their care and treatment.

Staff understood how to protect patients from the risk of harm or abuse.

The premises were clean and practices in place supported infection prevention and control.

We saw that people were cared for by appropriately supported staff.

Reports under our old system of regulation (including those from before CQC was created)