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BMI The Alexandra Hospital Good

Inspection Summary


Overall summary & rating

Good

Updated 27 January 2020

The Alexandra Hospital is operated by BMI Healthcare. The hospital was built in 1981 and is currently using 128 of its 172 registered beds for inpatient/day case activity. The hospital has an urgent care centre, seven theatres, an endoscopy unit, a minor procedure unit, dedicated children and young person’s ward, a complex range of diagnostic imaging services, a physiotherapy department, on site pharmacy, a five bedded level three/level two critical care ward and three progressive care beds and outpatients.

We inspected this service using our comprehensive inspection methodology. We carried out the unannounced part of the inspection on 30 July to 1 August 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, 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 service provided by this hospital was surgery. 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 surgery service level.

Services we rate

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

  • Staff worked especially hard to make the patient experience as pleasant as possible. Staff recognised and responded to the holistic needs of their patients from the first referral before admission to checks on their wellbeing after they were discharged from the hospital.

  • The hospital controlled infection risk well. The service used systems to identify and prevent surgical site infections. Staff used equipment and control measures to protect patients, themselves and others from infection. They kept equipment and the premises visibly clean.

  • Staff understood how to protect patients from abuse and the hospital worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it.

  • Staff completed and updated risk assessments for each patient and removed or minimised risks. Staff identified and quickly acted upon patients at risk of deterioration.

  • The hospital had enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix, and gave bank, agency and locum staff a full induction.

  • Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date, stored securely and easily available to all staff providing care.

  • The hospital managed patient safety incidents well. Staff recognised and reported incidents and near misses. Managers investigated incidents and shared lessons learned with the whole team and the wider service.

  • The hospital provided care and treatment based on national guidance and evidence-based practice.

  • Managers monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other hospitals to learn from them.

  • Staff gave patients enough food and drink to meet their needs and improve their health. Patients were assessed regularly to see if they were in pain.

  • The hospital made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them.

  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.

  • People could access the service when they needed it and received the right care promptly. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were in line with national standards.

  • Leaders had the skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in the service for patients and staff.

  • Leaders ran services well using reliable information systems. Staff understood the vision and values, and how to apply them in their work. Staff felt respected and valued. They were focussed on the needs of patients receiving care. The hospital engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However, we also found the following issues that the service provider needs to improve:

  • The children’s and young peoples service did not always provide safe care and treatment to those using the service. During inspection, we identified a number of concerns that had not been escalated to the senior management team prior to our inspection despite opportunities available to do this. In response to the risks raised on inspection, senior manages voluntarily closed the service to review the provisions and mitigate any risks.

  • The staffing provision in children and young people services was not always meeting national guidance to ensure there were enough nursing staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. The senior management team were not aware the service did not meet paediatric staffing standards. On inspection the service was suspended until the ward was staffed with a minimum of two registered paediatric nurses.

  • The children and young people services was not always inclusive in taking account of children, young people and their families' individual needs and preferences. Staff did not always make reasonable adjustments to help patients access services.

  • Information received post inspection confirmed the senior leadership team were reviewing the children and young people service leadership structure. They had also reviewed policies and processes to ensure the service was safe.

  • In children and young people services governance processes required strengthening to ensure risks and issues were identified and escalated and identified actions taken to reduce their impact.

  • Although staff completed patients’ fluid and nutrition charts where needed they did not always fully record the total fluids given or recorded what actions they had taken.

  • Information was not always easily accessible to patients and their relatives in formats that met their individual needs.

  • In medicine not all staff understood how and when to assess whether a patient had the capacity to make decisions about their care under the Mental Capacity Act 2005

  • Not all medical staff complied with the ‘bare below the elbows’ policy.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with one requirement notice that affected services for children and young people. Details are at the end of the report.

Ann Ford

Deputy Chief Inspector of Hospitals North

Inspection areas

Safe

Good

Updated 27 January 2020

Our rating of safe improved. We rated it as Good because:

  • The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well.

  • The service controlled infection risk well. The design, maintenance and use of facilities, premises and equipment kept people safe. Staff were trained to use them. Staff managed clinical waste well.

  • Staff completed and updated risk assessments for each patient and removed or minimised risks. Staff identified and quickly acted upon patients at risk of deterioration.

  • Staff assessed risks to patients, acted on them and kept good care records.

  • They managed medicines well.

  • The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.

However, we also found the following issues that the service provider needs to improve:

  • The critical care service did not meet the core standard requirement of twice daily consultant intensivist led ward rounds on the ward.

  • Not all medical staff observed the bare below the elbow’s guidance.

  • The patient records did not consistently include details of the consultant’s pre-operative notes.

  • Staff in the children and young people service were unable to articulate the specific risk issues about sepsis and the protocols in place.

  • The staffing provision in children and young people services was not always meeting national guidance to ensure there were enough nursing staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. This was raised on inspection and senior managers immediately suspended the service so that they could review staffing provisions. The action plan provided by senior managers after their review showed, staffing would be reviewed on a two weekly basis so that it could always be aligned to admissions to the children’s ward and to ensure the ward would be staffed with a minimum of two registered paediatric nurses.

Effective

Good

Updated 27 January 2020

Our rating of effective stayed the same. We rated it as Good because:

  • The service provided care and treatment based on national guidance and evidence-based practice. Managers checked to make sure staff followed guidance.
  • Staff gave patients enough food and drink to meet their needs and improve their health.
  • Staff assessed and monitored patients regularly to see if they were in pain and gave pain relief in a timely way.
  • The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and development.
  • Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent. They knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health.

However, we also found the following issues that the service provider needs to improve

  • In surgery staff did not always use pain scores to assess patients’ pain levels. Staff told us they did not have access to alternative tools to assess pain for non-verbal patients.
  • Surgery did not routinely submit data to external organisations in a timely way.
  • Patient records did not always contain enough information to establish whether informed consent had been obtained.
  • In medicine although staff completed patients’ fluid and nutrition charts where needed they did not always fully record the total of fluids given or recorded what actions they had taken.
  • In medicine there were no arrangements to monitor outcomes of people’s care and treatment as it was not routinely collected and monitored, which meant that we were unable to say if the intended outcomes for people were being achieved.
  • Not all staff in medicine understood how and when to assess whether a patient had the capacity to make decisions about their care under the Mental Capacity Act 2005.

Caring

Good

Updated 27 January 2020

Our rating of caring stayed the same. We rated it as Good because:

  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs.

  • Staff provided emotional support to patients, families and carers to minimise their distress. They understood patients’ personal, cultural and religious needs.

  • Staff supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment.

Responsive

Good

Updated 27 January 2020

Our rating of responsive stayed the same. We rated it as Good because:

  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.

  • People could access the service when they needed it and did not have to wait too long for treatment.

  • It was easy for people to give feedback and raise concerns about care received. The service treated concerns and complaints seriously, investigated them and shared lessons learned with most staff.

However, we also found the following issues that the service provider needs to improve

  • The children and young people services was not always inclusive in taking account of children, young people and their families' individual needs and preferences. Staff did not always make reasonable adjustments to help patients access services.

  • Information was not always easily accessible to patients and their relatives in formats that meet their individual needs.

Well-led

Requires improvement

Updated 27 January 2020

Our rating of well-led went down.We rated it as Requires improvement because:

  • Leaders in the children and young people services did not have the necessary experience and knowledge to lead effectively. They did not always understand and manage priorities and issues the service faced.
  • Managers were not aware of the concerns we raised in children and young people services until they were raised at the inspection which led to the suspension of the service until further action was taken. For example, leaders in this service did not understand the challenges to quality and sustainability or escalated risks to the senior management team and therefore these were not acted upon appropriately.
  • There was a lack of leadership and understanding of risks and governance in children and young people services. Governance and management of performance of risk needed strengthening to ensure staff identified and escalated relevant risks and issues and identified actions to reduce their impact.
  • The surgical service was ‘below the expected standard’ for submitting data to the National Joint Registry. It did not always meet the Patient Reported Outcome Measures target for submitting data.

However, we also found the following:

  • The hospital had a vision for what it wanted to achieve and a strategy to turn it into action, developed with all relevant stakeholders. Leaders and staff understood and knew how to apply them and monitor progress. Wards and departments their own departmental vision.
  • Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service promoted equality and diversity in daily work and provided opportunities for career development. The service had an open culture where patients, their families and staff could raise concerns without fear. All staff we spoke with told us that there had been a positive change in culture at the hospital over the last 12 months.
  • Staff were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service. There were close working relationships with medical directors of neighbouring trusts to share any concerns about a doctor’s practice.
  • Staff were committed to continually learning and improving services.
Checks on specific services

Medical care (including older people’s care)

Good

Updated 27 January 2020

Medical care services were a small proportion of hospital activity. The main service was surgical services. Where arrangements were the same, we have reported findings in the surgery service section.

Medical service included delivering chemotherapy, TAVI (transcatheter aortic valve replacement) and endoscopic procedures to insured, NHS funded and self-paying patients.

We rated this service as good because it was safe, effective, caring, responsive and well led.

Services for children & young people

Requires improvement

Updated 27 January 2020

Children and young people’s services were a small proportion of hospital activity. The main service was surgery. Where arrangements were the same, we have reported findings in the surgery section.

We rated this service as inadequate in well led and requires improvement in safe and responsive. The service was rated good in effective and caring.

Critical care

Good

Updated 27 January 2020

The critical care service supported the hospital’s main surgical services; it accepted both planned and unplanned admissions.

We rated the critical care service as good overall.

Surgery

Good

Updated 27 January 2020

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 because it was safe, effective, caring, responsive and well-led.

Diagnostic imaging

Good

Updated 27 January 2020

Diagnostic imaging services were available to consultants with practising privileges who were authorised as referrers. We rated the service as good overall. We rated safe, caring, responsive and well led as good. We inspected but did not rate effective.

Outpatients

Good

Updated 27 January 2020

The main service provided by this hospital was surgery. Where our findings on outpatients – for example, management arrangements – also apply to other services, we do not repeat the information but cross-refer to the surgery section.

We previously inspected and rated this service with diagnostic imaging, so we cannot compare previous ratings. We rated this service as good because it was safe, caring, responsive and well led. We inspected but did not rate effective.

Urgent and emergency services

Good

Updated 27 January 2020

The Private Walk in Centre in centre is located on the ground floor of the hospital and adjacent to the reception area, separate access is available for patients using this service. The centre is open seven days a week, Monday to Friday 8am-8pm and Saturday and Sunday 8am-6pm. This is a private walk-in service providing care for a range of minor illness and injuries. Patients, who attend with major injuries or complicated illness, are medically reviewed and stabilized before being transferred by ambulance to the local accident and emergency (A&E) department. The team can see patients over the age of three. The team offer private onward referral to specialist BMI consultants for further investigation. This is a fee-paying service.

We rated this service as good because it was safe, effective, caring, responsive and well led.