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BMI The Duchy Hospital Requires improvement


Inspection carried out on 31 July to 01 August 2017

During a routine inspection

Inspection carried out on 4, 5 and 19 October 2016

During an inspection looking at part of the service

The Duchy Hospital is operated by BMI Healthcare Limited. The hospital/service has 27 beds. Facilities include two operating theatres (both have laminar flow), X-ray, outpatient and diagnostic facilities. The hospital provides surgery and outpatients with diagnostic imaging services and we inspected both of these services. We did not inspect services for children or young people as the hospital had ceased to provide these services for children under 16 on 31st August 2016. At the time of the inspection, they did provide services for young people over the age of 16.

We inspected this hospital using our comprehensive inspection methodology. We carried out the announced part of the inspection on 4-5 October 2016 with an unannounced visit to the hospital on the 19th October 2016. To get to the heart of patients’ experiences of care and treatment, we ask the same five key questions of all services: are they safe, effective, caring, responsive to peoples’ 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 said to us and how the provider understood and complied with the Mental Capacity Act 2005.

We rated surgery as inadequate and outpatients and diagnostic imaging as requires improvement and the hospital as inadequate overall.

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 core service.

We found areas of practice that the service provider needs to improve in both surgery and the outpatients and diagnostic imaging services.

In surgery:

  • In the inpatient ward and theatre recovery area, sufficient numbers of suitably qualified, skilled and experienced nursing staff to meet patients’ needs were not always available.
  • In the theatre and outpatients department, the use of the five steps for safer surgery including the World Health Organisation (WHO) surgical safety checklist was not embedded. The WHO surgical safety checklist is a tool for the relevant clinical teams to improve patient safety.
  • Actions based on recommendations around theatre escorts were not always implemented in an effective way.
  • Pre-operative fasting guidance was not consistently delivered in line with national guidance and the best practice outcomes for patients.
  • The inpatient environment had carpets present and patient bedrooms did not have access to a clinical hand washbasin to perform hand hygiene. This was a recognised risk on the hospital risk register. At the time of inspection, the hospital had a refurbishment plan that was due for completion in 2020, however some of these plans, due to financial constraints, had been placed on-hold. However, since the inspection the provider has informed us that refurbishment work was now underway again in the service.
  • The environment used to decontaminate endoscope equipment did not meet best practice guidance (Management and decontamination of flexible endoscopes Health technical memorandum (HTM) 01-06). There were plans to move this offsite.
  • Based on the pre-inspection information request we identified inaccuracies in data held locally within the hospital and data held by the head office. This had the potential to affect any data used for benchmarking quality at the hospital compared with other BMI services.
  • Not all risks that staff identified to us including business, staffing and infrastructure risks were recorded on the risk register.
  • During our inspection, we saw a lack of cohesive leadership between the senior management team. Staff consistently told us that, although they felt supported by their immediate management, there was less support from senior management. In addition, they spoke about degrees of variance in their confidence in senior leadership and the responses they had received when raising concerns. Management had recognised there were issues and had involved external agencies to support relationship challenges within hospital teams.
  • The majority of staff we spoke with told us that there were relationship difficulties between staff working in the operating theatre and inpatient ward areas.
  • At a hospital level there was no clear ownership of the workforce and race equality standards (WRES).The organisation had a corporate workforce and race equality standards report. However, the report was for the organisation and not individual to the hospital.

In outpatients and diagnostic imaging services:

  • The use of the five steps for safer surgery including the World Health Organisation (WHO) checklist was not embedded in the outpatient department.
  • Patients who attended the outpatient department for a minor procedure under local anaesthetic, such as, cystoscopies (an invasive medical procedure used to examine the inside of the bladder) or excision of skin tags and moles did not have their observations recorded before or after the procedure.
  • There was no specialist ventilation in the minor procedure room. The room was used for a variety of procedures including: wound checks, excision of cysts and lesions including basal cell carcinomas (a type of skin cancer), removal of sutures, endoscopic biopsies and cystoscopies. Guidance from the Department of Health, The Health Technical Memorandum 03-01: Specialised ventilation for healthcare premises states endoscopy, day-case and minimum invasive suites, such as the minor procedure room, require a degree of specialist ventilation. Following our inspection, the hospital did a risk assessment and sought external assurance from a microbiologist regarding the use of the room. The evidence provided to us did not reference compliance with HTM03-01. The hospital continued to use the room for cystoscopies, although they have since advised that they no longer use the room for that purpose.
  • The Radiology department had recently changed Radiation Protection Advisors. An action plan was in place and they were in the process of reviewing standard radiology protocols. The deadline for completion was December 2016.
  • The hospital did not collect data on waiting times. However, staff in all departments told us the wait times for appointments were short. The radiology and outpatient managers both told us patients could get an appointment within a week.
  • The outpatient department did not have a DNA policy. The hospital recorded the number of NHS patients who DNA their appointment however, they did not collect data or audit the number of privately funded patients who DNA their appointment. If a patient DNA their appointment, they were contacted and an alternative appointment was made
  • We identified some risks in the departments that were not on the hospital’s risk register. For example, the lack of ventilation in the minor procedure room did not appear on the hospital’s risk register.
  • Some clinical areas within outpatients had carpets. This was not in line with Health Building Note 00-09: Infection control in the built environment.

However, we found the following areas of good practice:

  • The hospital environment was visibly clean.
  • There were effective processes for recording practising privileges, compliance, indemnity and appraisals.

  • Patients we spoke with were positive about their experience of care.
  • We observed that staff delivering care to patients were caring and compassionate.
  • There was good local level leadership on the inpatient ward and administration and outpatient department.
  • The hospital had an out of hours rota for anaesthetists to provide 24 hour cover for patients post-operatively and there was a service level agreement for emergency transfer arrangements with the local NHS trust.

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. We issued the hospital with five requirement notices that affected surgical and outpatients’ services. Details are at the end of the report.

Ellen Armistead

Deputy Chief Inspector of Hospitals (North Region)

Inspection carried out on 25 September 2013

During a routine inspection

People we spoke with told us they been involved in the planning and delivery of their treatment and that they felt respected and listened to. We spoke with four people during our inspection who were receiving treatment at the hospital.

People told us their stay had been made comfortable. They said they were treated well by the staff. One person told us, �I am confident the staff know what they are doing. Theatre staff were very nice they were all chatting; generally I found this very reassuring, they included me.� One person summed up what they felt of the hospital by saying �I think it is a lovely hospital, a bit like a cottage hospital, it is very friendly."

We looked at four people's medical and care records and saw that they were person centred and included essential risk assessments, which had been kept under review, to enable appropriate treatment, care and support to be given.

The hospital had in place policies and procedures covering infection control. People we spoke with told us that their rooms were kept clean. Areas we inspected were found to be clean.

Observations on the day of inspection, people we spoke with and records we looked at confirmed that there were sufficient staff to meet peoples care needs. People told us they were supported as and when needed.

The provider had systems in place to make sure people were safely cared for. This included policies and procedures and quality monitoring systems.

Inspection carried out on 4 December 2012

During a routine inspection

Patients we spoke with told us that they were happy with the care they received. They spoke positively about the staff, care and treatment provided and told us that staff treated them with respect. Everyone we spoke with felt they were involved in their care and in making decisions about their treatment. We received comments such as, �Every body has been fantastic.� Another commented, �The staff are responsive to my bell, they come in less than a minute.�

Patients we spoke with confirmed that their consent had been obtained prior to any surgery being carried out at the hospital. �I agreed to come in here last week and the consultant talked me through the pros and cons of my operation before I signed my consent form yesterday morning.�

When we spoke with patients in their own rooms, we saw that there were lockable facilities for their medication. Patients told us they managed their own medication. We also spoke to patients about if they knew how to make a complaint. They told us they were all quite happy with the overall service they received at the hospital, but were unaware as to how they made a complaint. Although this information was in the patient information guide in their rooms, which they all confirmed that they had received.

Inspection carried out on 8 November 2011

During a routine inspection

As part of our inspection we talked with a number of patients. They spoke positively about the staff and care provided and told us that staff treated them with respect. Everyone we spoke with felt they were involved in their care and in making decisions about their treatment. We received comments such as �I felt well prepared before my treatment, any questions I had trivial or not, were attended to�, that they had been treated "Extremely well" and their overall experience of the care they received was "Excellent".

Everyone we spoke with felt they had received sufficient information and were involved in making decisions about their treatment and one person told us �I had sufficient time to consider the information I was given, I didn�t feel rushed�.

Patients told us that they received a varied choice of food which was well prepared and presented. A number of positive comments were made, for example one person said that the food was �Excellent� and another said that the food �Couldn�t be better�.

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