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BMI Fawkham Manor Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 2 August 2017

Fawkham Manor Hospital is operated by BMI Healthcare Limited. The hospital has 30 beds. Facilities include two operating theatres, one of which has laminar flow, seven consulting rooms, X-ray, outpatient and diagnostic facilities.

Fawkham Manor Hospital provides surgery, medical care and outpatients and diagnostic imaging core services. This inspection was a focused, follow-up visit, and we inspected the surgical core service.

We previously inspected the hospital in August and November 2016 as part of our national programme to inspect and rate all independent hospitals. The 2016 inspection was brought forward because of information received, which raised concerns about the standard of governance at the location. Following our 2016 inspection, we rated the surgery core service as inadequate and outpatients and diagnostic imaging as requiring improvement. This gave the hospital an overall rating of inadequate, and we issued four requirement notices where the provider was not meeting the legal requirements of the Health and Social Care Act (Regulated Activities) Regulations 2014.

A serious incident occurred on 8 February 2017 that demonstrated to us that the safety monitoring systems in place at BMI Fawkham Manor Hospital were not effective. In March 2017 we issued a warning notice because the provider was not compliant with Regulation 12, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. There was a time scale of one week with a date set for the provider to be compliant by 20 March 2017. The provider demonstrated compliance with the warning notice, although not within the required timeframe.

During this inspection, we reviewed surgical services only. We carried out the announced part of the inspection on 10 and 11 April 2017, along with an unannounced visit to the hospital on 5 April 2017. To give the hospital’s overall rating, we have included the rating for outpatients and diagnostic imaging services in the ratings grid, which was taken from our previous inspection in 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. On this inspection, we did not inspect the caring domain as we found this to be good on our 2016 inspection and we had no information to suggest that this position had changed.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

Services we rate

We rated surgery as requires improvement. This was because:

  • Medical Advisory Committee (MAC) meeting minutes showed that not all the findings and learning from root cause analysis (RCA) investigations following serious incidents were shared and discussed at MAC meetings. This meant that not all consultants might have learnt lessons from serious incidents to help prevent recurrences.

  • There was a hospital risk register, which staff reviewed at monthly clinical governance committee meetings as a standard item. However, the MAC chair was not aware of any items on the risk register. When asked, the MAC chair said they felt there “were risks to the hospital, but none now”. This meant the MAC was not aware of key risks to the service and demonstrated weaknesses in governance.

  • Medicine fridge temperatures in theatres were not consistently recorded daily to ensure medicines remained safe to use.

  • Not all waste bins were labelled indicating the type of waste to be disposed. Bulk storage bins for clinical waste were adjacent to the patient car park and unsecured. This was not in line with Health Technical Memorandum 07-01, which states bulk storage areas should be away from routes used by the public, be totally enclosed and secure, and kept locked when not in use.

  • Three out of seven patient records we reviewed did not always show evidence of consultant or medical review when this was required. For example, we did not find evidence of a pre or post operation review by a consultant. This is not in line with the Royal College of Surgeons (RCS) (2014); good surgical practice, which recommends “surgeons must ensure that accurate, comprehensive, legible and contemporaneous records are maintained of all interactions with patients”.

  • Following concerns around poor staff compliance with the World Health Organisation (WHO) “Five Steps to Safer Surgery” checklist identified at our 2016 inspection, we found staff engagement with the WHO checklist remained inconsistent on our unannounced visit on 5 April 2017. However, we saw improvements in the way staff carried out the WHO checklist during our announced visit on 11 April 2017.

  • The hospital provided subsequent assurances that improvements with the WHO checklist were being maintained. We saw an observational audit carried out by an external theatre manager following our inspection. This showed 100% compliance with all areas of the WHO checklist. The auditor commented that the WHO checklist flowed much more routinely and that it was “well ingrained”. The executive team encouraged staff to report any non-compliance with the WHO checklist on the hospital’s incident reporting system. The interim director of clinical services told us staff had reported two incidents of consultant non-compliance.

  • We also saw a letter drafted by the MAC chair to the consultant body on 4 May 2017. This made explicit the requirement for staff to report breaches of the WHO checklist process as incidents on the electronic reporting system. We also saw an addendum to the hospital’s action plan, which provided details of the action being taken in respect of consultants who failed to engage with the WHO checklist process and best theatre practice. This included a meeting with the hospital director and the MAC chair that would be recorded in consultant files. Further or persistent failure to follow policy might result in loss of practicing privileges. This demonstrated the hospital was taking action to ensure continuing compliance with the WHO checklist and the requirements of Regulation 12 (1) (2) (b), Safe care and treatment, of the Health and Social Care Act (Regulated Activities) Regulations 2014.

  • However, internal hospital staff carrying out WHO checklist audits did not always have audit training. This meant the hospital might not have had assurances staff carried out WHO checklist audits correctly.

  • Patients had signed four out of six consent forms we reviewed on the day of surgery. This was not in line with guidance from the RCS Good Surgical Practice 2014, which states staff should “obtain the patient’s consent prior to surgery and ensure that the patient has sufficient time and information to make an informed decision”.

  • Patient reportable outcome measures (PROMs) data showed the hospital’s patient outcomes following groin hernia repair and primary knee replacement were worse than the England averages between April 2015 and March 2016.

  • The hospital did not have a robust system in place to assess the competence and record the use of external staff as surgical first assistants.

  • The service cancelled 30 operations on the day of surgery, for a non-clinical reason within the last 12 months. The hospital offered only a third of these patients with another appointment within 28 days of their cancelled appointment. This was in not in line with the NHS Constitution pledge.

  • The service did not always use complaints as an opportunity to learn lessons and improve.

  • Staff demonstrated limited knowledge around the additional support required for patients with learning disabilities.

  • There was no step-free wheelchair access to baths or showers in the ward.

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 five requirement notices that affected the surgical core service. Details are at the end of the report.

Professor Edward Baker

Deputy Chief Inspector of Hospitals (South)

Inspection areas

Safe

Requires improvement

Updated 2 August 2017

We rated safe as requires improvement because:

  • Three out of seven patient records we reviewed did not always show evidence of consultant or medical review when this was required. This was not in line with Royal College of Surgeons (RCS) guidelines.
  • MAC meeting minutes showed that not all the findings and learning from root cause analysis (RCA) investigations following serious incidents were shared and discussed at MAC meetings. This meant that not all consultants might have learnt lessons from serious incidents to help prevent recurrences.
  • On the ward we saw that there was no date when controlled drugs (CDs) had been received from pharmacy in the CD register. We also saw when an error had occurred this had been crossed out with multiple lines. These practices were not in line with Nursing and Midwifery Council (NMC) Standards for medicine management.
  • In theatres, medicine fridge temperatures were not consistently recorded daily to ensure medicines remained safe to use.
  • There were clean items of equipment stored inappropriately in dirty areas, such as the sluice.
  • Dirty items such as soiled linen skips were being kept in the corridor due to a lack of storage space.
  • Staff were not always observing best practice in the use of personal protective equipment.
  • There were no handwashing sinks in patient’s bedrooms.
  • Not all waste bins were labelled indicating the type of waste to be disposed. Bulk storage bins for clinical waste were adjacent to the patient car park and unsecured.
  • Following concerns around poor staff compliance with the World Health Organisation (WHO) “Five Steps to Safer Surgery” checklist identified at our 2016 inspection, we found staff engagement with the WHO checklist remained inconsistent on our unannounced visit on 5 April 2017. However, we saw improvements in the way staff carried out the WHO checklist during our announced visit on 11 April 2017.

However:

  • The hospital had significantly improved the cleanliness and state of repair of the theatre environment since our last inspection. We found the theatre environment to be visibly clean and tidy. Floors, ceilings, and walls were all clean and intact, and met Department of Health guidance.
  • We observed staff adhering to the “bare below the elbows” requirement, in accordance with corporate policy.
  • Incident reporting had improved and staff were beginning to report non-compliance with the peri-operative WHO checklist as incidents.
  • Safeguarding arrangements were sufficiently robust and staff were trained to the appropriate level.
  • Theatre staff were no longer block signing for controlled drugs.
  • Records were generally well maintained and stored securely.

Effective

Requires improvement

Updated 2 August 2017

We rated effective as requires improvement because:

  • Consultants did not obtain patient consent consistently in advance of the day of the procedure. This was not in line with guidance from the RCS Good Surgical Practice 2014.

  • Patient reportable outcome measures (PROMs) data showed the hospital’s patient outcomes following groin hernia repair and primary knee replacement were worse than the England averages between April 2015 and March 2016.

  • The hospital did not have an effective system in place to assess the competence and record the use of external staff as surgical first assistants.

  • Staff had received mental capacity training, however all staff we spoke with told us patients living with dementia would lack capacity. This was not in line with the Mental Capacity Act, 2005.

  • Hospital data showed the hospital was not on target for ensuring all staff would receive an appraisal for the current year.

However:

  • The service planned and delivered care and treatment in line with current evidence-based guidance, standards, best practice and legislation. Regular monitoring and audit ensured consistency of practice.

  • Information about people’s care and treatment, and their outcomes, was routinely collected and discussed at senior management team meetings.

Caring

Good

Updated 2 August 2017

At our last inspection in 2016, we rated caring as good. We saw no evidence to suggest a change to the good rating for caring at this inspection.

Responsive

Requires improvement

Updated 2 August 2017

We rated responsive as requires improvement because:

  • The service cancelled 30 operations on the day of surgery, for a non-clinical reason within the last 12 months. The hospital offered only a third of these patients with another appointment within 28 days of their cancelled appointment. This was in not in line with the NHS Constitution pledge.

  • The service did not always use complaints as an opportunity to learn lessons and improve.

  • Staff demonstrated limited knowledge around the additional support required for patients with learning disabilities.

  • There was no step-free wheelchair access to baths or showers in the ward.

However:

  • The service made reasonable adjustments and took action to remove barriers for patients living with dementia who may find it hard to use or access services. We saw improvements in this area since our last inspection in 2016.

  • Translation services were available from an external provider to provide face to face and telephone services if required and staff knew how to access this. Menus were available in a number of different languages including Polish, Iranian and Lithuanian as well as large print.

  • Access to the service was straightforward and timely.

  • The hospital scored better than the England average in the Patient Led Assessment of the Care Environment (PLACE) in 2016. The results were used to improve the patient experience.

  • There was clear information displayed to patients on how to make a complaint about their care or treatment.

Well-led

Requires improvement

Updated 2 August 2017

We rated well-led as requires improvement because:

  • Medical advisory committee (MAC) meeting minutes showed that not all the findings and learning from root cause analysis (RCA) investigations following serious incidents were shared and discussed at MAC meetings. This meant that not all consultants might have learnt lessons from serious incidents to help prevent recurrences.

  • There was a hospital risk register, which staff reviewed at monthly clinical governance committee meetings as a standard item. However, the MAC Chair was not aware of any items on the risk register. When asked, the MAC chair said they felt there “were risks to the hospital, but none now”. Neither the MAC Chair nor the MAC membership were aware of any items on the hospital risk register.

  • Internal hospital staff auditing compliance with the World Health Organisation (WHO) “Five Steps to Safer Surgery” checklist did not always have audit training. This meant the hospital might not have had assurances staff carried out WHO checklist audits correctly.

  • There was a culture of consultants persistently failing to fully engage with the WHO checklist in theatres. However, the hospital had begun to address this issue by empowering staff to report consultant non-compliance on the electronic incident reporting system and taking action against consultants that failed to comply.

  • Some staff told us the uncertainty of not having a permanent executive director adversely affected morale. However, staff felt the interim executive director was supportive and approachable.

However:

  • The interim executive team encouraged learning and a culture of openness and transparency. They operated an “open door policy” and encouraged staff to raise concerns.

  • The hospital shared the corporate BMI Healthcare vision. This was to provide the best outcomes, the best patient experience, and the most cost-effective care. Staff we spoke with had some understanding of the goals and values of the hospital and how it had set out to achieve them.

Checks on specific services

Outpatients and diagnostic imaging

Requires improvement

Updated 23 February 2017

Outpatients & diagnostic imaging

We rated the outpatient and diagnostic imaging department at BMI Fawkham Manor as requiring improvement. This was because:

  • We found areas of concern related to infection prevention and control, including noncompliance with the Department of Health’s Health Building Note 00.09: infection control in the built environment (HBN 00.09) in the diagnostics imaging department.
  • In the diagnostic imaging department, we found concerns regarding compliance with the Ionising Radiation Regulations 1999 (IRR99).
  • A full record of outpatient clinic notes was not kept at the hospital.
  • There was a lack of secure storage of patient information and records in the diagnostic imaging department.
  • Staff did not demonstrate adequate knowledge and understanding of safeguarding issues.
  • We found instances where a patient’s privacy and confidentiality was compromised.
  • The facilities and surroundings were not tailored to the treatment of children and young people and we were not given assurance that a paediatric nurse, or other staff member with the appropriate level of safeguarding knowledge, was available on site when children were seen in the department.
  • Staff did not have an adequate understanding of caring for patients living with dementia.
  • Relatives and occasionally members of staff were used if translation was required rather than the interpreter service.
  • We looked at several pieces of electrical equipment but could not find evidence of safety checks, which would indicate it was safe to use.
  • Overall, we found that hospital management did not have oversight of the issues we identified during the inspection.

However,

  • Staff mostly had a clear understanding of the paper-based incident reporting process and most were able to give examples of incident reporting. Incidents were discussed at team meetings and learning from incidents was demonstrated.
  • Staff managed outpatient prescriptions and medicines in line with best practice and stored them securely.
  • The outpatient and diagnostic imaging departments had sufficient numbers of appropriately trained staff to provide safe care to patients. The majority of staff had completed the hospital’s mandatory training programme.
  • The outpatients department had an ongoing audit programme which monitored areas for improvement.
  • Policies and guidelines were based on National Institute for Health and Care Excellence (NICE) and other learned bodies guidance.
  • Staff were competent to perform their roles.
  • Health professionals worked together to provide services for patients.
  • The diagnostic imaging and pharmacy departments provided on call services, 24 hours a day seven days a week.
  • The service offered a variety of appointment times to suit the needs of the patients.
  • Staff were proud of the work they did at the hospital.
  • Staff were positive about their direct line management and felt senior management was visible and approachable.

Surgery

Requires improvement

Updated 2 August 2017

  • Surgery was the main activity of the hospital. We rated this service as requires improvement, because there were gaps in assurance about safety.
  • The prevention and control of infection required improvement. Infection prevention and control in theatres, while better than on previous visits, was in need of further work to bring it fully up to the required standard. The ward bedrooms still lacked hand washing sinks. Storage remained a problem with clean items stored in areas that were not appropriate.
  • The management of controlled drugs in the operating theatres had improved but the ward staff were not signing for the receipt of controlled drugs and the CD book was scored through multiple times, in contravention of the guidance.
  • There was no record of consultant review in some patient records.
  • Some patient outcomes were worse than expected compared with similar services. Primary knee replacement outcomes were significantly worse than other similar hospitals. It is noted that primary hip replacement outcomes were better than average.
  • Consent was not always obtained in advance of the day of surgery in line with relevant guidance and legislation. Some consent records were poorly completed with abbreviations and were difficult to read.
  • There was insufficient assurance about the suitability of surgical first assistants.
  • The arrangements for governance and performance management did not always operate effectively, although we saw significant improvements in this area since our last inspection in 2016.

However

  • Incident reporting had improved since our previous inspection visits and there was evidence provided that demonstrated that non-compliance with the WHO checklist was now being monitored through the incident reporting processes.
  • The hospital provided subsequent assurances that improvements with the WHO checklist were being maintained.
  • The service took the needs of different people into account when planning and delivering services, for example, patients living with dementia and patients who did not speak English as a first language.
  • Safeguarding training had improved and was now delivered face to face rather than online.
  • The theatre staff were now monitoring the patients temperature throughout surgery.