• Hospital
  • Independent hospital

The Manor Hospital

Overall: Good

Church End, Biddenham, Bedford, Bedfordshire, MK40 4AW (01234) 364252

Provided and run by:
Circle Health Group Limited

Latest inspection summary

On this page

Background to this inspection

Updated 4 July 2018

BMI The Manor Hospital was opened in 1983 and, following three ownerships, is now operated by BMI Healthcare. It was originally the manor house of Biddenham, a village near the town of Bedford, and is a grade two listed building. The additional ward, theatre extensions and the administration building were added in 1982. It is a private hospital, which primarily serves the communities of the Bedfordshire area. It also accepts patient referrals from outside this area.

The hospital is registered to provide the following regulated activities:

  • Surgical procedures

  • Diagnostic and screening

  • Treatment of disease, disorder or injury

  • Family planning

The hospital has a registered manager who has been in post since April 2017.

The registered manager is the accountable officer for controlled drugs.

The hospital is registered for 23 inpatient beds (with 19 currently in use), all with private en-suite facilities, Wi-Fi, television and telephone. The facilities are laid out over two floors. Situated on the ground floor of the main building is one operating theatre with laminar flow, a two-bedded recovery area, a dedicated endoscopy unit, the ward, and imaging department, which includes radiography and ultrasound scanning. Upstairs in the main house is the outpatient department, which includes six consulting rooms, one minor treatment room, pre-assessment, and waiting area. The ‘Barns’ part of the site houses the physiotherapy department and health screening services. Facilities include a physiotherapy gymnasium, one private treatment room, a two-curtained cubicle and hand therapy station. Administration staff are housed in a separate building. The hospital is managed by BMI Healthcare and is part of a network of 59 hospitals and clinics across the UK.

The hospital provides surgery, outpatient and diagnostic imaging services for adults only. No persons under the age of 18 are seen and/or treated at the hospital. Prior to March 2018, the hospital did occasionally see young persons of 16 to 17 years of age. These were privately funded appointments.

The hospital offers services to NHS patients, self-pay funded patients and privately insured patients.

BMI The Manor Hospital has been inspected four times by the Care Quality Commission (CQC), between 2011 and 2015. At the last comprehensive inspection in October 2015, we rated the hospital requires improvement overall. We also issued the hospital three requirement notices in relation to regulations that were not being met, and where they needed to make significant improvements in the healthcare provided.

We inspected the services using our comprehensive inspection methodology. We carried out the announced (staff knew we were coming) part of our inspection on 24 and 25 April 2018, along with an unannounced (staff did not know we were coming) on 8 May 2018.

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.   

Overall inspection

Good

Updated 4 July 2018

BMI The Manor Hospital is operated by BMI Healthcare. The hospital is registered for 23 inpatient beds. Facilities include one operating theatre with laminar flow, a dedicated endoscopy unit, and outpatient and diagnostic facilities.

The hospital provides surgery, outpatients and diagnostic imaging. We inspected surgery, outpatients and diagnostic imaging.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 24 and 25 April 2018, along with an unannounced visit to the hospital on 8 May 2018.

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 – also apply to other services, we do not repeat the information but cross-refer to the surgery core service.

See the surgery section for main findings.

Services we rate

We found safety, caring, responsive and well-led was good. Effective required improvement. This led to a rating of good overall.

Summary of main findings:

  • There were systems in place to keep patients safe, including the reporting and investigation of incidents. Learning from incidents was cascaded to all staff.

  • Staffing levels were sufficient to meet the needs of patients and there was an effective multidisciplinary approach to care and treatment. Staff worked well together to benefit patients.

  • Staff were proud of the hospital and were committed to providing the best possible care for their patients. We observed positive interactions between staff and patients. All patients spoke highly of the care they had received.

  • The hospital was focused on providing quality care and had a defined strategy, which was aligned to its vision. Staff were committed to providing a positive patient experience.

  • The executive director was well respected, visible and supportive. Staff felt valued by their departmental managers and confident to report concerns.

  • There were effective governance structures in place to ensure that risk and quality were regularly reviewed and actions were taken to address performance issues, where indicated.

  • There was a comprehensive complaints management process with a culture of being open and honest with patients. There was a complaints policy and complaints were taken seriously, investigated and learning was shared with staff.

  • When things went wrong, staff apologised and gave patients honest information and suitable support.

  • There were effective arrangements in place for the management of medicines.

  • Patients’ views and experiences were gathered and acted on to shape and improve the services and culture.

  • Staff ensured that patients’ privacy and dignity was maintained at all times. Chaperones were available for patients during procedures as required.

  • However

  • There was a lack of consistency with the consent process, with some patients being consented when they were admitted for treatment. This was not in line with national guidance. We raised this issue with the senior management team, and immediate action was taken to address our concerns.

  • Mandatory and training completion rates were below those expected by the organisation.

  • Some corporate policies and local standard operating procedures had expired their review date. This meant there was a risk that staff may not be following the latest evidence based guidance.

  • Local risk registers lacked details and we were not assured they were regularly reviewed. However, we found the hospital risk register was detailed and included actions taken to minimise the risks identified.

  • Not all staff had received an annual appraisal.

We found areas of good practice in relation to surgery:

  • Patients had access to care and treatment in a timely way and cancellations to surgery were minimal.

  • Patients were appropriately assessed prior to surgery and there were processes in place to transfer patients should they require a higher level of care.

  • Audits were completed in line with the corporate audit programme and actions were taken to improve outcomes where indicated.

And some areas for improvement:

  • Some competency frameworks were out of date and the assessment process was not robust in all areas.

  • Not all staff were aware of feedback from audits.

  • Some departmental managers did not always feel sufficiently supported and one-to-one sessions, which they found beneficial, were often cancelled.

We found areas of good practice in relation to outpatient care:

  • There were robust systems in place to ensure that patients and staff were protected by adherence to national guidelines relating to ionising radiation and diagnostic imaging.

  • Patient care and treatment was delivered in line with national guidance.

  • There was bespoke written information provided to patients in the physiotherapy department.

And some areas for improvement:

  • The outpatient risk register did not include all risks identified within the department and staff were referring to an out of date paper version.

  • Following this inspection, we told the provider that it should make some improvements, even though a regulation had not been breached, to help the service improve. Details are at the end of the report.

Heidi Smoult

Deputy Inspector of Hospitals

Outpatients and diagnostic imaging

Good

Updated 4 July 2018

Outpatients and diagnostic imaging services were a small proportion of hospital activity. The main service was surgery. Where arrangements were the same, we have reported findings in the surgery section.

We rated this service as good because it was safe, caring, responsive and well-led. We did not rate the service for being effective.

Surgery

Good

Updated 4 July 2018

Surgery was the main activity of the hospital. Where our findings on surgery also apply to other services, we do not repeat the information but cross-refer to the surgery section.

We rated this service as good because it was safe, caring and well-led, although it required improvement for being effective.