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Inspection Summary


Overall summary & rating

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

Inspection areas

Safe

Good

Updated 4 July 2018

We rated safe as good because:

  • There were systems for the reporting and investigation of safety incidents that were well understood by staff. Incidents were investigated, actions were taken to minimise recurrence and lessons learned were shared with staff.

  • The hospital was visibly clean and tidy. Staff used personal protective equipment to minimise the risk of cross infection. The hospital reported no surgical site infections from February 2017 and January 2018.

  • There were sufficient numbers of nursing, radiology, medical and support staff to meet patients’ needs.

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

  • Medical records were well maintained and stored securely to maintain patient confidentiality.

  • Equipment in the radiology department was well maintained and had been screened to ensure it was fit for purpose.

  • 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.

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

  • However:

  • Mandatory training compliance rates were variable and did not always meet hospital targets.

  • Safeguarding adults and children training compliance rates were variable and did not always meet hospital targets. However, staff understood their responsibilities in relation to safeguarding vulnerable adults and children from suspected or actual abuse.

  • Some equipment in theatres was old and in need of replacement. This had been identified and was listed on the hospital’s risk register.

Effective

Requires improvement

Updated 4 July 2018

We rated effective as requires improvement because:

  • We found some corporate and local policies had expired their review date. This meant there was a risk that staff may not be following the latest evidence-based guidance. We raised this issue with the senior management team, and immediate action was taken to address our concerns.

  • 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.

  • Not all staff had received an annual appraisal.

  • Some competency frameworks were out of date and the assessment process was not robust in all areas.

  • However:

  • Audits were completed in line with the corporate audit programme and actions were taken to improve outcomes where indicated. However, not all staff were aware of feedback from audits.

  • There was a good multidisciplinary approach to care and treatment. This involved a range of staff working together to meet the needs of patients. Staff communicated effectively and worked well together in order to benefit patients.

  • There was a culture of staff development and learning. Staff were supported to access additional training and were competent in their roles.

  • There was an awareness of best practice and national guidance, which was implemented well in the physiotherapy and imaging departments.

  • There was availability of seven-day services in the imaging department and pharmacy. They both offered an on-call service 24-hours a day, seven days a week.

Caring

Good

Updated 4 July 2018

We rated caring as good because:

  • We saw that staff were friendly, helpful and polite at all times. We saw that staff introduced themselves by name and fully explained procedures to patients.

  • Patients and relatives told us that staff were kind, attentive and caring.

  • Staff ensured that privacy and dignity was respected at all times. Chaperones were available and posters were displayed to inform patients of this option.

  • Staff encouraged patients to be actively involved in the decision-making process for their care and treatment.

Responsive

Good

Updated 4 July 2018

We rated responsive as good because:

  • Services were designed around the needs of the local population. Clinics were held at different times of day to facilitate flexible appointment times that were convenient for patients.

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

  • Patients were assessed prior to admission to ensure that the hospital could safely meet their needs.

  • Written information about conditions and procedures was available and was provided to patients. There was bespoke written information provided to patients in the physiotherapy department.

  • Reasonable adjustments were made to improve access to services for all patients. Each reception had a low height desk suitable for wheelchair users and a hearing loop available to assist communication with patients with a hearing impairment. Facilities ensured that services were accessible to wheelchair users.

  • 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.

  • However:

  • None of the NHS patients we spoke with in the outpatient department had been offered a choice of appointment time.

Well-led

Good

Updated 4 July 2018

We rated well-led as good because:

  • Staff worked well together as a team and felt supported and respected by their colleagues. Staff took pride in their work.

  • Staff felt valued by their departmental managers and found them approachable and told us they were visible leaders.

  • The executive director was well respected, visible and supportive.

  • 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.

  • 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.

  • The hospital risk register was detailed and included actions taken to minimise the risks identified. However, the outpatient risk register did not include all risks identified within the department and we were not assured that staff always accessed the current risk register, as they referred to an out of date paper version during our inspection.

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

  • Staff cared about the services they provided and were proud to work at the hospital. Staff were committed to providing the best possible care for their patients.

  • However

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

Checks on specific services

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.