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BMI The Beardwood Hospital Good

Inspection Summary


Overall summary & rating

Good

Updated 26 May 2017

The Beardwood Hospital is operated by BMI Healthcare. We carried out a comprehensive inspection of BMI The Beardwood Hospital on the 5 and 6 October 2016 and an unannounced visit on the 10 October 2016 as part of our national programme to inspect and rate all independent hospitals. We inspected the core services of surgical services and outpatients and diagnostic services as these incorporated the main activities undertaken by the provider, BMI Healthcare Limited, at this location.

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.

The main services provided by this hospital were surgery and outpatients and diagnostics. The hospital also offered a dedicated oncology service for patients undergoing chemotherapy which we have incorporated in the review of the outpatient core service. We did not inspect a private service that operated at this location as this was a service from another provider, Alliance Medical. Where our findings on surgery for example, management arrangements – also apply to other services, we do not repeat the information but cross-refer to the surgical core service.

We rated this hospital as good overall because:

  • There was a strong incident reporting culture within the hospital, however, incidents that occurred were of no or low harm. There was a safety focused culture within the hospital and when incidents did occur they were fully investigated, lessons were cascaded to staff through a variety of means and action plans were implemented to prevent reoccurrence.
  • The hospital provided care and treatment that was in line with national guidelines and recommendations. There was a programme of audit in place to assess hospital compliance with policies and care pathways. Compliance with hospital policies and care pathways was good.
  • Staff at the hospital provided care that was compassionate and caring. We observed staff treating patients with respect and dignity at all times. Patients reported that staff were very caring. The hospital participated in the NHS friends and family questionnaire and 98% of patients responded that they would recommend the hospital to others.
  • The hospital was responsive to the needs of the local population and services were planned with patient needs in mind. Patients had flexibility about when they could attend for appointments and treatment. The hospital provided services to patients in a timely manner.
  • The hospital leadership was effective in disseminating the organisational vision. There were systems in place which articulated a clear vision for services based on the needs of the patient and the provision of clinically effective services. There were robust governance structures in place which ensured that services provided were clinically effective and patient centred. Staff morale at the hospital was high, with staff reporting that they felt well supported to deliver good care to patients.

We found areas of practice that require improvement in surgery.

  • The different incident reporting systems did not always correspond. Surgical site infections were not recorded as clinical incidents, even when they required a root cause analysis, and the number of falls on the quality dashboard did not match those on the incident log. An incident involving a serious injury to a patient did not appear on the incident log.

  • We reviewed five world health organisation (WHO) safety checklists and observed a further two. We found that most steps were undertaken appropriately, but it was not consistently undertaken or embedded.

  • Surgical site infection rates were higher than other independent hospitals.

Following this inspection, we told the provider that it should make other improvements, even though a regulation had not been breached, to help the service improve.

Details are at the end of the report.

Ellen Armistead

Deputy Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 26 May 2017

We rated safe as Requires improvement because:

  • The different incident reporting systems did not always correspond. Surgical site infections were not recorded as clinical incidents, even when they required a root cause analysis, and the number of falls on the quality dashboard did not match those on the incident log. An incident involving a serious injury to a patient did not appear on the incident log.

  • We reviewed five world health organisation (WHO) safety checklists and observed a further two. We found that most steps were undertaken appropriately, but it was not consistently undertaken or embedded.

  • Surgical site infection rates were higher than other independent hospitals.

However,

  • There was a robust system in place to report incidents and staff knew how to report an incident. Incidents were recorded and lessons learnt were disseminated across the hospital. Where repeat incidents had occurred, for example holes in surgical equipment packaging, staff had been pro-active and innovative in trying to resolve this. Openness and transparency about safety was encouraged. Any lessons learnt from incidents were cascaded across the hospital through a number of routes and there was a system in place to ensure all staff saw the lessons learnt.
  • Nursing staffing was regularly reviewed and calculated based on patient acuity and dependency. Staffing in theatre was in line with national guidance. There were sufficient staff across outpatients and diagnostics and oncology to provide safe care and treatment.
  • There were clear processes in place to access resident medical officers and consultants 24 hours a day. Systems were in place to manage the care of deteriorating patients.
  • There was a system in place to ensure all equipment was in clean, in working order and adhering to all relevant safety standards.
  • Record keeping was good in patient records and prescription charts.
  • Staff were compliant with the safeguarding training targets and there was information in all clinical areas about how to raise a safeguarding concern.
  • There were systems in place to monitor compliance with the hospital prevention and control of infection policy and reporting arrangements on compliance rates were robust. All areas were visibly clean and tidy and a cleaning schedule was in place and regularly monitored.
  • The diagnostics and imaging department carried out treatment in line with the Ionising Radiation (Medical Exposure) Regulations (IR(ME)R.

Effective

Good

Updated 26 May 2017

We rated effective as Good because:

  • People were receiving care and treatment in line with current evidence based guidance and standards.
  • Outcomes data indicated that the hospital was performing at a comparable level with other independent hospitals in terms of unplanned returns to theatre, unplanned transfers and unplanned readmissions.
  • We saw evidence of pain being assessed and treated accordingly.
  • Assessments for nutrition and hydration were completed and documented.
  • There were opportunities for staff to undertake courses and work in different roles which allowed them to develop professionally.
  • There was participation in relevant local and national audits, and actions from these were discussed and monitored at monthly governance meetings.

However;

Compliance with annual appraisals was variable in surgical services. However, an action plan was in place to address this.

Caring

Good

Updated 26 May 2017

We rated caring as Good because:

  • Staff were caring and compassionate to patient’s needs, and treated patients with dignity and respect. Patients were supported, and were involved in planning their treatment and care.
  • Patients were allocated a named nurse which meant they knew who was caring for them and who to approach if they needed assistance.
  • Feedback from patients was positive about the way staff treated and cared for them.
  • The hospital sought feedback from patients about the service using a BMI questionnaire and the NHS friends and family test. The results were consistently positive as 98% of patients said they would recommend the hospital as a good place to go for treatment.

Responsive

Good

Updated 26 May 2017

We rated responsive as Good because:

  • The booking system for patients to be treated was flexible and allowed patient choice. There were no waiting lists for surgery.
  • An interpreting service was available for patients who did not speak English as their first language and quiet rooms were available on request, for people who required space for prayer or meditation.
  • Patients completed a comprehensive pre-assessment process prior to admission.
  • Visiting was permitted throughout the day.
  • There was a policy for complaints and response times were monitored by senior management. Senior managers had received training in dealing with complaints. We were told about one complaint relating to outpatient/diagnostic charging. In response to this the hospital now provided clearer information about charging. Actions and learning were discussed at monthly governance meetings and disseminated to staff. We saw evidence of this dissemination when a staff nurse reported the actions of the complaint that had been previously mentioned by executive director of the hospital.

However,

  • There had been occasions when family members had been used to translate during pre-operative assessment appointments. This is not in line with best practice.
  • The outpatients department was signposted. During the inspection we observed numerous patients and relatives making their way to the main reception which was in a separate building, requiring them to be redirected, however all correspondence indicates where patients should report to prior to them attending the hospital. The signposting did not meet the needs of patients with a visual impairment.

Well-led

Good

Updated 26 May 2017

We rated well-led as Good because:

  • The hospital had a clear vision for providing services to patients. This vision was disseminated to staff and staff shared the vision.
  • There was a robust governance framework in place, which oversaw the strategic and operational direction for the hospital.
  • The medical advisory committee (MAC) was highly engaged and a central part of the governance structure. We saw evidence that the MAC was involved in making key decisions about clinical services.
  • Staff morale was very positive and all staff reported that they could raise issues of concern with departmental managers and senior managers.

However,

  • Although we saw evidence of a hospital risk plan which included a risk register, the register did not have dates when risks were put onto the register or timescales for when identified risks were to be removed.
Checks on specific services

Outpatients and diagnostic imaging

Good

Updated 26 May 2017

Overall, we rated out-patients and diagnostics services as good. Out patients and diagnostics comprised of a significant amount of hospital activity. In addition we inspected oncology services, including a four bed day care unit and included our findings in this section.

Where our findings on out-patients and diagnostics also apply to other services, we do not repeat the information but cross-refer to the surgery section.

We rated this service as good because it was safe, caring, responsive and well-led. We did not rate the service for being effective. 

Surgery

Good

Updated 26 May 2017

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.

We rated this service as good overall. The service was good in effective, caring, responsive and well-led, although it required improvement for being safe.