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BMI Gisburne Park Hospital Good


Inspection carried out on 23, 24 August and 2 September 2016

During a routine inspection

Overall we found services good at BMI Gisburne.

We inspected the core services of surgery and outpatients and diagnostic imaging.

  • Incidents were reported by staff through effective systems. Lessons were learnt and investigation findings and improvements made were fed back to staff. There were systems in place to keep people safe and staff were aware of how to ensure patients were safeguarded from abuse.
  • Medicines were stored safely and given to patients in a timely manner. The staffing levels and skills mix was sufficient to meet patients’ needs.
  • Equipment was maintained, appropriately checked and visibly clean. Medical equipment was checked and maintained by an independent company.
  • Patient records were stored securely and access was limited to those who needed to use them.
  • There were defects in the carpet on the ward corridor and we found floors in three patient bathrooms which were dirty in the corners and grouting on the tiles were not as clean as they should have been. We found that this had been addressed at our unannounced visit.
  • Staff assessed and responded to patients’ risks and used recognised assessments but these were not always fully completed.
  • The majority of staff had completed their mandatory training.
  • Senior staff were aware of their responsibilities relating to the duty of candour legislation and they were able to give us examples of when this had been implemented. The hospital had a duty of candour process in place to ensure that people had been appropriately informed of an incident and the actions that had been taken to prevent recurrence.
  • Surgical procedures were carried out by a team of consultant surgeons and anaesthetists who were mainly employed by other organisations (such as in the NHS) in substantive posts and had practising privileges with the hospital.
  • The consultants and anaesthetists were responsible for their individual patients during their hospital stay.
  • Resident registered medical officers (RMOs) were employed to provide medical cover when the consultant was not available.

  • Patients received care and treatment according to national guidelines such as National Institute for Health and Care Excellence (NICE) and the Royal Colleges of Nursing and Surgeons. Surgery services participated in national audits. Findings from performance reported outcomes measures (PROMs) and the National Joint Registry showed the majority of patients had a positive outcome following their care and treatment.
  • The hospital monitored patient outcomes through surveys to ensure that patients were satisfied with the service they received.
  • BMI corporate policies were based on National Institute for Health and Care Excellence (NICE), national and royal college guidelines were available to staff on the intranet.
  • The rate of unplanned readmissions following surgery was within expected levels when compared to other independent hospitals.
  • Care and treatment was provided by suitably trained, competent staff that worked well as part of a multidisciplinary team. The majority of staff had completed their appraisals.
  • Procedures were in place to ensure that consultants holding practicing privileges were valid to practice. There were procedures in place to ensure all consultant requests to practice were reviewed by the Medical Advisory Committee (MAC).
  • Staff sought consent from patients prior to delivering care and treatment and understood what actions to take if a patient lacked the capacity to make their own decisions.

  • Without exception, patients spoke positively about their care and treatment. Staff treated patients with dignity and respect and patients were kept involved in their care. Patient feedback from the NHS Friends and Family test and patient satisfaction surveys showed most patients were positive about recommending services to their friends and family.

  • There was daily planning by staff to ensure patients were admitted and discharged in a timely manner. There was sufficient capacity in the ward and theatres so patients could be seen promptly and receive the right level of care before and after surgery.
  • There were systems in place to support vulnerable patients. Complaints about the services were resolved in a timely manner and information about complaints was shared with staff to aid learning.
  • The department accessed translation services for those patients whose first language was not English, and information was available to patients in differing formats, if required. A hearing loop was available for those patients who were hard of hearing.
  • The hospital had not implemented recognised schemes to help meet the individual needs of patients living with dementia.

  • There were governance structures in place which included a risk register. The hospital’s vision and values had been cascaded across the services and staff had a clear understanding of what these involved. There was clearly visible leadership within the services. Staff were positive about the culture within the services and the level of support they received. There was routine public and staff engagement. All staff were committed to delivering good, compassionate care and were motivated to work at the hospital.

Inspection carried out on 15 October 2013

During a routine inspection

Our inspection on 25 June 2013 found recruitment procedures did not always include the relevant checks in line with the current regulations. Following the inspection, the provider sent us an action plan stating these issues would be addressed by 1 October 2013. We visited the hospital again to check the actions taken and found the necessary improvements had been made.

On this inspection we found the recruitment and references policies and procedures had been revised and updated. We also noted the necessary checks and documentation had been obtained prior to staff commencing work in the hospital. This ensured staff were suitably qualified and skilled to carry out their role safely and effectively.

Inspection carried out on 25 June 2013

During a routine inspection

Patients told us they were satisfied with the care and treatment they had received and confirmed they were involved in decisions about their care. One patient said, �They have been excellent in every way� and another patient commented, �I have been given every opportunity to ask questions and I have been kept well informed�.

Patients� needs and wishes were considered and assessed appropriately and care pathway plans were developed depending on what treatment or procedure they required. Multidisciplinary progress notes were maintained in order to keep the staff informed of up to date information about patients� needs and circumstances.

Appropriate references and police checks were carried out before a new member of staff started work in the hospital. However, we found the policies and procedures for the recruitment of new staff had not been updated in line with current legislation and there was a gap of information in one of the staff�s files checked.

Staff were given opportunities to update and extend their training in line with their roles. Staff spoken with were positive about their employment and told us they were well supported by the management team.

There were established and effective systems in place to monitor the quality and safety of the service which included the analysis of patient feedback.

Inspection carried out on 5 September 2012

During a routine inspection

People made complimentary comments about the service, one person told us �It�s amazing, the service has been more than I expected� and another person commented, �I�ve been happy with everything, all the staff are very good and very caring�. During our visit we observed positive and respectful interactions between the staff and patients. Records, treatment plans and risk assessments were maintained and updated as necessary. However, we found the treatment plans on the dependency unit lacked detail about people�s personal support needs.

Staff had access to appropriate policies and procedures on the protection of children and vulnerable adults. Training on safeguarding vulnerable adults was being rolled out to staff at the time of our visit.

Staff were provided with ongoing opportunities for training and development and were given an appraisal of their work performance.

There were established systems in place to monitor the quality and operation of the service and a quality account was published on an annual basis. However, we found feedback from people on the dependency unit had not been collated or analysed, which meant trends and patterns had not been identified and addressed and the staff training records system was not integrated so it was therefore difficult to determine the training status for individual staff.