You are here

We are carrying out a review of quality at BMI Chelsfield Park Hospital. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary


Overall summary & rating

Good

Updated 6 December 2016

Chelsfield Park hospital is one of 59 hospitals and clinics provided by BMI Healthcare Limited. BMI Healthcare is the UK's largest private hospital group and was formed in 1970. In 1993 after various changes, the group was renamed BMI Healthcare, and its new corporate group became General Healthcare Group (GHG). In 2006 GHG was acquired by a consortium led jointly by Netcare Limited, a South African healthcare company.

We inspected the hospital as part of our independent hospital inspection programme. The inspection was conducted using the CQC’s comprehensive inspection methodology. This was a routine planned inspection.

The hospital provides a range of medical, surgical and diagnostic services. The onsite facilities include two operating theatres (both with laminar airflow), 36 registered beds spread across two floors, a minor procedure theatre, seven consulting rooms and a minor procedure room.

The hospital offers physiotherapy treatment as both an inpatient and outpatient service in its own dedicated physiotherapy suite. The imaging department provides plain x-ray, ultrasound, and mobile MRI onsite four days a week, and full field digital mammography.

The dedicated assisted conception unit was not included in this inspection.

Services offered include general surgery, bariatrics, and cosmetic surgery. Diagnostic imaging and endoscopy provide diagnostic services. In addition there is limited general medicine provision, oncology and physiotherapy. Patients are self-paying or use private medical insurance. Some services are available to NHS patients through the NHS choose and book system or spot contracts.

The announced inspection took place between 12 and 13 July 2016, followed by a routine unannounced visit on 21 July 2016.

This was a comprehensive planned inspection of all core services provided at the hospital: surgery, outpatient and diagnostic imaging, both of which include services for children and young people. General medical services are provided to patients using the same nursing staff, patient rooms and facilities as other patients. For this reason we have not reported this separately but have included endoscopy and children and young peoples services within surgery.

Are services safe at this hospital

  • Improvements were required to ensure a safe service was consistently provided. This included improving the completion of the World Health Organisation (WHO) ‘five steps to safer surgery’ checklist, and patient treatment and care records.
  • Infection prevention and control practice in theatres and on the wards was mostly good. The use of personal protective equipment was not always used by consultants during procedures which may have posed as a risk of exposure.
  • Staff were provided with relevant safety training, including safeguarding vulnerable people. They were knowledgeable about the hospital’s safeguarding policy and clear about their responsibilities to report concerns. Staff were supported by a designated safeguarding lead. However, the number of staff trained to safeguarding level 3 did not meet the recommended guidance.
  • Medicine optimisation was managed safely.
  • Staff were fully aware of the incident reporting process, and there was a formal system for reviewing and learning such matters. The duty of candour was understood by staff with regards to incidents, which met the threshold of informing relevant individuals.
  • Nursing staffing levels were organised to ensure the delivery of safe care. The service ensured a Resident Medical Officer (RMO) was on duty at all times.
  • Consultants with practising privileges took ultimate responsibility for treatment and care.
  • There were arrangements for communicating patient related information between shift changes, and at times when the admitting consultant needed to be made aware of their respective patient’s condition.
  • A national early warning score was used to identify patients whose condition might deteriorate, and transfer arrangements had been established for patients who required higher levels of treatment or care.

Are services effective at this hospital

  • Staff provided care and treatment, which took account of nationally recognised evidence based guidance and professional standards. Audit of practices followed a defined programme and included medicine management, and urinary catheters. Action plans were completed and acted upon where audits achieved less than 100% compliance.
  • Policies related to service provision at the location were shared with staff and then discussed at the Medical Advisory Committee.
  • Pain management and nutritional support was integral to the provision of effective patient care.
  • There were effective arrangements for reviewing and agreeing consultant practising privileges, and for removing these when required information was not forthcoming. The revalidation of the consultants and registered nursing staffs fitness to practise ensured services could be delivered effectively.
  • There were nine unplanned returns to theatre during the reporting period April 2015 to March 2016. Unplanned readmissions within 28 days of discharge for the same period was 18. There were five unplanned transfers of inpatients to another hospital, which was better than other similar independent hospitals.
  • NHS Patients participated in the patient reported outcome measures (PROMS) data collection if they had undergone surgery for hip or knee replacement and inguinal hernia repair. Insufficient data was available for the period April 2014 to March 2015 (reported February 2016) to calculate the average adjusted health gain score for either primary knee or hip replacement.
  • Staff had been provided with training in the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) as part of mandatory training. They understood their responsibilities, and were clear about the processes to follow if they thought a patient lacked capacity to make decisions about their care. The Gillick test and the Fraser guidelines, which related to a child’s capacity to give independent consent to medical procedures, were understood by relevant clinical staff.
  • Patients were provided with information as part of the consent process; however, most patient notes reviewed showed consent was obtained on the day of treatment.

Are services caring at this hospital

  • The hospital participated in the ‘friends and family test’ (FFT). Between October 2015 and March 2016 the hospital reported 100% of patients would recommend the hospital to their friends and families. The amount of patients who responded to the test was moderate (between 30% and 58%).
  • The Patient Led Assessments of the Care Environment (PLACE) audit between February 2015 and June 2015 score for privacy, dignity and wellbeing was 92%, compared to an England average of 87% for independent acute hospitals.
  • Staff recognised patients individuality and ensured they provided sufficient information and emotional support to enable a rapid recovery. Staff were respectful in their administrations, and treated patients and family members with kindness, courtesy and compassion.

Are services responsive at this hospital

  • The executive team worked with clinical commissioning groups to determine the range of surgical and other services provided to NHS patients within the surrounding population. Private provision of services reflected the agreed range of activities, based on the suitability of facilities, available support and risk criteria.
  • An inclusion/acceptance criterion was applied by staff after assessing the patient’s needs. All patients are risk assessed for potential to require extended recovery care. The admitting consultant would make decisions regarding the suitability of admitting patients with specific needs associated with dementia or learning disabilities.
  • The Resident Medical Officer reviewed patients throughout the day and was available out of hours. Consultants reviewed their own patients and were required to attend to their patients within a thirty minute journey time, should the need arise. Transfer arrangements were set up in the event of a patient’s condition deteriorating.
  • The hospital dealt with complaints and concerns responsively, and learning from such matters was used to improve the quality of care.

Are services well led at this hospital

  • Staff were aware of the expectations of executive team and understood what the vision and values were. They were supported by an effective and responsive leadership at the executive level, as well as their respective departments.
  • Staff enjoyed working at the hospital, and described an open culture and of feeling valued and supported. The recent changes in management at the hospital were positively acknowledged.
  • The Medical Advisory Committee worked with the executive team to ensure the monitoring of quality of services was reviewed, and challenged where needed. They were responsible for reviewed practising privilege, including fit and proper person information, before agreeing acceptance to use the service.
  • Governance arrangements ensured incidents, complaints, audit results and policy development were reviewed and learning was shared appropriately. However, the risk register, which was a temporary document, was not sufficiently robust and lacked evidence of review dates for many of the identified risks.
  • Staff were encouraged to continuously learn and improvement was fostered through training and development opportunities.
  • The availability of capital helped the service to improve and develop services. Recent purchases included a bariatric operating table, new theatre stack systems and endoscopes.
  • As an approved service for Bariatric surgery, equipment was available to support the service, and a designated team of specialty trained staff worked with the consultant to ensure patients received the required standards of treatment and care.
  • An enhanced recovery program provided a comprehensive rehabilitation program for orthopaedic patients, including specialised physiotherapy to achieve earlier mobilisation and discharge.
  • The pharmacy manager had implemented a pharmaceutical care plan, and an antibiotic care plan had also been introduced to improve practices.
  • The service was working toward obtaining accreditation for the endoscopy services with an external body.

Our key findings were as follows:

  • The service was led by a dedicated local executive team, supported by loyal staff, who were professional in their duties and responsibilities.
  • The areas in which patients received treatment and care were noted to be clean and well organised. Infection prevention and control measures were followed by the majority of staff.
  • Staffing levels, skills and experience contributed to high standards of care and good patient experiences.
  • Patients’ needs including effective pain management and nutrition were optimised.

  • The standards of leadership and governance arrangements contributed to the effectiveness and responsiveness of the services.
  • There were sufficient and appropriately skilled staff available to support the safe delivery of patient care.
  • The nutritional and hydration needs of patients were assessed and catered for.

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

Importantly, the provider should:

  • Improve compliance with the World Health Organisation (WHO) ‘five steps to safer surgery’ procedures.

  • Improve consultant compliance with the use of personal protective equipment during invasive procedures, in line with NICE guidelines and BMI policy.
  • Improve the completion of patient records to enable the availability of a fully detailed record.
  • Consider how professional guidelines can be applied to support the safeguarding training further.
  • Improve the use of the risk register with the incorporation of review dates for all identified risks.
  • Consider having leaflets available in other languages as well as in English.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 6 December 2016

  • Improvements were required to ensure a safe service was consistently provided. This included improving the completion of the World Health Organisation (WHO) ‘five steps to safer surgery’ checklist, and patient treatment and care records.
  • Infection prevention and control practice in theatres and on the wards was mostly good. The use of personal protective equipment was not always used by consultants during procedures which may have posed as a risk of exposure.
  • Staff were provided with relevant safety training, including safeguarding vulnerable people. They were knowledgeable about the hospital’s safeguarding policy and clear about their responsibilities to report concerns. Staff were supported by a designated safeguarding lead. However, the number of staff trained to safeguarding level 3 did not meet the recommended guidance.
  • Medicine optimisation was managed safely.
  • Staff were fully aware of the incident reporting process, and there was a formal system for reviewing and learning such matters. The duty of candour was understood by staff with regards to incidents, which met the threshold of informing relevant individuals.
  • Nursing staffing levels were organised to ensure the delivery of safe care. The service ensured a Resident Medical Officer (RMO) was on duty at all times.
  • Consultants with practising privileges took ultimate responsibility for treatment and care.
  • There were arrangements for communicating patient related information between shift changes, and at times when the admitting consultant needed to be made aware of their respective patient’s condition. A national early warning score was used to identify patients whose condition might deteriorate, and transfer arrangements had been established for patients who required higher levels of treatment or care.

Effective

Good

Updated 6 December 2016

  • Staff provided care and treatment, which took account of nationally recognised evidence based guidance and professional standards. Audit of practices followed a defined programme and included medicine management, and urinary catheters. Action plans were completed and acted upon where audits achieved less than 100% compliance.
  • Policies related to service provision at the location were shared with the Medical Advisory Committee and signed off, before disseminating across the staff groups.
  • Pain management and nutritional support was integral to the provision of effective patient.
  • There were effective arrangements for reviewing and agreeing consultant practising privileges, and for removing these when required information was not forthcoming. The revalidation of the consultants and registered nursing staffs fitness to practise ensured services could be delivered effectively.
  • There were nine unplanned returns to theatre during the reporting period April 2015 to March 2016. Unplanned readmissions within 28 days of discharge for the same period was 18. There were five unplanned transfers of inpatients to another hospital, which was better than other similar independent hospitals.
  • NHS Patients participated in the patient reported outcome measures (PROMS) data collection if they had undergone surgery for hip or knee replacement and inguinal hernia repair. Insufficient data was available for the period April 2014 to March 2015 (reported February 2016) to calculate the average adjusted health gain score for either primary knee or hip replacement.
  • Staff had been provided with training in the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) as part of mandatory training. They understood their responsibilities, and were clear about the processes to follow if they thought a patient lacked capacity to make decisions about their care. The Gillick test and the Fraser guidelines, which related to a child’s capacity to give independent consent to medical procedures, were understood by relevant clinical staff.
  • Patients were provided with information as part of the consent process; however, most patient notes reviewed showed consent was obtained on the day of treatment.

Caring

Good

Updated 6 December 2016

  • The hospital participated in the ‘friends and family test’ (FFT). Between October 2015 and March 2016 the hospital reported 100% of patients would recommend the hospital to their friends and families. The amount of patients who responded to the test was moderate (between 30% and 58%).
  • The Patient Led Assessments of the Care Environment (PLACE) between February 2015 and June 2015 privacy, dignity and wellbeing scored 92% compared to an England average of 87% for independent acute hospitals.
  • Staff recognised patients individuality and ensured they provided sufficient information and emotional support to enable a rapid recovery. Staff were respectful in their administrations, and treated patients and family members with kindness, courtesy and compassion.

Responsive

Good

Updated 6 December 2016

  • The executive team worked with clinical commissioning groups to determine the range of surgical and other services provided to NHS patients within the surrounding population. Private provision of services reflected the agreed range of activities, based on the suitability of facilities, available support and risk criteria.
  • An inclusion/acceptance criterion was applied by staff after assessing the patient’s needs. High risk patients and those requiring complex surgery were not accepted. The admitting consultant would make decisions regarding the suitability of admitting patients with specific needs associated with dementia or learning disabilities.
  • The Resident Medical Officer reviewed patients throughout the day and was available out of hours. Consultants reviewed their own patients and were required to attend to their patients within a thirty minute time frame, should the need arise. Transfer arrangements were set up in the event of a patient’s condition deteriorating.
  • The hospital dealt with complaints and concerns responsively, and learning from such matters was used to improve the quality of care.

Well-led

Good

Updated 6 December 2016

  • Staff were aware of the expectations of executive team and understood what the vision and values were. They were supported by an effective and responsive leadership at the executive level, as well as their respective departments.
  • Staff enjoyed working at the hospital, and described an open culture and of feeling valued and supported. The recent changes in management at the hospital were positively acknowledged.
  • The Medical Advisory Committee worked with the executive team to ensure the monitoring of quality of services was reviewed, and challenged where needed. They were responsible for reviewed practising privilege, including fit and proper person information, before agreeing acceptance to use the service.
  • Governance arrangements ensured incidents, complaints, audit results and policy development were reviewed and learning was shared appropriately. However, the risk register was not sufficiently robust and lacked evidence of review dates for many of the identified risks.
  • Staff were encouraged to continuously learn and improvement was fostered through training and development opportunities.
  • The availability of capital helped the service to improve and develop services. Recent purchases included a bariatric operating table, new theatre stacker and endoscopes.
  • As an approved service for Bariatric surgery, equipment was available to support the service, and a designated team of specialty trained staff worked with the consultant to ensure patients received the required standards of treatment and care.
  • An enhanced recovery program provided a comprehensive rehabilitation program for orthopaedic patients, including specialised physiotherapy to achieve earlier mobilisation and discharge.
  • The pharmacy manager had implemented a pharmaceutical care plan, and an antibiotic care plan had also been introduced to improve practices.
  • The service was working toward obtaining accreditation for the endoscopy services with an external body.
Checks on specific services

Outpatients and diagnostic imaging

Good

Updated 6 December 2016

Overall, we rated the outpatients department, diagnostic imaging and oncology services as good. However, we rated safety as requires improvement, and there was insufficient evidence to rate the effectiveness of services.

The outpatients, physiotherapy, and diagnostic imaging departments provided a broad range of services for both privately funded and NHS funded patients. The patients we spoke with were complimentary about the care, treatment, and service they had received in both departments.

Patients we spoke with told us they were treated with dignity and respect. All patient feedback on the inspection was positive. They described the service as ‘very good’ and ‘professional’, and described the process of making an appointment as easy.

The oncology department provided treatment for cancer patients by means of chemotherapy, monoclonal antibodies therapy, and supportive therapies. The service was provided by Chemotherapy specialist trained nurses.

Staff were competent and worked to national guidelines, ensuring patients received the best care and treatment.

The culture within both departments was patient focused, open, and honest. The staff we spoke to felt valued and worked well together. Staff followed policies and procedures to manage risks and made sure they protected patients from the risk of harm.

There were short waiting times for appointments. Private patients were seen within one week, and NHS patients were usually seen within four weeks of referral. We found patients could get appointments with their chosen consultant and most clinics started on time.

The departments, including oncology, were visibly clean, well equipped and we observed staff using personal protective equipment (PPE) appropriately.

However;

Some staff involved in the direct care of children and young people had not received the required level of safeguarding training. Non clinical staff had not been trained to identify patients who may become unwell whilst awaiting their appointment.

Nursing staff receiving patient calls to the out of hour’s oncology service did not always include an assessment of the patient’s temperature. This is an important indicator for sepsis diagnosis.

Oncology patient notes did not always contain a summary of the multidisciplinary team (MDT) held at the consultants NHS trust. As a result, staff did not have up to date information on the patient.

It was not always clear if equipment used for outpatient care had been cleaned.

Surgery

Good

Updated 6 December 2016

We rated surgical services as requires improvement for safe and good for effective, caring, responsive and well-led.

Implementation of the World Health Organisation (WHO) 5 steps to safer surgery checklist was not consistently completed.

Infection prevention and control practices were not always consistently adhered to.

Patient records were not always completed with required information.

Whilst there were appropriate staffing levels and the skills of staff enabled them to support the delivery of care, the level of safeguarding training did not meet best practice guidelines.

Surgical services provided good care and treatment to patients, and had a compassionate and patient centered approach.

Patients received information about their treatment and were involved in decisions about their care, and treatment plans. We observed staff maintain patients’ respect and dignity at all times.

Medical and nursing staff carried out effective risk assessments from pre-assessment through to discharge.

Staff followed evidence based care and treatment, and monitored and reviewed patient outcomes. The staff worked effectively across different disciplines and had good links with staff at other BMI hospitals and local NHS services.

There was effective and responsive leadership at the executive level, and staff commented favourably on the hospital manager and other senior leaders

Governance arrangements ensured incidents, complaints, audit results and policy development were reviewed and learning was shared appropriately.