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BMI The Chiltern Hospital Requires improvement

Reports


Inspection carried out on 20th August 2019

During an inspection looking at part of the service

BMI The Chiltern Hospital is operated by BMI Healthcare Limited. The hospital has 66 beds which are divided between three wards, Misbourne, Chalfont and Shardeloes wards. Facilities at the hospital include three operating theatres, an endoscopy suite, a physiotherapy department with a rehabilitation gym and hydro pool and outpatient and diagnostic facilities.

The hospital provides surgery, medical care, services for children and young people, outpatients, and diagnostic imaging.

Following the comprehensive inspection, which was carried out on 15-17 January 2019, the provider was issued with a warning notice relating to the children and young people service on 04 February 2019.

We carried out an unannounced focused inspection on 20 August 2019, to assess compliance against the warning notice. Our inspection targeted the key concerns identified in the warning notice.

At the inspection we found the provider had made considerable progress on all issues identified in the warning notice and we found the following improvements:

  • There was evidence governance processes were in place to ensure the effective running of the service and to safeguard children and young people that used the service.

  • Systems and processes for the recruitment of staff ensured staff held the essential qualifications for the role they were employed for.

  • The children and young people service risk assessed the staffing levels against patient activity and made sure there was safe staffing. There was on-call cover when a children and young people nurse was not on-site at the hospital.

  • The BMI policy and procedures for the staffing of paediatric services was adhered to.

The hospital was compliant with the warning notice.

Dr Nigel Acheson

Deputy Chief Inspector of Hospitals (London and South)

Inspection carried out on 15-17 January 2019

During a routine inspection

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

We found the following issue that the service provider needs to improve:

  • The service provided mandatory training in key skills to all staff and processes in place to monitor compliance, but not all staff had completed this training.

  • Not all areas were patients received care and treatment were fit for purpose.

  • Most equipment was suitable but the paperwork to evidence that equipment had been tested and serviced to ensure it was fit for purpose was not always available, up to date or accurate.

  • Despite children being seen and treated at the hospital not all staff required to completed training in paediatric basic life support (PBLS) as part of their mandatory training had done so.

  • The service stored medicines safely and securely however did not always follow best practice when prescribing and recording the medicines administered in all departments.

  • There was a lack of oversight of which staff had had read and were competent to use Patient Group Directions (PGDs).

  • Not all departments had sufficient numbers of nurses with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.

  • Not all departments used a system to monitor safety results and in areas that did collect this data this was not displayed

  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Whilst managers checked to make sure staff followed guidance, this guidance was not always the most up to date.

  • Children did not always have their care and treatment delivered or overseen by appropriately qualified staff in line with the provider’s staffing policies and procedures.

  • Not all departments had ensured their staff were competent for their roles. In the event of a paediatric emergency a competent member of staff may not always be available.

  • Management of the diagnostic department was still in its infancy and was in the process of developing the right skills and abilities to run a service or had just begun to address some of the challenges in their area.

  • While systems were in place to identify risks and mitigate these, the systems were not always effective in identifying where improvements were required.

  • The provider had a governance framework which was used to improve their clinical, corporate, staff and financial performance. However, these were not always fully embedded into operational practice.

However, we also 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.

  • The service controlled infection risks and kept equipment and the premises clean.

  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately.

  • Staff completed and updated risk assessments for each patient. They kept clear records and asked for support when necessary.

  • The service had enough medical staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.

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

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

  • Staff put patients at the centre of all that they did.

  • Staff took time to involve patients in their care and provided emotional support to patients to minimise their distress.

  • We observed how staff demonstrated a kind and caring attitude to patients and took time to speak with patients and their relatives in a respectful, patient and considerate way.

  • The hospital planned services around the needs and demands of patients, taking into account patients’ individual needs.

  • People could access the service when they needed it.

  • The service treated concerns and complaints seriously, investigated them and learnt lessons from the results, sharing these both internally and with other BMI hospitals.

  • The service had a vision for what it wanted to achieve and workable plans to turn it into action, which it had developed with staff and patients.

  • The service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.

  • The service engaged well with patients and staff to and manage appropriate services.

    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 three requirement notices that affected children and young people and diagnostic services. Details are at the end of the report.

    Nigel Acheson

    Deputy Chief Inspector of Hospitals (London and South Central)

Inspection carried out on 26-27 July and 1 August 2016

During a routine inspection

BMI The Chiltern Hospital opened in March 1982 and is part of BMI Healthcare. The Chiltern Hospital is part of the BMI South Buckinghamshire Hospitals group. The senior management is shared between this hospital and two other services. We inspected one of these services, The Shelburne Hospital at the same time as The Chiltern Hospital.

The Chiltern Hospital has 66 inpatient beds with 55 in use, which are divided between three wards. These are Misbourne Ward, the oncology and endoscopy unit; Chalfont Ward for in-patients and for day cases and short-stay Shardeloes Ward.

The operating department consist of three theatres. In out patients there are 11 consulting rooms with the additional supporting services of audiology, a minor operations room, colposcopy and treatment rooms. The hospital also provides pathology service, has a radiology department providing x-rays, ultrasound scans, Computerised Tomography (CT), Magnetic Resonance Imaging (MRI), bone density scanning, and mammography, a physiotherapy department with a hydrotherapy pool, and pharmacy.

The hospital provides a range of services to patients who are self-funded or use private medical insurance. Some treatment was available for NHS funded patients through the NHS e-Referral Service. Services include general surgery, orthopaedics, cosmetic surgery, ophthalmology, ENT, gynaecology and urology, oncology, physiotherapy and diagnostic imaging. The hospital was not providing services for children and young people.

The executive director, had recently moved from another hospital within the group, was applying to become the registered manager. They were supported by a director of clinical services, a director of operations and a team of heads of departments.

We inspected the hospital as part of our planned inspection programme. This was a comprehensive inspection and we looked at the three core services provided by the hospital: medicine, surgery, outpatients and diagnostic imaging.

The announced inspection took place on 26 and 27 July and an unannounced visit on 1 August 2016.

The hospital was rated good for caring and responsive and requires improvement for safe, effective and well-led services.

Our key findings were as follows:

Are services safe at this hospital?

By safe, we mean people are protected from abuse and avoidable harm.

  • Staff were clear about their responsibilities to report incidents, however the process for the management of reported incidents was not robust and investigations and the sharing of learning did not always take way in a timely way.

  • Processes to protect people from harm, such as infection control, the safe handling of medicines and equipment safety checks were being followed. However staff in theatres did not always follow systems and processes to keep patients safe.

  • Patients were assessed and action was taken in response to risk. This included the assessment of patients to ensure only patients who the hospital could safely support received treatment.

  • Patient records were stored securely. However, medical staff did not always achieve the required minimum standard of documentation in patient records.

  • Staff were aware of safeguarding and were clear about their responsibilities to safeguard people at risk. However training to safeguard children was not currently being provided to the level described in the hospitals policy or safeguarding children and young people: roles and competencies for health care staff Intercollegiate document : March 2014.

  • In general staffing levels and skill mix were planned, implemented and reviewed to keep people safe at all times. This was not the case for the operating departmentwhere staffing levels were not always in line with national guidance. Staff in the operating department were also undertaking dual roles without the support of a local hospital policy or risk assessments.

  • The hospital compliance target for mandatory training was 85%. As of April 2016, compliance with mandatory training for staff working at the hospital was less than 50% compliant.

  • There was a good understanding of the principles of the duty of candour, and the need to be open and honest.

Are services effective at this hospital?

By effective, we mean that people’s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence.

  • Patients’ care and treatment was planned and delivered using evidence based guidance.

  • Most staff were qualified and had the skills needed to carry out their roles effectively. Some theatre staff were undertaking the role of surgical first assistant without fully completing a recognised competency based course. There was no assurance that staff were competent to undertake the role.

  • There was good multidisciplinary working across all teams in the hospital so patients received co-ordinated care and treatment.

  • The hospital provided care to inpatients seven days a week, with access to diagnostic imaging and theatres via an on-call system.

  • Staff had access to the information needed to assess, plan and deliver care to people in a timely way.

  • Consent to care and treatment was obtained in line with legislation and guidance, and staff had an understanding of the principles of the mental capacity act.

  • The hospital had systems in place for granting practicing privileges to consultants and when necessary suspended or removed these. However, the process for the biennial reviews was not being effectively managed.

  • The hospital routinely collected and submitted data on patient outcomes. Although senior staff discussed this information at regional level, there was no evidence of how the hospital shared and used the information locally to improve outcomes for patients.

Are services caring at this hospital?

By caring, we mean that staff involve and treat people with compassion, kindness, dignity and respect.

  • Nursing, theatre and medical staff were caring, kind and treated patients with dignity and respect.

  • Patients felt they received sufficient information about their planned treatment and were involved in decisions about their care.

  • Patients consistently told us they would recommend the service to friends and family.

Are services responsive at this hospital?

By responsive, we mean that services are organised so they meet people’s needs.

  • The hospital planned and delivered services in a way that met the needs of the local population. The importance of flexibility and choice was reflected in the service.

  • Patients had timely access to initial assessment, diagnosis and urgent treatment at a time to suit them.

  • The needs of different people were generally taken into account when planning and delivering services including cultural, language, mental or physical needs. The service had strict selection criteria to ensure only patients whom the hospital had the facilities to care for were referred

  • Discharge arrangements were planned but flexible, and care was provided until patients could be discharged safely.

  • The hospital dealt with the majority of complaints promptly, and there was evidence that the complaints were discussed amongst staff. Complaints were used to improve the quality of care.

Are services well-led at this hospital?

By well-led, we mean that the leadership, management and governance of the organisation assures the delivery of high-quality person-centred care, supports learning and innovations and promotes an open and fair culture.

  • There was a corporate vision in place, supported by a hospital business plan. Senior managers were aware of the key risks that may affect them achieving the vision.

  • Governance processes were not always effective in monitoring the quality and safety of the service at a local level. Practices were taking place in the operating department that were not reflective of corporate polices or current national guidance.

  • Managers and staff did not use the hospital risk register effectively to identify and manage risks within the service and there were no risk register at department level.

  • The lack of a consistent and experienced theatre manager to lead and manage the operating department had resulted in no-one taking clear accountability and responsibility for the quality and development of the service. Local leadership was being developed with some department managers being new to the organisation.

  • Heads of department found the daily senior team meeting an effective way to share key information with them.

  • Staff felt they supported each other well in their teams and this had helped during a number of senior staffing changes at the hospital.

  • They valued the changes the new executive director had made, particularly improving the appearance of the hospital and listening to their concerns.

After the inspection the provider was issued with a requirement notice letter, as we had identified potential failings to comply with two regulations relating to good governance and staffing; the detail of which is contained within the report and listed in the must actions at the end of the report. We asked the provider to submit an action plan to show how they would address these concerns and demonstrate how they would reduce the associated risks to patients and staff. The provider submitted a detailed action plan within the agreed timeframe which we felt was sufficient to comply with the requirement notice. A responsible person was allocated to each action, with a date for completion. Compliance with the action plan will be monitored through regular engagement meetings with the provider.

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

Importantly, the provider must:

  • The provider must ensure that all staff acting as a surgical first assistant have been assessed as competent for the role. In addition, the evidence of completed competencies and log of cases should be available in accordance with the BMI Healthcare Surgical First Assistance policy.

  • The provider must ensure it completes regular reviews of compliance with BMI Healthcare policies, with action taken for areas of non-compliance, including the renewal of practising privileges.

  • The provider must ensure that staffing levels in theatres are in line with current national guidance and the BMI Healthcare policy.

  • The provider must ensure when staff are undertaking a dual role this is supported by a local policy and risk assessment.

  • The provider must ensure staff in the operating theatre fully comply with the Five Steps to Safer Surgery at all times.

  • The provider must ensure there is robust monitoring of the safety and quality of the surgery service at a local level, with risks identified and timely action taken to manage the risks.

  • The provider must ensure the hospital risk register reflects the current risks faced by the hospital and in sufficient detail to show how they are monitoring the risks.

  • The provider must ensure there is robust monitoring of the safety and quality of the outpatients and diagnostic imaging service at a local level, with risks identified and timely action taken to manage risks.

  • The provider must ensure that all incidents are monitored at each hospital and individual clinical location to be able to identify trends.

In addition the provider should:

  • The provider should ensure a trend analysis of all incident reports is completed, with action plans devised as a result.

  • The provider should ensure all patient chairs have a wipeable surface to ensure they can be appropriately cleaned.

  • The provider should ensure all floors in the operating department are kept clear so they can be cleaned and there are no trip hazards to staff.

  • The provider should ensure all areas in the operating department meet fire safety regulations.

  • The provider should ensure all patient care records are completed in full, by the multidisciplinary staff providing care and treatment

  • The provider should ensure all staff are up-to-date with all of their mandatory training.

  • The provider should ensure all staff complete safeguarding children training appropriate to their role.

  • The provider should ensure all the key recommendations of the Perioperative Care Collaborative Statement on Surgical First Assistants have been considered, with action taken as indicated.

  • The provider should ensure patient surgical outcome data is shared and discussed at relevant departmental meetings so changes can be made to practice where necessary.

  • The provider should ensure for all audits there is a clear action plan, with accountability for completion of any actions, by an agreed date.

  • The provider should ensure all theatre staff receive an annual appraisal.

  • The provider should ensure formal written on-call arrangements are in place for all relevant teams.

  • The provider should ensure the gastroenterologists explain to patients the need for possible transfer to the NHS hospital should complications from the procedure occur.

  • The provider should consider arranging an external review of its theatre service to seek an independent review of the standards of the service.

  • The provider should consider reviewing the layout of the changing rooms in diagnostic imaging to ensure it meets the needs of all patients.

  • The provider should consider displaying safety thermometer information in all clinical areas as considered best practice.

  • The provider should train staff in line with the BMI Safeguarding Children policy. All staff who have some degree of contact with children should complete a minimum of level 2 safeguarding training.

The provider should consider formalising arrangements for diabetic specialist nurses from the NHS to assess and treat patients at both the Chiltern and Shelburne hospitals

Professor Sir Mike RichardsChief Inspector of Hospitals

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 16 January 2014

During a routine inspection

Patients told us they felt fully involved in their assessment and treatment. One patient said communication between the hospital and patients was; "Excellent." Patients said treatment options were fully discussed and they received the necessary information in a way they could understand and in a timely manner.

We looked at care record files for seven people; including inpatients and outpatients. We saw documentation included patient personal details such as address and date of birth, consent to treatment, clinical history of the patient, operation and treatment details. This showed patients' needs were assessed and care and treatment was planned and delivered in line with their individual care plan and in a way that was intended to ensure patients' safety and welfare.

We spoke with a senior pharmacist who explained the system for monitoring medication brought into the hospital by patients. They told us pharmacist support was available 24hrs each day, including through an out of hours system. This meant staff could access advice and medication at any time patients required it. This showed appropriate arrangements were in place in relation to obtaining medicine. They described the system for accurately recording medication administered on the wards. This confirmed medicines were prescribed and given to people appropriately.

We looked at five staff recruitment files. They included an enhanced Criminal Records Bureau (CRB) or Disclosure and Barring Service (DBS) check. We saw at least two references had been taken up and checked, there was photographic proof of identity and a full employment history. We found the right to work in the United Kingdom had been established and health checks had been carried out to establish applicants' physical and mental fitness. This showed appropriate checks were undertaken before staff began work.

Patients were made aware of the complaints procedure, in a format which met their needs. Patients told us they were aware they were able to make complaints if they felt they needed to. We saw there were notices and information leaflets about how to complain throughout the hospital. We saw patient feedback was positively canvassed and facilitated. For example, we saw a leaflet informed patients; "We want your stay with us to be trouble-free. So if you have any comment on the level of service or care, please speak to a member of staff right away..."

Inspection carried out on 12 February 2013

During a routine inspection

All of the people we had conversations with told us they were satisfied with the care they received. They said it had met their expectations and in three cases people told us it had exceeded them. People said they had been able to understand the treatment choices available to them.

We spoke with three in-patients about their experience. They told us they had completed a thorough pre-admission assessment and consultation process. This had established their medical history and they told us they had been involved at every stage in determining treatment options. One person told us they had not been under any pressure at any time and had been able to take their time discussing alternative courses of action open to them. Two of the people we spoke with were post-operative. They said the standard of the surgical team had been 'outstanding' and 'excellent'. They were particularly positive about the nursing support they had received immediately following their operations.

We were told all staff involved with paediatric patients had completed their paediatric safeguarding training. We were able to confirm staff training undertaken and planned from records seen. We saw the provider had policies and procedures in place on safeguarding adults and children.

We saw there were boxes and feedback forms readily available in reception. This provided people with an easy and early opportunity to comment on their experience if they chose to do so.

Inspection carried out on 16 November 2011

During a routine inspection

People who use the service told us that staff were very good at respecting their privacy and dignity. They told us they had been involved in discussions about their care and treatment. They said they had been given the opportunity to ask questions and had received thorough explanations on such things as consent to their treatment and the risks and benefits involved in their procedures. They said that where possible they had been encouraged to do as much for themselves as they could.

People told us they had completed a pre-admission assessment and a further assessment on arrival at the Chiltern Hospital. They said they had been asked about their needs as part of the assessment process. People felt that staff were very familiar with their needs and how to meet them. They said that staff always provided an explanation of what they were doing and why when providing care and treatment.

People said they felt safe and that their possessions were secure at the Chiltern Hospital. They told us they had no concerns about the way staff treated them. They said that staff appeared competent in looking after them and were generally very responsive. They felt that staff were polite and respectful.

All the people we spoke with had been provided with questionnaires asking for their views on their care and their stay at the Chiltern Hospital. They felt confident in raising any concerns with staff and said that there was always an opportunity to feedback or comment if they wanted to.

One person summarised her time at the Chiltern Hospital by saying: �My experience here has been very good. I feel that my treatment has achieved everything I wanted it to. This is a very pleasant environment�.

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