You are here

BMI The Chaucer Hospital Good

Inspection Summary

Overall summary & rating


Updated 6 March 2017

BMI Chaucer Hospital is operated by BMI Healthcare Limited. The hospital is registered for 60 beds, and these are split across two inpatient wards, one of which has four enhanced recovery beds with integral patient monitoring and telemetry. The hospital has two main theatres (1 with laminar flow) and a minor operations theatre based in outpatients. The hospital also has a dedicated Endoscopy Suite, 11 consulting rooms, a colposcopy suite, a Macmillan accredited Oncology unit, a physiotherapy department, Health Screening department and an HFEA licensed Assisted Conception Unit. The hospital has MRI, CT, ultrasound, X-ray and digital mammography within its imaging department. The hospital offers a wide range of surgical and medical procedures, including ENT, orthopaedics, gynaecology, oncology, general surgery, general medicine, gastroenterology, fertility services, ophthalmology, cosmetic surgery, urology, pain management.

We inspected this service using our comprehensive inspection methodology. We carried out the comprehensive announced of the inspection on 1 and 2 November 2016. With an unannounced inspection taking place on 11 November 2016.

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.

We rated this hospital as good overall.

  • The senior management team, supported by the Heads of Departments, had a good knowledge of how services were being provided and were quick to address any shortcomings that were identified. Although relatively new in post the hospital executive director had made a significant impact on the hospital and staff felt that they had been a positive influence. They accepted full responsibility and ownership of the quality of care and treatment within their hospital and encouraged their staff to have a similar sense of pride in the hospital. Both the hospital director and the Director of nursing were able to talk to us in detail about all aspects of the services provided.
  • The care delivered was planned and delivered in a way that promoted safety and ensured that peoples individual care needs were met. We saw patients had their individual risks identified, monitored and managed and that the quality of service provided was regularly monitored.
  • The Executive Director was in overall charge of the hospital and all employed staff were line managed through her direct reports. She had eight heads of departments reporting directly to her including the Director of Nursing, quality and risk manager, imaging manager, pharmacy manager, physiotherapy manager, hospital services manager and materials manager.
  • The Medical Advisory Committee (MAC) met bi-monthly and included representation from all specialities offered at the hospital. It was attended by the Executive Director and the director of nursing. A wide range of topics were discussed and action taken in response to any concerns raised. The minutes of the MAC meetings were distributed to all consultants.
  • The MAC reviewed practising privileges every year. This included a review of patient outcomes, appraisals, General Medical Council (GMC) registrations and medical indemnity insurance. The hospital told us that 22 consultants had had their practising privileges removed; this was due mainly to no longer providing paediatric services at the hospital, along with retirement or relocation. One consultant had their practising privileges suspended this was due to failing to provide up to date documentation the hospital required to renew their practising privileges. This showed the hospital had a good procedure in place to make sure all consultants were experienced and fit to care for patients.
  • Consultant revalidation was part of the requirement for maintaining their practising privileges. Consultants only performed operations they were used to performing at the acute NHS trust where they were employed. This ensured they were competent and confident in undertaking operations and procedures. If a consultant wanted to carry out a new procedure, this had to be agreed as part of their practising privileges.
  • The hospital used an agency that provided a Resident Medical Officer (RMO) onsite 24-hours a day, seven days a week, on a rotational basis. The RMO worked two weeks on, followed by two weeks off. The RMO undertook regular ward rounds to make sure the patients were safe. If the RMO was called out during a significant part of the night or was unwell, the RMO told us there were contingency plans in place to obtain cover. All staff and the RMO told us there were no concerns about the support they received from consultants and their availability.
  • The hospital used the corporate BMI Healthcare Nursing Dependency and Skill Mix Planning Tool, to determine staffing levels. The nursing rota was entered into the system monthly and adjustments made 24 hours in advance based on patient numbers and dependency. This meant that the hospital ensured that staffing levels and mix were sufficient to provide safe care for patients.
  • We saw a strong safety culture with policies and systems in place to allow staff to challenge practice they felt posed a risk. The hospital risk register 2016 was divided into categories such as patient safety, information management, financial, reputation, governance, operational, leadership and workforce, workforce health and safety, and facilities and infrastructure. The risk register detailed the risks, mitigations, actions, allocated key lead, and committee who had responsibility for ensuring existing risk controls and actions were completed for the identified risks.
  • There were robust governance systems that were known and understood by staff and which were used to monitor the provision and to drive service improvements. The Clinical Governance Committee (CGC), met monthly and discussed complaints and incidents, patient safety issues such as safeguarding and infection control, risk register review. There was also a standing agenda item to review external and national guidance and new legislation, such as National Institute of Health and Care Excellence (NICE) guidance, such as NICE CG42, Dementia: supporting people with dementia and their carers in health and social care. This ensured the hospital implemented and maintained best practice, and any issues affecting safety and quality of patient care were known, disseminated managed and monitored.
  • A clinical governance bulletin was produced across the BMI Healthcare organisation which supported the hospital monthly to manage risk. The bulletin identified changes in legislation relating to NICE publications and alerts regarding medicines and equipment. It also provided details of issues of best practice at other hospitals so that shared learning could be applied locally.
  • There was a positive staff culture with many staff having worked at the hospital for a very long time. These core staff offered stability and continuity which was balanced by newer appointed staff who brought a fresh perspective and allowed for the introduction of new ways of working.
  • The hospital was undergoing major renovation works at the time of our inspection. Despite this we found that corridors and patient areas were clean, and kept safe. Although we still found areas in need of renovation the Executive director was able to show us a plan of current works along with a plan of works going forward. The changes already made had improved the appearance and safety of the hospital, for example flooring that met with requirements for infection control.

We found areas of practice that required improvement in both surgery and in outpatients and diagnostic imaging services.

  • All waste bins should be correctly labelled in line with in accordance with Health Technical Memorandum (HTM): Safe Management of Healthcare Waste, control of substances hazardous to health (COSHH), and health and safety at work regulations

  • The procedure for cleaning of nasoendoscopes should be reviewed to ensure dirty instruments do not come into contact with clean areas.

  • The hospital should ensure that language interpreters are only accessed via the formal translation service.

  • Take action to ensure all staff have an annual performance appraisal.

  • Ensure that staff document consent in line with national guidance from the General Medical Council and Royal College of Surgeons.

  • Ensure there is an accurate checklist is available for staff to use when checking equipment for the difficult intubation trolley.

  • Ensure all medical equipment is up-to-date with service and safety checks.

  • Ensure there are systems in place for making sure all medicines are within date.

  • The provider should ensure that that appropriate balance checks of all Controlled Drugs (CDs) are carried out regularly.

  • Take action to ensure all staff are compliant with safeguarding of vulnerable adults and safeguarding children training.

  • Take action to ensure staff are aware of the mental capacity act, and deprivation of liberties, and how it applies to their role.

  • Ensure dedicated hand hygiene sinks in patient bedrooms are included when carrying out refurbishment in accordance with the Department of Health’s Health Building Note 00-09.

  • Ensure carpets are removed from clinical areas and patient bedrooms in accordance with Department of Health’s Health Building Note 00-09.

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 it move to a higher rating.

Professor Edward baker

Deputy Chief Inspector of Hospitals (South East)

Inspection areas



Updated 6 March 2017

Incidents were reported, investigated and learning evidenced. Reports were communicated to all staff.

Patients were cared for in a visibly clean environment that was well maintained. There were arrangements to prevent the spread of infection and compliance with these was monitored. There were no outbreaks of serious infection reported.

The hospital was undergoing an extensive renovation programme at the time of our inspection which was improving areas such as flooring to make them easy to clean for the purposes of infection control. This had not been completed and there were still areas of the hospital that required updating and a rolling programme in place to address these areas.

There were processes for assessing and responding to patient risk. The service had enough staff with the skills and experience to care for the number of patients and their level of need.

The majority of staff had completed the provider’s mandatory training programme. Staff were aware of their responsibilities with regard to the protection of people in vulnerable circumstances.

There were adequate supplies of appropriate equipment that was properly maintained to deliver care and treatment and staff were competent in its use. Staff demonstrated good medicines storage, management and administration. Although there was room for improvement in the recording of patient own controlled medications.



Updated 6 March 2017

We found care and treatment reflected current national guidance. There were formal systems in place for collecting comparative data regarding patient outcomes.

Staff worked with other health professionals in and out of the hospital to provide services for patients. Patients were cared for by staff who had undergone specialist training for the role and who had their competency reviewed.

There were arrangements that enabled patients to access advice and support seven days a week, 24 hours per day.

There was comprehensive assessment of patient needs. This included clinical needs, physical health, nutrition and hydration needs. Patients received adequate pain relief.

Patients provided informed, written consent before commencing their treatment. However, we found one example where consent had not been obtained following BMI policy. Where patients lacked capacity to make decisions, most staff were able to explain what steps to take to ensure relevant legal requirements were met, although staff in theatres were not always able to describe their responsibilities around this legislation.

There was a proactive audit programme that included national, corporate, hospital and departmental audits. Results were shared throughout the hospital and collated to identify themes.



Updated 6 March 2017

Staff provided sensitive, caring and individualised personal care to patients. Staff supported patients to cope emotionally with their care and treatment as needed.

Patients commented positively about the care provided from all staff they interacted with. Staff treated patients courteously and with respect. Patients felt well informed and involved in their procedures and care, including their care after discharge.

Patients and their relatives were involved in their care and were given adequate information about their diagnosis and treatment. Families were encouraged to participate in the personal care of their relatives with support from staff.

We observed patients treated with compassion, care and dignity. Patient feedback was positive and staff demonstrated commitment to continuous improvement.



Updated 6 March 2017

There were a variety of mechanisms to provide psychological support to patients and their supporters. This range of service meant that each patient could access a service that was relevant to their particular needs. For example those with spiritual needs, those requiring bariatric equipment, patients whose first language was not English, or support for people living with dementia or learning disabilities. However we did find in the outpatients department that staff did not always access translation services appropriately.

The services were delivered in a way that met the needs of the local population and allowed patients to access care and treatment when they needed it.

Waiting times, delays and cancellations were minimal and well managed. Patients told us staff were responsive to their needs.

Complaints management was a priority in the hospital. The process was transparent and open with learning communicated across the hospital.



Updated 6 March 2017

There were clear organisational structures and roles and responsibilities. The senior management team were highly visible and accessible across the hospital. Staff described an open culture and said managers were approachable at all times.

Staff spoke highly about their departmental managers and the support they provided to them and patients. All staff said managers supported them to report concerns and their managers would act on them. They told us their managers regularly updated them on issues that affected the separate departments and the whole hospital.

There were good governance, risk and quality systems and processes that staff understood. The committee structure supported this with reports disseminated and discussed appropriately. Staff from all departments had a clear ambition for their services and were aware of the vision of their departments.

Staff asked patients to complete satisfaction surveys on the quality of care and service provided. Departments used the results of the survey to improve services. The hospital had a risk register which was reviewed at the governance committee meetings.

The management team had an understanding of the Workforce Race Equality Standard (WRES) as there is a national requirement to produce key data relating to race quality in the workplace. BMI had started to collect data nationally which they currently held, for example the numbers of staff from black and ethnic minority groups. The management team was in the process of implementing reporting processes to capture the data to enable them to fully comply with WRES reporting requirements.

Checks on specific services

Medical care (including older people’s care)


Updated 6 March 2017

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

The hospital had an open and honest reporting culture and learned incidents. The incident reporting system was paper based. Staff had a good understanding of how to use the system and were able to describe examples of incidents they had reported.

There were systems to keep people safe, these included systems to manage medicines, the risk of infection and the identification and management of risk. Staff understood their responsibilities in relation to safeguarding those in vulnerable circumstances.

There were adequate number of staff at all times to meet the needs of patients who were competent and supported to do their jobs.

Care was delivered in line with national guidance and patient outcomes were good when benchmarked.

Patients were satisfied with their experience and were treated with dignity and respect. They were involved in their care and treatment.

Patients could access care when they needed it and there were arrangements to ensure their individual needs were met and patients consented to their treatment.

Complaints were well managed and lessons learnt to improve the service.

Staff understood the vision, values and strategy of the hospital and demonstrated this in their work.

There were robust governance arrangements which meant the leadership team could be assured of the quality and safety of the service.

Staff felt supported by their leaders who were approachable and visible in the clinical areas.


Although the hospital had systems in place for supporting staff with learning and development,  in practice few staff working in endoscopy had received an annual appraisal due to capacity constraints.

Outpatients and diagnostic imaging


Updated 6 March 2017

People who used the services were protected from abuse and avoidable harm and staff were aware of the processes and reporting systems for recording incidents and safeguarding concerns. Staffing levels were sufficient to provide care in a safe way and staff appropriately responded to changing risks.

Hygiene and infection control practices were followed. Patient records were held securely.

The care and treatment provided to people was evidence based and in line with relevant standards and legislation, including National Institute for Health and Care Excellence (NICE) and professional organisational guidelines.

Staff provided care and treatment to people who used the services in a caring and compassionate way and people were involved in decisions about their care.

The hospital planned the services to meet the needs of the local population. Waiting times for initial assessment, and treatment, following referral were low, and the services met the waiting time targets. Staff treated people as individuals, and made appropriate adjustments as necessary.

There was a robust governance framework and strong management and leadership within the hospital. A comprehensive audit programme and a risk register were in place.

There was good staff engagement within the services and staff felt supported by the management team.


We found the procedure for cleaning of nasoendoscopes did not ensure that ensure dirty instruments did not come into contact with clean areas.

We found two waste bins that had not been labelled appropriately.

We found that although staff had access to translation services these were not always being accessed appropriately by staff.

We found that the diagnostic imaging department changing cubicles were not large enough to accommodate a wheelchair and no alternative changing area was available.



Updated 6 March 2017

Patient safety at the hospital was monitored, incidents were reported and the learning from incidents was used to improve patient care. Staffing levels met the patients’ needs and there was good multi-disciplinary team working. Medicines were mostly stored safely and the environment was clean and records were stored securely.

Patients received care and treatment according to national guidelines such as National Institute for Health and Clinical Excellence (NICE) and the Royal Colleges. Surgery services participated in national audits.

Patients spoke positively about their care, patients were treated with privacy and dignity.

The hospital was meeting national targets for referral to treatment times and processes were in place to support vulnerable patients. Complaints were dealt with efficiently.

Governance structures were good and there was effective teamwork with visible leadership within the services. Staff were positive about the culture within the surgical services and the level of support they received from their managers.


Level 2 Safeguarding of vulnerable adults training compliance was below the BMI Target rate.

We saw one case where consent procedures had not been followed. However, the hospital was aware of this, had reported it as an incident and were investigating.

We found one difficult intubation tray with a completed weekly checklist to indicate that daily checks were made. However, we found the contents of the trolley did not match the checklist.

We found six pieces of medical equipment were out of service date The Quality and Risk manager was informed at the time of inspection; they immediately contacted the relevant companies, and ensured they had a date to service the equipment.

We completed a check of 10 stock medicines on Cornwallis ward and found one medicine, which had gone out of date the day before the inspection.

We found some theatre staff lacked awareness of the mental capacity act, and deprivation of liberties, and how it applies to their role.

We found some patient bedrooms did not have dedicated hand hygiene sinks.

We found that some clinical areas still had carpet in situ.

Termination of pregnancy

Updated 6 March 2017

We regulate this service but we do not currently have a legal duty to rate it. We highlight good practice and issues that service providers need to improve and take regulatory action as necessary.

BMI The Chaucer Hospital had performed two surgical Termination of pregnancy’s (ToP) within the reporting period. Due to the low numbers of procedures, we were unable to discuss experiences with patients during this inspection. However we reviewed both patient records and were able to review hospital policy and procedures around ToP.

We found that the hospital followed current guidance for ToP. In the two records we looked at we saw that this guidance had been followed and that both patients had received safe care.