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Inspection report

Date of Inspection: 25 January 2012
Date of Publication: 24 February 2012
Inspection Report published 24 February 2012 PDF

The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care (outcome 16)

Meeting this standard

We checked that people who use this service

  • Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.

How this check was done

Our judgement

The quality of service provided to patients was regularly monitored. There was evidence of learning and changes in practice in response to analyses of incidents and audits. Risks to patient safety were managed effectively.

Overall, we found that BMI The Garden Hospital was meeting this essential standard.

User experience

Patients we spoke with were happy with the quality of care and treatment provided to them. For example, one patient said, ‘the level of care is second to none’.

Other evidence

Clinical outcomes of surgery were monitored. Measures included post-operative infection rates and unplanned returns to theatre. Clinical Governance reports recorded all incidents and accidents affecting patients, staff and visitors that had taken place. These were monitored and reviewed by the Medical Advisory Committee (MAC) which met on a quarterly basis. Minutes of recent meetings confirmed that monitoring of the quality of services was taking place on a regular basis. Changes implemented as a result of clinical incidents were recorded in minutes of MAC meetings.

Patients were encouraged to complete satisfaction surveys in relation to their use of services at the hospital. Questionnaires were analysed by an external company and the results fed back to staff. Patient feedback scores from the surveys were benchmarked against other hospitals provided by BMI Healthcare Limited. The report of satisfaction surveys completed in December 2012 showed that 95% of patients were satisfied with the care and treatment they had received. 99% said they would recommend the hospital to others.

Audits were carried out on a regular basis as a way of monitoring compliance with policies and procedures. We saw that audits had been conducted of post-operative pain and temperature and consent to care and treatment for example. Where audits identified areas for improvement these were addressed. A correct site surgery audit conducted in October 2011 showed that WHO surgical checklists were being completed for all operations. However, in a few instances it was reported that checklists had been completed in full before surgery began, which was not the correct procedure. An action plan was in place to ensure that checklists were completed at the appropriate stage of surgery.

We saw other examples of where audits had identified areas for improvement. For example, a pharmacy audit of controlled drug administration in theatres identified that some anaesthetists were administering controlled drugs without a witness and not always accurately recording the amount being discarded. An action plan had been put in place and immediate training provided to staff. A follow-up audit was planned to ensure that controlled drugs legislation was being complied with.

More than 150 consultants had been granted practising privileges at the hospital. Practising privileges were reviewed every two years. Reviews included consideration of any complaints about the consultant and any incidents in which they were involved. We saw MAC meeting minutes that confirmed the reviews had taken place. All new applicants for practising privileges were granted the right to practise within their area of expertise only and this was reviewed after six months. This assured the provider that consultants were able to provide safe care and treatment to patients.

We saw a number of personnel files of consultants providing services at the hospital including those carrying out cosmetic surgery. These showed that consultants had undergone the necessary checks including Criminal Records Bureau checks. Their professional registration was up-to-date and there was a copy of a current annual appraisal on file.

Theatre staff told us that if they had any concerns about the practice of a particular surgeon they would raise this with senior managers. We were given an example of where this had happened and the action taken as a result.