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BMI The Droitwich Spa Hospital Requires improvement


Inspection carried out on 22 to 23 January 2019 8 February 2019

During a routine inspection

The Droitwich Spa Hospital is operated by BMI Healthcare Limited. The hospital has 46 registered beds offering ensuite facilities, satellite television and telephone amenities. Facilities include three operating theatres, an endoscopy unit, 11 outpatient rooms and diagnostic services including X- ray and magnetic resonance imaging (MRI) and a physiotherapy department.

The hospital provides a range of surgical procedures, outpatient clinics and diagnostic imaging facilities. During our inspection we visited all services within the hospital. Services included surgical procedures and outpatient appointments for preoperative and postoperative review, as well as outpatient treatments such as naso-endoscope and dermatology procedures. In the reporting period of August 2017 to July 2018, there were 683 inpatient procedures, 3,823 day-case episodes of care and 18,731 outpatient attendances. The outpatient appointments were a combination of patients accessing treatment and surgical outpatient consultations.

We inspected this service using our comprehensive inspection methodology. We carried out unannounced visits as part of the inspection on 22-23 January 2019 and 8 February 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 will also apply to other services, we do not repeat the information but cross-refer to the surgery core service.

Services we rate

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

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

  • Not all risk assessments were completed effectively in line with the hospital policy. All consultants are required to complete the venous thromboembolism (VTE) decision box, following assessment, to ensure that patients at risk are identified and appropriately treated
  • In the diagnostic imaging service, processes were not in place to ensure quality testing programmes were completed and that diagnostic reference levels were created and monitored.
  • Clinical audits were not completed within the diagnostic imaging service.
  • Outstanding recommendations following external audits within the diagnostic imaging service required completion and review.
  • Appraisal reviews and mandatory training compliance for some staff was below the hospital target.
  • Regular reviews of the backlog of NHS patient record coding to promote assurance that future obligations are met.
  • Ensure that sinks and taps conform to Health Building Note 00-10 ‘Part C Sanitary Assemblies’, in clinical areas to allow correct hand hygiene practices.
  • The World Health Organisation’ five steps to safer surgery’ checklist for all surgical procedures carried out in the operating theatres were not always completed within all operative specialties.
  • Not all radiography staff had completed the appropriate training and competencies regarding radiation risks and regulations in line with IR(ME)R 2017.
  • Processes and procedures are required to be in place to record and audit consent.
  • Agency staff within the diagnostic imaging department require specific induction for radiographers.
  • To maximise efficiency of operating department time and available staffing resources effective working processes should be developed across departments, within the hospital.

We found good practice within the services:

  • Services within the hospital such as surgery, medicine and outpatients provided mandatory training in key skills to staff.
  • The surgical and outpatient services followed best practice when prescribing, giving and recording medicines. Storage of controlled medicines followed best practice. Patients received the right medication, at the right dose, at the right time.
  • Surgical services in the hospital provided care and treatment based on national guidance and there was evidence of its effectiveness.
  • The hospital controlled infection risk well. Staff kept themselves, equipment and the premises clean.

  • There was effective multidisciplinary working across the hospital. Staff in different teams worked together 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. Patients were treated with dignity, respect and kindness during all interactions with staff.
  • 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. They were communicated with and received information in a way that they could understand.
  • Hospital services were planned and developed to meet the needs of the local population for both private and NHS patients.
  • The service had suitable premises and equipment. Hospital premises were clean, well maintained, and suitably equipped. There was an equipment replacement programme to ensure that all large items of equipment were replaced when they became outdated.

  • All services within the hospital engaged well with patients, staff, the public and local organisations to plan and manage appropriate services and collaborated with partner organisations effectively.
  • The hospital was committed to improving by learning from when things went well or wrong, promoting training and innovation.

  • Managers across the hospital promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
  • People could access the service when they needed it. Waiting times from treatment were and arrangements to admit, treat and discharge patients were in line with good practice.

Following this inspection, we told the provider that it must take some actions to comply with the regulations. Additionally, it should make other improvements, even though a regulation had not been breached, to help the service improve. We issued the provider with three requirement notices that affected diagnostic imaging, outpatient services and surgery. Details are at the end of the report.

Amanda Stanford

Acting Deputy Chief Inspector of Hospitals (Central)

Inspection carried out on 16, 17 and 31 August 2016

During a routine inspection

BMI The Droitwich Spa Hospital was purpose built and constructed in 1985. In 2013, the hospital opened an additional wing, which provided additional bedrooms and consulting rooms. The hospital has 46 registered beds, three operating theatres, 11 outpatient consulting rooms and an endoscopy suite.

The hospital provides outpatient consultations and a range of surgical procedures for adults aged 19 and over, to privately funded, insured and NHS patients.

We carried out this comprehensive inspection, as part of our national programme to inspect and rate all independent hospitals under our new methodology. We carried out an announced inspection of BMI The Droitwich Spa Hospital on the 16, 17 of August 2016 and an unannounced inspection on 31 August 2016.

We did not inspect the MRI or CT scanning services as these are provided and managed by another registered provider.

Our key findings were as follows:

We rated the hospital as requires improvement overall, with surgery rated requires improvement and outpatients and diagnostic imaging rated as good. Three of the five key questions we always ask, namely is the hospital effective, caring and responsive were rated as good overall, with safe and well-led rated as requiring improvement.

Are services safe at this hospital/service?

  • The provider did not have robust procedures to ensure that invasive equipment (naso-endoscopes) were decontaminated in line with national guidance.
  • Clinical areas were observed to be clean and tidy. However, we did observe some individual instances of poor infection control and prevention practice.
  • The service complied with the completion of the five steps to safer surgery checklist. However, consultants had to be encouraged by the theatre nursing team to complete this in a consistent way.
  • Clinical areas at the hospital that had not been refurbished were not compliant with current Health Building guidance.
  • The hospital did not have an in-date service level agreement with local hospitals regarding the emergency transfer of patients should they deteriorate and require additional intervention. However, subsequent to our inspection, the hospital has provided a copy of an SLA for transfer of critically ill patients to a nearby NHS trust, signed in January 2017.
  • We found that safe medicines management procedures were not consistent with hospital policy at all times, in the operating theatres. However, the issues we identified had been rectified at our unannounced inspection.
  • The director of clinical services was the lead for safeguarding at the hospital and was trained to level three in both safeguarding children and vulnerable adults. There were arrangements in place to safeguard adults from abuse that reflected relevant legislation and local requirements. Staff knew how to recognise and report a safeguarding incident.
  • Patient safety was monitored and incidents were investigated to assist learning and improve care. Staff had awareness of the importance of the duty of candour regulation.
  • Handovers were well structured within the service with both safety and resuscitation huddles taking place each morning in theatres and on the ward.

Are services effective at this hospital/service?

  • Patients received care according to national guidelines such as National Institute of Health and Care Excellence (NICE) and Royal College of Surgeons.
  • Patients had their needs assessed, care goals identified, care planned and delivered in line with evidence-based guidance, standards and best practice.
  • Policies and procedures reflected current guidelines and adherence was monitored with a schedule of local audits. There was evidence of actions and audit results being shared with staff.
  • There were processes and procedures in place for staff to manage patients’ pain and ensure that patients’ nutrition and hydration needs were met.
  • Staff were aware of their responsibilities surrounding consent and staff understood their responsibilities under the Mental Capacity Act 2005 (MCA).
  • There were effective arrangements for the admission and discharge of patients. Discharge planning began during the pre-operative assessment process.
  • All personal files of consultants with practising privileges at the hospital contained details of indemnity insurance and evidence of registration with the GMC. However, out of 151 consultants with practising privileges, 51 consultant’s files required their biennial review, as per the hospital’s policy. This meant that we could not be assured that all the practising agreements terms were being met.
  • Staff appraisal rates were low within theatres. We saw that 35% of registered nurses and 40% of operating department practitioners had received their annual appraisal.

Are services caring at this hospital/service?

  • Patients were unanimously complimentary about the care they had received. This was also reflected in the positive feedback in patient satisfaction surveys.
  • Patients felt that they were part of the decision making process regarding their treatment plan. We saw that staff provided an unhurried approach and treated patients with respect.
  • Patient’s privacy and dignity was maintained at all times during our inspection.
  • There were appropriate arrangements to support and meet the emotional and spiritual needs of patients including an open visiting policy and access to chaplaincy.

Are services responsive at this hospital/service?

  • Patients’ specific requirements such as learning disabilities or mental capacity issues were identified at pre assessment. This included screening for patients living with dementia to ensure appropriate arrangements were made to meet individual patient needs, such as longer appointments or arrangements for relatives or carers to stay with them in hospital.
  • The hospital met its national (admitted) target with 94% of NHS funded patients being treated within 18 weeks from referral.
  • Patients had short waiting times in departments prior to consultations or appointments.
  • Complaints were handled effectively and confidentially. Themes from complaints were communication of fees and consultant’s attitude. We saw that action had been taken to address these issues.

Are services well led at this hospital/service?

  • Practising privileges were not being reviewed as per hospital policy. This meant the appropriate systems and processes were not the in place to ensure consultants with practising privileges met required standards to practice.
  • Leaders had not ensured that there was an in-date service level agreement in place for patients who became critically ill and required transfer to a local NHS hospital. Subsequent to our inspection, the hospital provided a copy, confirming that this was now in place (January 2017).
  • There were improvements that were required related to infection prevention, medicines management and storage at the hospital. We could not always be assured that identified quality and performance issues were being addressed.
  • The hospitals risk register was at a corporate level. This meant that it did not always describe risks found at a local or departmental level.
  • The vision and values were clearly displayed in the hospital and had been shared with staff across the ward and theatre areas. Most staff had an awareness of these and knew where to find the information.
  • There was clear and visible leadership at both an executive and head of department level. Staff including administrators, nurses and catering staff told us they were highly motivated and felt valued and supported by their immediate line managers
  • The team safety “huddle’ meeting, had been introduced within the hospital to improve communication across departments. This appeared to have been positively received by staff from different departments and disciplines.

Importantly, the provider must:

  • Implement procedures to ensure that invasive equipment (naso-endoscopes) are decontaminated in line with national guidance.
  • Ensure that all members of clinical staff work within infection prevention and control guidelines.
  • Ensure that all staff consistently participate and complete the five steps to safer surgery checklist.

In addition the provider should:

  • Ensure the safe management of medicines at the hospital complies with policy and guidelines. This includes the procedure for managing the medicine keys within the ward area.
  • Ensure all staff receive a regular appraisal to support and promote development.
  • Ensure all consultants practising privileges are reviewed in line with company policy
  • Ensure that sinks and taps which conform to Health Building Note 00-10 Part C Sanitary Assemblies are available in clinical areas to allow correct hand hygiene practice.
  • Ensure carpets in clinical areas are replaced with flooring that meets the requirements of Health Building Note (HBN) 00-09: Infection control in the built environment.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 19 December 2013

During a routine inspection

We spoke with three people who received care and treatment on the day of our inspection and some family members that were present at the time. Everyone told us that they were happy with the quality of care and treatment received which met their expectations. One person told us: �Very impressed with treatment� and: �All of the staff without exception have been exceptional. � �Another person said: �I have had no lack of attention� and: �They (the staff) have been very caring, listen to me and talked to me. This is a place I feel that I can relax in.�

The three people we spoke with told us that they were well aware of why they had to be in hospital. People told us that they had been well informed about their surgical procedures. They said that staff spoke with them often and explained what was happening and why. One person told us: �Consultant showed me the x-rays and explained my options for treatment. I did not walk away with any questions as I felt very informed.�

We found that people�s care records were detailed and clear with any identified risks to people�s health and welfare documented. We also saw that the World Health Organisation (WHO) surgical checklist was in use to promote people�s safety before surgery commenced. Arrangements were in place to deal with medical emergencies to further ensure people were in safe hands during their hospital stay.

We saw that people who used the service had their medicines as prescribed at the right time and in the right way. This made sure people�s health needs were effectively met whilst they were in hospital and there were guidelines in place to ensure people�s pain was well managed.

We found that minimum staffing levels were maintained to ensure that the needs of people who used the service.

The registered manager and the registered provider had responsive systems in place to monitor and review people�s experiences and complaints. This meant that positive outcomes for people were continually developed, reviewed and improved upon when needed.

Inspection carried out on 17 September 2012

During a routine inspection

During our inspection we tracked through the care and operation procedure processes to check that relevant information had been gathered and recorded. We found that the hospital had robust systems in place to ensure that people received appropriate care. Risk assessments and safety checks had been carried out to protect people who had used the service from injuries and harm.

We spoke with two people who were receiving services and one who had previously had an operation at the hospital. They told us they had been well informed before making decisions about their procedure and care needs. We found evidence that people had given their written consent for the operation they were due to have. They also advised us that the standard of care they had received was good. One person who had recently had a procedure said, "I've stayed here myself and it's been absolutely perfect."

The hospital asked people for their views and experiences of care on a regular basis. We looked at the analysis of these surveys. The reports indicated that people were satisfied with their procedure and delivery of care. We found that very few negative comments had been made. We asked people if they knew how to make a complaint, they told us they did but had not needed to.

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