We carried out a comprehensive inspection of BMI The Esperance Hospital on the 21/22 and 29 June 2016 as part of our national programme to inspect and rate all independent hospitals. We inspected the core services of surgical services, medical services and out-patient and diagnostic services as these incorporated the activity undertaken by the provider, BMI Healthcare Limited at this location.
We also made a judgement on whether the hospital had made improvements on requirement notices which had been served by CQC at a previous inspection of the service in June 2015.
We rated all three core services as good overall, and found that the hospital had mostly made the improvements required of them following requirement notices.
Are services safe at this hospital?
We found that there were sufficient numbers of medical, nursing and diagnostic staff to deliver care safely and that patient risk was assessed and responded to. However, mandatory training rates in surgery were worse than the BMI Healthcare target of 90%. This meant the hospital did not have assurance all staff had the necessary up-to-date training to keep patients safe.
Hospital infection prevention and control practices were mostly followed and these were regularly monitored, to reduce the risk of spread of infections. However, we saw some examples of poor compliance with infection control policies. This included staff not adhering to uniform policy and not being bare below the elbows. In theatres we saw staff re-using a single-use item for multiple patients.
There were a number of hand wash basins and floor surfaces that did not meet the standards required for a clinical area. We found that the hospital had not put in sufficient measures to ensure that the infection risk associated with carpeted areas had been addressed. Although we could see that some areas of the hospital carpets had been replaced and were told that this work would continue the hospital needs to address the progress and speed of these refurbishments as a priority.
In the theatre suite, it was not clearly signposted as to which doors were fire doors. Staff were unclear about fire evacuation procedures. This meant the hospital might not have been able to keep patients safe in the event of a fire. Fire signage, lighting and escape routes across the hospital did not always meet the recommended HTM 05 – 02.
The management of sharps and labelling of sharps bins in theatres did not follow best practice.
We found that staff understood and fulfilled their responsibilities to raise concerns and report incidents, we also found that the hospital fully investigated incidents and shared learning from them to help prevent recurrences. The hospital gave safeguarding sufficient priority because staff received safeguarding training to an appropriate level and staff demonstrated that they knew how to escalate safeguarding concerns. Staff were also aware of and applied the Duty of Candour regulations.
Are services effective at this hospital?
The hospital monitored consultants working under practising privileges. There were systems in place to ensure that consultants were competent to perform their roles, and records were kept and monitored to ensure that both consultants and the Resident Medical Officer (RMO) had DBS checks, appraisals, and relevant qualifications in place to perform their roles.
Staff planned and delivered patient care in line with current evidence-based guidance, standards, best practice and legislation. The hospital monitored this to ensure consistency of practice. People had comprehensive assessments of their needs. This included consideration of clinical needs, mental health, physical health, nutrition and hydration needs. The hospital routinely collected and monitored information about people’s care and treatment, and their outcomes. The hospital used this information to improve care.
We found that staff obtained and recorded consent in line with relevant guidance and legislation. Staff could access the information they needed to assess, plan and deliver care to people in a timely way and were aware of the Mental Capacity Act and Deprivation of Liberty Safeguards legislation.
There was a good multidisciplinary team approach to care and treatment. Staff had the right qualifications, skills and knowledge to do their job. However, there was a low rate of staff appraisals in theatres.
We found that agency staff records on Devonshire ward did not show that all staff had demonstrated competency in all required areas before being signed off as competent to work unsupervised. This meant the hospital might not have had assurance all agency staff had the necessary induction to enable them to work competently on the ward without direct supervision.
Are services Caring at this hospital?
We observed that patients were treated with dignity and respect and their privacy was maintained. We saw that staff offered appropriate emotional support. Patients who shared their views said they were treated well, with compassion, and that their expectations were exceeded. We saw that results of the friends and family test and other patients satisfaction surveys demonstrated that patients would recommend the hospital to others.
Are services responsive at this hospital?
Services were planned and delivered to meet the needs of the local population. Patients could be referred in a number of ways and patients could choose appointments which suited them. Cancellations were minimal and managed appropriately and services ran on time.
The service made reasonable adjustments and took action to remove barriers for people who found it hard to use or access services. Staff had access to translation services. However, Staff were not aware there was a system available to print written information such as pre-appointment information and leaflets in other languages.
We saw openness and transparency in how the service dealt with complaints. The service always took complaints and concerns seriously and responded in a timely way. We saw evidence the service learnt from complaints and made improvements to working practices where appropriate.
Are services well led at this hospital?
We found that the hospital managers may be obtaining false assurance from their audit results as we found that compliance with WHO and staffs understanding of VTE screening did not meet with the assurances that hospital audit scores conveyed.
We found that poor infection control practices were going unchallenged which could indicate that staff did not feel empowered to challenge poor practice when they saw it.
The hospital’s clinical governance committee scheduled to meet every two months. However, meeting minutes showed the committee only met four times in the last year. The clinical governance committee was responsible for ensuring the hospital used appropriate systems and processes to deliver safe, high quality patient care.
We saw a comprehensive clinical audit schedule to provide quality assurance. However, we saw that the hospital missed some scheduled audits. For example, the hospital did not have results for scheduled audits in IPC in January, February or March 2016. This meant the executive team might not have had up-to-date assurance of quality in some areas.
The leadership, governance and culture promoted the delivery of person-centred care. The board and other levels of governance within the organisation functioned effectively and interacted with each other appropriately. Quality received sufficient coverage in all relevant meetings. The hospital reported information on people’s experiences and reviewed this alongside other performance data.
Leaders modelled and encouraged cooperative, supportive relationships among staff. Staff felt respected, valued and supported. Candour, openness, honesty and transparency were evident throughout the service.
We saw staff were focused on providing the best service for all patients, and were proud to work at the hospital. Managers encouraged staff to recognise and celebrate success.
The management team had an understanding of the Workforce Race Equality Standard (WRES) as there is a national requirement to produce key data relating to race quality in the workplace. BMI had started to collect data nationally which they currently held, for example the numbers of staff from black and ethnic minority groups. The management team was in the process of implementing reporting processes to capture the data to enable them to fully comply with WRES reporting requirements.
We saw areas of outstanding practice including:
The hospital had a chaperone policy that was followed by the outpatient staff, there was signage in all rooms and patients were aware they could ask for a chaperone if needed. Staff maintained a chaperone register which demonstrated where and when chaperones had been required.
However, there were also areas of where the provider needs to make improvements.
Importantly, the provider must:
- Take action to ensure they are compliant with Health Technical Memorandum (HTM) 05-02: Fire Code Guidance and ensure adequate lighting and signage for fire escapes, along with ensuring fire escapes are kept free from foliage. They must also address their fire plan in theatres as a priority and ensure that signage is correct and placed to ensure that staff and visitors understand which doors are fire doors, which direction to travel in the event of a fire, and that staff understand evacuation and fire policies and procedures.
- Take urgent action to ensure staff do not reuse single-use items on more than one patient.
- Ensure that the risks associated with carpeted clinical areas and corridors areas are addressed. This should include regular cleaning and appropriate mitigation for risks associated with spillages and infection control. Although we could see that some areas of the hospital carpets had been replaced and were told that this work would continue the hospital does need to address the progress and speed of these refurbishments as a priority.
In addition the provider should:
- Take action to ensure all staff are compliant with mandatory training.
- Take action to ensure all staff have an annual performance appraisal.
- Take action to ensure they keep accurate records of all agency staff competencies on Devonshire ward.
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Ensure that staff follow BMI Healthcare corporate policy to check the pregnancy status of all female patients of potential childbearing age before surgery in line with professional guidance from NICE and the NPSA.
- Consider installing level access showers on Devonshire ward to maximise independence for wheelchair users.
- Ensure all staff are aware written information such as leaflets are available for patients in other languages, though an electronic printing system.
- Ensure that all staff follow hand hygiene best practice processes in all areas of the hospital, including being “bare below the elbow”.
- Consider actions to regulate the temperature in the endoscopy suite to prevent the drying cabinet from overheating.
Professor Sir Mike Richards Chief Inspector of Hospitals
Professor Sir Mike Richards
Chief Inspector of Hospitals