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BMI The Blackheath Hospital Good

Reports


Inspection carried out on 15/01/2019

During an inspection looking at part of the service

BMI The Blackheath Hospital is an acute independent hospital that provides outpatient, day care and inpatient services. A range of services such as physiotherapy and medical imaging are available on site. The hospital offers a range of surgical procedures and cancer care as well as rapid access to assessment and investigation and level 2 critical care. Services are available to people with private or corporate health insurance or to those paying for one off treatment. The hospital also offers services to NHS patients on behalf of the NHS through local contractual arrangements.

The hospital provides surgery, services for children and young people, outpatients and diagnostic imaging. We inspected only surgical services at this inspection.

We inspected this service using our focussed inspection methodology to follow up on a requirement notice issued following a comprehensive inspection of the hospital in July 2016. This inspection was unannounced and our visit to the hospital took place on 15 January 2019.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services:

  • Are they safe?
  • Are they effective?
  • Are they caring?
  • Are they responsive to people's needs?
  • Are they 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.

During the inspection, we visited two wards, three theatres and a two-bedded high dependency unit. We spoke with 18 staff including registered nurses, health care assistants, reception staff, medical staff, operating department practitioners, and senior managers. We spoke with nine patients and two carers. During our inspection, we reviewed 11 sets of patient records.

There were no special reviews or investigations of the hospital ongoing by the CQC at any time of or during the 12 months prior to this inspection. The hospital has been inspected two times previously and the most recent inspection, prior to this one, took place in July 2016. At the July 2016 inspection, we found that the hospital was meeting all standards of quality and safety it was inspected against except regulation 12 Safe, care and treatment. This breach of regulation was due to poor decontamination practices in the endoscopy unit and the CQC issued a requirement notice for the hospital to take action. At this inspection, we found that this had improved since the last inspection and was no longer a breach in regulation. Please read the surgery report below for further details.

The hospital had an appropriately appointed registered manager who had started the role in October 2018.

Services we rate

Our rating of this hospital stayed the same. We rated it as Good overall.

We found good practice in relation to surgery:

  • The service controlled infection risk well.
  • The service had enough staff to provide the right care and treatment.
  • The service made sure staff were competent for their roles.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff cared for patients with compassion.
  • The hospital planned and provided services in a way that met the needs of local people.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.
  • The hospital and wider organisation had a vision for what it wanted to achieve and workable plans to turn it into action.
  • Managers promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
  • The hospital used a systematic approach to continually improving the quality of its services.
  • The hospital had effective systems for identifying risks, planning to eliminate or reduce them.

We found areas of outstanding practice in surgery:

  • Daily head of department meetings with the executive director and all head of departments had a unique multidisciplinary approach which enabled colloborative working, easy sharing of learning, escalation of concerns and cascading of information to departmental staff.
  • Patients received interactive exercise information which included demonstrations videos to help with their recovery at home.

We found areas of practice that require improvement in surgery:

  • The hospital should ensure it complies with its own target for mandatory training.
  • The hospital should ensure there is an appropriate space to store used surgical equipment.
  • The hospital should ensure all incidents are reported in a timely manner.
  • The hospital should ensure they compare the difference in patient outcome measures scores (PROMS) between NHS and private patients.
  • The hospital should ensure its promotes an inclusive culture with regard to patients with additional needs.

Following this inspection, we told the provider that it should make some improvements, even though a regulation had not been breached, to help the service improve. Details are at the end of the report.

Professor Edward Baker

Chief Inspector of Hospitals

Inspection carried out on 12-13 July 2016

During a routine inspection

Overall we rated this hospital as good.

Many improvements had been made since the previous inspection including the recruitment of more paediatric trained nurses, a rolling programme to replace the carpeting in clinical areas and the upgrading of the critical care unit to provide care for patients requiring level 2 care.

The hospital had taken action to minimise most of the risks to patients.  There was a system for reporting and learning from incidents and safety checks including the World Health Organisation checklist were completed. The rate of clinical incidents was similar to the average when compared to the 15 other independent acute providers.

Staff had received the appropriate level training and were aware of the action to take in response to abuse/suspected abuse of children or adults.

Patient areas were clean and equipment was available and safety checks carried out.

Children were cared for by paediatric trained nurses and medical staff providing treatment for children had to confirm on an annual basis that they met basic requirements for volumes of children treated.

There was evidence of some national and local audits taking place and care and treatment was evidence based.

The majority of staff had attended mandatory training and were supported to develop their clinical and leadership skills.

Patients' had their personal, nutritional and pain needs met by staff who were kind, friendly and treated them with dignity.

Privately funded patients were able to access treatment in agreement with their consultant and NHS funded patients were generally treated within national waiting times. Some services had expanded their availability to meet patient's needs.

Local leadership had been improved and senior leadership had been strengthened. Staff commented positively about leaders at all levels, they felt able to raise concerns and were proud to work at the hospital. They were committed to providing high quality care for patients.

There was some patient engagement through hospital surveys and the family and friends test.

However;

Decontamination in endoscopy did not meet best practice guidance.

There were no dedicated hand wash basins in patient bedrooms for staff or visitors and no hand washing facilities within the ward corridors.

There was a low uptake of appraisals in some staff groups and there was no formal on call rota for radiologists

Some staff were unaware of their responsibilities in relation to the consent, capacity and the deprivation of liberty safeguards and who the dementia champion was.

Confidentially for patients when registering at the urgent care centre (UCC) was potentially compromised and there was no system to monitor patients who may deteriorate while waiting to be seen by a doctor.

Inspection carried out on 10-12 and 20 February 2015

During an inspection looking at part of the service

BMI The Blackheath hospital is an acute independent hospital that provides outpatient, day care and inpatient services. The hospital is owned and managed by BMI Healthcare Limited.

A range of services such as physiotherapy and medical imaging are available on site. The hospital offers a range of surgical procedures and cancer care as well as rapid access to assessment and investigation. The hospital does not provide Level 2 critical care services as defined by the Faculty of Intensive Care Medicine standards 2013.

Services are available to people with private or corporate health insurance or to those paying for one off treatment. Fixed prices, agreed in advance are available. The hospital also offers services to NHS patients on behalf of the NHS through local contractual arrangements.

We carried out a comprehensive inspection of BMI The Blackheath Hospital on 10 – 12 and 20 February 2015. The inspection formed part of a pilot programme of inspections in independent healthcare settings. The inspection reviewed how the hospital provided outpatient, medical care, surgical services, care to children (outpatients from birth and interventional from aged three to 15 years) and young people and urgent care services as these were the five core services provided by the hospital from the eight that that are usually inspected by the Care Quality Commission (CQC) as part of its approach to hospital inspection.

Prior to the inspection, in December 2014, the hospital a new Executive Director was appointed. One of the first decisions they took was to stop terminations of pregnancy being carried out due to the low numbers carried out in the last two years.

This location has been awarded a shadow rating. Shadow ratings apply to inspections which are undertaken during the development of our approach and before our final methodology is confirmed and published.”

Our key findings were as follows:

Are services safe?

  • The hospital was using an incident reporting system which had both a paper and electronic stage. Incidents are initially recorded on a paper form and then recorded and managed electronically in the Quality and Risk Department. The quality of investigation reports into incidents varied but where recommendations had been made we found they had been actioned. The hospital risk register included mainly environmental risks;the only clinical risk related to the endoscopy unit.
  • Medicines were well managed. The hospital had a pharmacy manager, a pharmacist and three technicians. A pharmacist and pharmacy technician visited the wards twice daily. Medicines and controlled drugs were stored safely and regular audits including missed doses and medicine errors were carried out and the results shared with staff.
  • The infection prevention and control (IPC) nurse had been in post for four months at the time of the inspection and although the results of IPC audits, use of personal protective equipment and cleanliness of mattress, showed good practice, staff attendance at training needed to improve.
  • The endoscopy unit was an area of concern as it did not comply with national guidance, which had been published in 2012, for the decontamination of endoscopes.
  • The environment in inpatient areas did not always comply with national guidance for infection prevention and control.
  • Staff were aware of their responsibilities in relation to safeguarding children and who to contact if they had any concerns.
  • Although the hospital admitted children and young people as day cases and on occasion as inpatients, it did not have a dedicated area to care for them. They were nursed in private rooms on the same wards. The hospital told us they carried out specific risk assessments yearly as a minimum but we did not see them during our inspection.
  • There was a lack of clarity about the level of care provided by the hospital. Although the hospital states it has a high dependency unit (HDU), it had a two bed area where it could provide Level 1 enhanced patient care. Staff confirmed it operated as an extension of the recovery unit the service did not meet the requirements for Level 2 critical care in terms of staffing, equipment, environment and training, as outlined by the standards of the Faculty of Intensive Care Medicine 2013. .
  • Service level agreements were in place to transfer both children and adults to NHS hospitals should their condition deteriorate and they required high dependency care.

  • The area dedicated for patients requiring high dependency care did not comply with modern building standards (HBN 04-02 Health Building Note for critical care units)
  • There were sufficient nurses employed to care for adult inpatients and outpatients, with bank nurses used to cover vacancies and sickness absence.
  • Although the hospital treated children and young people it only had one paediatric trained nurse and used bank or agency paediatric trained nurses to supplement this.
  • Over 300 doctors worked at the hospital under practising privileges and there was 24 hour 7 day cover by a Resident Medical Officer (RMO) for inpatients and a separate RMO. When not in the hospital, consultants were available via phone and the RMO told us they were available if needed.
  • The hospital used paper records for patient care and most of the ones we reviewed were up to date. Records that were incomplete and or/inaccurate were due to omissions that had occurred on the night shift.

Are services effective?

  • Care and treatment was informed by national guidance and local policies and procedures we reviewed were up to date. Most nursing staff were aware of policies and guidance except some of those caring for children having surgery.
  • The hospital was carrying out some audits including national audits and readmission rates following treatment were low.
  • Good Surgical Practice 2014 (RCS) says that surgeons should take part regularly in morbidity and mortality meetings. The hospital did not have a dedicated mortality and morbidity meeting. Expected and unexpected deaths were reported and investigated as incidents and were an agenda item at the Clinical Effectiveness meetings along with a list of other agenda items. There had had been seven deaths in the last year but none of them were unexpected.
  • All nursing staff working in theatres and recovery had received specific training and been assessed as competent to care for children. Experience and training for RMOs in caring for children varied.
  • Information provided by the hospital demonstrated that only one nurse had been trained to care for patients requiring Level 2 critical care.
  • Nutritional assessments were carried out on patients.
  • Although staff had attended training on the Mental Capacity Act 2005, some staff had very little awareness about their role and responsibilities in relation to assessing patient’s capacity. Staff were also unaware of the hospital's policy for Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders and the template did not include sections to record an assessment of a patient’s capacity or discussions with patients and their relatives.
  • There was a multidisciplinary approach to care with range of multidisciplinary meetings in place. The hospital did not have a permanent occupational therapist and social work services response times varied.

Are services caring

  • All of the patients, children and young people we spoke with were positive about the care they had received at the hospital.
  • Parents told us they were involved in all aspects of their child’s care and staff used appropriate
  • Forms of communication to explain procedures to children. Patients told us their consultant explained their diagnosis and discussed their treatment options with them including the risks and benefits.
  • We observed staff speaking with patients in a caring manner and maintained their dignity and respect.

Are services responsive?

  • The hospital was meeting the national standards for referral to treatment times for NHS funded patients.
  • The hospital had specific operating days for children and they were prioritised at the beginning of the list. Where appropriate, treatment could be arranged to minimise disruption to attendance at school.
  • The hospital had generic information about procedures and there was no specific information for children.
  • The majority of patients attending the urgent care centre were seen within 15 minutes, of being registered, by either a nurse of doctor.
  • Service level agreements were in place to transfer both children and adults to NHS hospitals should their condition deteriorate and they required high dependency care.

  • The hospital was experiencing delays with pre-assessment and some patients were not seen till the day of their procedure. Some discharges were delayed due to the lack of an occupational therapist.
  • There were limited resources and training for staff to care for patients with complex needs such as those living with dementia or learning disabilities. Although staff told us the hospital did not admit patients with complex needs. Staff had access to an interpreter service but awareness of this was variable.

Are services well-led?

  • Some services had experienced vacancies in key leadership roles including the inpatient manager, infection prevention and control (IPC) and theatres and endoscopy. An inpatient manager had been in post for three months at the time of the inspection and IPC lead nurse part time for four months
  • The impact of the lack of an endoscopy lead and IPC lead are reflected in some of the concerns found during the inspection.
  • Many staff told us their manager was visible and they were supported to do their job and felt able to raise concerns.
  • Although there some systems in place to minimise risk to patients and monitor the quality of care provided they needed to be strengthened. Some aspects of infection prevention and control needed further development. 
  • There was a lack of clarity about the level of critical care provided. Some senior staff confirmed that they did not provide Level 2 critical care. The hospital provided Level 1 enhanced care or extended recovery care.
  • The hospital had a Medical Advisory Committee chaired by a consultant with representation from each of the specialities. The Director of Clinical Services also attended the meeting. The agenda had standing items which included applications for practising privileges, practising privileges renewed and practising privileges suspended or withdrawn.
  • Support and resources for children and young people were limited and there was a reliance on one permanent member of staff who was paediatric trained to deliver the service albeit with some support from bank staff.

Was the hospital well-led?

  • Prior to the inspection there had been a change in the senior leadership in the hospital and a new Executive Director had taken up their post in December 2014. The hospital had also become part of a cluster of three hospitals and the current Director of Clinical Services was transferring to another hospital within the cluster. As well as managing BMI The Blackheath Hospital, the Executive Director would have oversight of all three hospitals within the cluster.
  • The Executive Director was clear that one of the priorities was to review the services provided at each hospital and develop a clinical strategy that achieved the best from the three sites in terms of performance and quality of care. This work already had started with the decision to cease termination of pregnancies due to the low numbers being carried out.
  • The Executive Director had established regular forums with staff to keep them informed about changes and address any questions/concerns they had. All of the staff we spoke with were positive about working at the hospital and the support they received from their manager. The Director of Clinical Services was the professional lead for nurses and attended many of the governance and management meetings including the Medical Advisory Committee (MAC).
  • The MAC had representatives from all the clinical services provided at the hospital along with a GP from one of the clinical commissioning groups.
  • Although some nurses had attended leadership courses, the Director of Clinical Services told us that nursing leadership needed to be further developed.
  • Systems to monitor the quality of care and performance were in place but need to be further developed and more service specific.
  • Although the hospital had collected information about some of its services, it was not using it to review and improve the quality of care provided, for example the Urgent Care Centre.
  • The hospital was aware of some of the issues highlighted in this report but had been slow to take action.
  • The Director for Clinical Services met with commissioners of NHS funded care and reviewed performance and quality information including incidents and waiting times.
  • The hospital sought the views of patients about their experience through a range of surveys. and although the number of responses varied the majority of responses were positive about the hospital and staff. The hospital had identified themes from complaints and taken action including where the complaint involved a particular consultant.

We saw one area of outstanding practice:

  • In May 2014 the Oncology Suite achieved the Macmillan Quality Environment Mark.

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

  • Review and improve its systems to monitor and improve the quality of care for all of the services it provides.
  • The hospital does not provided Level 2 critical care as defined by the Faculty of Intensive Care Medicine standards 2013.
  • Arrangements for decontamination in the endoscopy unit were not in line the national guidance published in 2012.
  • The environment did not meet the national guidance for infection prevention and control
  • Staff were unaware of their responsibilities in relation to the Mental Capacity Act 2005. The forms for  Do Not Attempt Cardiopulmonary Resuscitation orders did not did not allow for the patient’s capacity to be assessed or to include information about best interest meetings.
  • Staff had not received training about how to provide care and support for patients who had learning difficulties or who were living with dementia.
  • Systems to monitor and improve the quality of care provided need to be strengthened.

Importantly, the provider must:

  • Review and develop its systems to monitor and improve the quality and safety of care for all of the services it provides.
  • Improve attendance at infection prevention and control (IPC) training and ensure the inpatient environment is compliant with national IPC guidance.
  • Take action to improve the arrangements for decontamination in the endoscopy unit and the environment and hand washing facilities in inpatient areas to ensure they comply with national guidance.
  • Clarify the level of care it provides and ensure it complies with national standards and accurately reflect this in any information provided to patients, members of the public and NHS commissioning groups.
  • The provider must ensure staff are aware of their responsibilities in relation to the Mental Capacity Act 2005 and Do Not Attempt Cardio-Pulmonary Resuscitation orders.
  • Provide training and support for staff to care for patients living with dementia or who have learning difficulties

In addition the provider should:

  • Continue to recruit to vacant manager/lead posts
  • Review the resources and training for staff ,including medical staff, for children and young people.
  • Provide training and support for staff to care for patients living with dementia or who have learning difficulties.
  • Ensure that information about patients care and treatment is recorded and is accurate and that staff are aware of the possible risks for patients if this is not done.
  • Review and develop care pathways for patients admitted with medical conditions. 

  • The provider should develop a more comprehensive policy around the care of the dying in areas such as the duties of the differing staff groups, withdrawal of active treatments, informing relatives and next of kin and organ donation would provide assurance that all patients were receiving the best possible care.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 10 February 2015

During Reference: R6 not found

Inspection carried out on 6 November 2013

During a routine inspection

The people we spoke with were mostly positive about their care and treatment at the hospital. One person said, “My overall care has been extremely good.” Another told us, “I know what’s going to happen at each appointment.”

There were appropriate arrangements in place to ensure patients’ consent before treatment. Patients we spoke with felt staff took the time to discuss and explain their diagnosis and treatment and felt involved in decisions about this. One person said, “The discussion is never one sided.”

There were enough qualified, skilled and experienced staff to meet people’s needs. One patient we spoke with said, “I have never felt that there are not enough staff and have never had to wait long for staff to come to provide care and support.” Another patient said, “Staff always respond when I press my bell.”

Staff received appropriate training, professional development, appraisal and supervision and were supported in their roles.

We found that people’s care, treatment and support needs were met in most respects and we observed staff interacting positively with them in a caring and responsive manner.

However, we found some shortcomings in the care and welfare of people using the services, the safety and suitability of premises and in assessing and monitoring the quality of service provision

Inspection carried out on 30 October 2012

During a routine inspection

Patients we spoke with that were privately funded consistently confirmed that they had clear and timely information about all associated costs with their treatment.

There were various arrangements in place to accommodate people's needs, values and diversity such as wheelchair access and special dietary options.

Patients confirmed that the hospital had worked with their other care providers to make sure they were properly cared for.

Our inspection of 31 January 2012 found that the hospital equipment had not been properly maintained. When we inspected on 30 October 2012, we found that equipment was properly maintained and suitable for its purpose.

Members of staff received professional training and development, and felt supported by their colleagues.

The provider took account of complaints and comments to improve the service. Patients were encouraged to complete feedback forms prior to their discharge from the hospital, and this information was reviewed and shared with the staff team.

Inspection carried out on 21 March 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

Inspection carried out on 31 January 2012

During a routine inspection

People said that they had been well cared for by staff. They said that staff always introduced themselves and were kind and sympathetic. The people we spoke with were positive about the care that they had received.

They also said that they felt fully informed about the care and treatment that was being provided to them. They said that their care and treatment and the possible risks were explained to them in detail prior to being admitted to the hospital. They said that this was outlined again by the consultant before any procedure was carried out.

People said that they were made aware of how to make comments about the care and treatment the hospital provided to them. The people we spoke with did not have any concerns about the way they had been cared for or treated.

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