You are here

BMI The Cavell Hospital Good

Reports


Inspection carried out on 8 to 9 April 2019

During a routine inspection

BMI The Cavell Hospital is operated by BMI Healthcare Limited. The hospital provided inpatient and day care services and had a total of 27 beds. hospital has two theatres, endoscopy, phlebotomy and minor operations room, outpatients and diagnostic imaging department.

The hospital provides surgery, medical care, outpatients and diagnostic imaging. We inspected surgery, medical care and outpatients.

We inspected this service using our comprehensive inspection methodology. We carried out the unannounced inspection on 8 to 9 April 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 improved. We rated it as good overall.

We found the following areas of good practice:

  • Staff understood how to protect patients from abuse. Staff had training on how to recognise and report abuse and they knew how to apply it.
  • Staff used control measures to prevent the spread of infection. The treatment and consultation rooms we saw were clean. Trolleys were also clean.
  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
  • Staff gave patients enough food and drink to meet their needs and improve their health.
  • Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
  • Staff provided emotional support to patients to minimise their distress.
  • Staff involved patients and those close to them in decisions about their care and treatment.
  • The service 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 staff. We were given examples where the service had learned from complaints. Patients told us that when something was not to their satisfaction and they raised it with staff, the response was constructive and helpful.
  • The service took account of patients’ individual needs.
  • The service had a vision for what it wanted to achieve. The strategy was developed by the corporate senior management team, with objectives cascaded to the hospital teams.
  • The service managed and used information to support its activities, using secure electronic systems with security safeguards. The service worked to good information governance processes.
  • The service engaged well with patients and staff, the public and local organisations to plan and manage appropriate services.

However, we also found areas of practice that require improvement:

Medical Care

  • The service lacked an effective system to assess, respond to and manage risks to oncology patients during out of hours including medical emergencies. For example, the oncology 24 hours help line was not always staffed by appropriately trained oncology staff.
  • Not all staff had received an annual appraisal. Current appraisal rates for nursing staff were 75% which was below the hospital standard of 90%. This was still an on-going issue and no improvement noted since the last inspection. The hospital aimed to complete staff appraisal by June 2019.
  • The hospital wide pain audits showed low compliance in the completion of pain assessment.
  • The nurses working in the endoscopy unit had not been endoscopy trained.
  • There was low morale among the endoscopy staff due to insufficient break times when the clinics were over booked and the lack of an endoscopy lead. There was a vacancy for the new role of an endoscopy clinical support manager.

Surgery

  • There continued to be some issues where records were not always available, clear or up-to-date, especially in pre-operative assessment.
  • The service did not always have enough permanent nursing staff. During our inspection there were not enough permanent staff members in pre-operative assessment.
  • Not all staff received an annual appraisal. The hospital standard was 90% and the service reported 70% of theatre staff completed an annual appraisal. On the ward, 76% of nursing staff completed an annual appraisal. Annual appraisal rates for healthcare assistants was 60% on the ward.

Outpatients

  • Although the service followed best practice most of the time, we found some issues with the storage of medicines. Resuscitation trolleys were not in a temperature controlled area as advised by the pharmacist due to the storage of medicines on them. Sachets of fluids were found on nurse trolleys kept in treatment rooms that were not temperature controlled.
  • Not all staff were not aware of the General Data Protection Regulation 2016 (GDPR).
  • Patients were not always kept informed of delayed appointment times. Waiting times for clinics were not displayed in waiting areas.

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.

Nigel Acheson

Deputy Chief Inspector of Hospitals

Inspection carried out on 21 - 23 June 2016

During a routine inspection

BMI The Cavell Hospital is an acute independent hospital in Enfield that provides outpatient, day care and inpatient services. It has 27 registered beds. The hospital is owned and managed by BMI Healthcare Limited.

The hospital comprises two main buildings; the original hospital (Cavell building) dates from 1976 and accommodates the consulting rooms, physiotherapy department and endoscopy suite. The newer main building (Trent building) dates from 1994 and houses the imaging suite, ward and theatres.

The hospital provides a range of services including surgical procedures, outpatient consultations and diagnostic imaging services. Services are provided to both insured and self-pay private patients and to NHS patients.

We inspected the hospital on 21-23 June 2016 as part of our independent hospital inspection programme. The inspection was conducted using the CQC’s comprehensive inspection methodology. It was a routine planned inspection. We inspected the following three core services at the hospital: medicine, surgery and outpatients and diagnostic imaging.

Prior to the inspection, the hospital's senior management team took the decision to stop treating children, with the exception of over 16s who were on an adult care pathway.

Facts and Data

The hospital had 27 beds which were used for inpatients and day-case patients. All rooms had en suite facilities. Twenty-six percent of the patients seen at the hospital in 2015 were NHS funded, and the remaining 74% were insured and self-pay patients.

BMI The Cavell provided an outpatient service for various specialties. This included, but was not limited to, gynaecology, cardiology, dermatology, oncology, ophthalmology and orthopaedics. Outpatient services were provided from 13 consulting rooms, in addition to a nurse treatment room, an imaging suite and a physiotherapy department which also provided post-operative treatments and rehabilitation. There were over 27,500 first (46%) and follow-up (54%) outpatient appointments booked at the hospital from January to December 2015.

The hospital had two operating theatres, one with laminar flow. There were 5,070 visits to the theatre between January 2015 and December 2015. The five most common surgical procedures performed were:

  • Hysteroscopy including biopsy, dilatation, curettage and polypectomy (495)

  • Image-guided injection(s) into joint(s) (311)

  • Phacoemulsification of lens with implant -unilateral (212)

  • Therapeutic endoscopic operations on uterus (208)

  • Multiple arthroscopic op on knee (inc meniscectomy) (179).

Medical care included chemotherapy and endoscopy. The chemotherapy service was situated on the Trent Ward, in four designated single accommodation rooms. The endoscopy services included gastroscopy, colonoscopy, oesophageal dilatation and flexible cystoscopy. The dedicated endoscopy unit was situated in the Cavell building separate to the main theatre located within the Trent building.

There were 153 doctors with practising privileges at the hospital and 79.6 whole time equivalent employed staff.

Patients were admitted and treated under the direct care of a consultant and medical care was supported 24 hours a day by an onsite resident medical officer (RMO) Patients were cared for and supported by registered nurses, health care assistants and allied health professionals such as physiotherapists and pharmacists who were employed by the hospital.

The hospital Accountable Officer for Controlled Drugs is the Executive Director.

BMI The Cavell Hospital was last inspected by the CQC in February 2014.

We inspected and reported on the following three core services:

• Medical care

• Surgery

• Outpatients and diagnostic imaging

We rated the hospital as Requires Improvement overall.

Our key findings were as follows:

Are services safe at this hospital?

We rated safe as requires improvement for all three core services because:

The environment did not always comply with national guidelines relating to infection prevention and control. Rooms used for chemotherapy were used by other patients on occasions increasing the risk of immuno-compromised patients getting an infection. There was a known issue with the temperature control system for theatres, however, the hospital had plans to resolve this. Funding was approved for replacement of the DX units, and temporary chiller units were being installed in the interim to ensure the temperature of the theatre environment was controlled, as there was a minimum 12 week order time for the replacement units.

Patient records were not always complete. For example, some outpatient records did not include care plans. Staff were unable to access records for chemotherapy patients outside of daytime hospital hours. Some records had poor legibility.

There were systems for reporting incidents, however, these were not always implemented.

The hospital pharmacy did not hold an up to date list of authorised signatories for staff working in theatres and on the ward.

There was no formal anaesthetic on-call rota, the hospital relied on an informal agreement that anaesthetists in charge of the list were responsible for patient up to 48 hours post-operatively.

However,

Patients were appropriately monitored for signs of deterioration and patient records we reviewed had evidence of National Early Warning Scores (NEWS) being completed. Staff knew what actions to take if NEWS was elevated.

The hospital monitored and reported hospital acquired infections. In the year prior to inspection there had been no incidents reported of hospital acquired infections such as MRSA or C Difficile and the rate of surgical site infection was within the expected range.

Staffing levels and skill mix were planned using an acuity tool and there were enough staff on duty on every shift to ensure patients received safe care.

Medicines were managed safely and stored appropriately. Clinical waste including medicines, sharps objects and chemotherapy waste, was disposed of safely.

Staff demonstrated an understanding of their responsibilities in relation to safeguarding and knew how to raise concerns.

Are services effective at this hospital?

We rated effective as requires improvement overall because:

For medical care, there was limited evidence of how practice was audited against current evidence-based guidance, standards and best practice. There was no regular physician representative on the medical advisory committee (MAC) or at the clinical governance committee. The hospital did not audit use of National Institutes for Care Excellence (NICE) guidelines and other evidence based practice in the outpatient department. However, the hospital participated in national audits in endoscopy, which showed good outcomes within an expected range.

Staff appraisal rates did not meet the hospital target for some staff groups. There were gaps in clinical supervision of the Resident Medical Officers (RMO).

There were limited opportunities for multidisciplinary team (MDT) working in the outpatient department and there were no formal arrangements to ensure MDT discussion of medical patients except oncology patients.

Staff in outpatients did not always have the complete information they needed before providing care and treatment. Systems to manage and share care records were uncoordinated.

Documentation around 'do not attempt resuscitation' (DNACPR) was not in line with the organisation’s policy and discussions with family members were not always recorded.

However,

The MAC chair worked closely with the senior management team and the clinical governance committee to ensure that the hospital was completing and acting on audits.

Surgical care and treatment was provided in line with national guidelines and most outcomes for patients were within the expected range.

We found evidence of good MDT working in surgery, and for oncology patients.

There was evidence of good pain management. Consent to care and treatment was obtained in line with legislation and guidance. Staff showed a good understanding of the consent process including assessing capacity for consent.

Staff were competent and had the necessary skills and knowledge to provide safe care and treatment.

Are services caring at this hospital?

We rated caring as good for all three core services because:

Nursing, medical and other healthcare professionals were caring and patients were positive about their care and experiences.

Patients were treated with dignity and respect. They were kept informed about their care and treatment and felt supported by staff.

Staff encouraged patients to complete the NHS Friends and Family Test (FFT) and we saw the FFT scores for the period of July to December 2015 were consistently between 98% and 100% which was better than the national average.

Are services responsive at this hospital?

We rated responsive as good overall because:

The hospital consistently performed better than the England average for independent acute hospitals for referral to treatment (RTT) pathways in 2015.

The hospital had an admission policy to ensure only patients whose needs could be met were admitted. Senior nurses worked closely with consultants to ensure the policy was being adhered to.

Staff completed dementia awareness training and ensured patients who lived with dementia or who had learning disability were seen quickly to minimise the possibility of distress to them.

Complaints were acknowledged, investigated and responded to in a timely manner, and were discussed at the complaints review forum.

However,

The hospital did not monitor diagnostic imaging and procedures waiting times.

Information on how to make a complaint was not always clearly displayed.

Are services well led at this hospital?

We rated well led as requires improvement overall because:

Within the year prior to inspection there had been senior management vacancies which meant managers had not been able to effectively implement the arrangements for governance and performance management. For example, there had been no permanent Head of Clinical Services for 16 months.

There was a lack of effective medical leadership and medical care was not regularly represented at the MAC.

Although there was an audit calendar in place, some audits were not regularly completed.

However,

Staff were aware of the vision and strategy of the hospital. For example, they told us of plans for a new high dependency unit.

There was a team of suitably qualified heads of department with managerial responsibilities.

The MAC reviewed all new consultants before practising privileges were approved; this included their scope of practice. The hospital had an effective system in place to ensure that practising privileges were updated with the relevant information.

Staff told us the senior management team were visible, approachable and supportive. We observed that staff worked well as a team.

There were also areas of poor practice where the provider needs to make improvements.

Importantly, the provider must:

Review the governance arrangements to ensure structures, processes and systems of accountability for the medical service are clearly set out, understood and effective.

Ensure the chemotherapy service is complying with national guidance for monitoring and reporting neutropenic sepsis and other patient outcomes.

Keep an up to date list of authorised signatories of staff that can order medicines in the hospital pharmacy, so that staff who undertake this responsibility can be identified.

Ensure that when risks are identified that they are recorded, reviewed regularly and timely action is taken to mitigate them.

Ensure patient records are complete and up to date, including care plans, nursing assessments and do not attempt cardiopulmonary resuscitation orders.

Ensure all consultants who are transporting and storing medical records are registered with the Information Commissioners Office.

Improve staff attendance at mandatory training.

Ensure all relevant staff can access records in the chemotherapy service out of hours.

Ensure all staff have an annual appraisal.

In addition the provider should:

Ensure the medical service benchmarks its performance so it can monitor and improve its service. This includes ensuring the audit schedule and calendar are followed.

Review the multidisciplinary arrangements for all medical patients and ensure they meet national requirements.

Establish a formal service level agreement for the emergency transfer of unwell patients for treatment in local NHS facilities.

Ensure all staff comply with infection prevention and control practices such as being bare below the elbow and decontaminating hands between patient contacts.

Ensure all clinical areas comply with the requirements of Health Building Notice (HBN) 00-09: Infection control in the built environment.

Ensure patients have access to information on how to make a complaint as well as information on how to access external support.

Ensure all staff involved in care and treatment have access to full information related to patients' treatment to support decision-making.

Audit the use of National Institutes for Care Excellence (NICE) guidelines to ensure these are followed when providing treatment.

Enable multidisciplinary involvement in outpatients to ensure treatment options are considered in full and knowledge is shared.

Monitor key performance indicators, such as whether patients with suspected cancer were seen promptly, diagnostic imaging and procedures waiting times, and the time it took to issue an appointment letter from receipt of referral, to ensure quality monitoring and continuous improvement.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 4 February 2014

During a routine inspection

Patients� needs were assessed and care and treatment provided compassionately and safely. Typical comments we received from patients included: �the staff make clear they are working with you to make sure you are happy� and �I have received exceptional care.� Patients were satisfied with the meals provided. For example, one patient said, �the meals are very tasty and very nutritional with lots of vegetables.� Another patient told us, �it always arrives hot, it�s well-presented and there are good-sized portions.� There was a wide choice of meals and special diets were catered for. Patients� nutritional needs were assessed to ensure they were protected against the risks of inadequate nutrition and hydration.

The hospital was well-led and there were systems in place to assess and monitor the quality of service that patients received and ensure care was provided safely and effectively. Patients told us they felt able to raise any concerns or worries they had and were confident they would be listened to by staff. Complaints were responded to effectively. Most equipment used on the ward and in theatres was checked and serviced regularly to ensure that it was functioning effectively and fit for purpose.

Inspection carried out on 12 March 2013

During a routine inspection

We spoke with three patients about the care and treatment they had received in the hospital. Everyone was positive about their experience. For example, one patient told us their admission had been �fantastic, from start to finish.� Another said, �it has been a delight to be here.� Staff were described as �very attentive�. Everyone confirmed that consent had been discussed with them before they underwent a surgical procedure. Treatment was discussed in detail and the risks and benefits of the procedure explained in detail.

There were effective systems in place to reduce the risk and spread of infection. A patient told us, �the cleanliness is very good. The nurses always use soap, the cleaners are very good and I can�t fault the place.� Equipment used in the care and treatment of patients was regularly serviced and maintained.

Staff were suitably qualified and received appropriate training to enable them to provide safe care and treatment. Patients had confidence in the knowledge and skills of staff. One patient told us, �the staff are absolutely fantastic.� Another said, �the instant I arrived it was good and welcoming�. Appropriate and accurate records were kept by the service and they were promptly located when requested.

Inspection carried out on 20 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 15 December 2011

During a routine inspection

We spoke to a number of patients in the hospital and they told us they were happy with the care they received. Staff were described as �lovely�, �friendly� and �warm�. Patients were given enough information to help them make decisions about their treatment. The privacy and dignity of patients was respected by staff, particularly whilst providing personal care. The overall service was described as �excellent� by one patient, which was typical of the comments we received.

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