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Inspection carried out on 24 to 25 April and 8 May 2018

During a routine inspection

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 carried out on 6, 7 and 14 October 2015

During a routine inspection

We carried out an announced inspection visit of BMI The Manor Hospital on 6 and 7 October and an unannounced inspection on 14 October 2015.

Our key findings were as follows:

Are services safe at this hospital?

By safe, we mean that people are assured that they are protected from abuse and avoidable harm.

  • Staff were encouraged to report incidents and there was an incident reporting system in place that staff were aware of.

  • Feedback from incidents was varied and we were not reassured that staff learnt from all reported incidents.

  • The hospital reported no never events and no serious incidents. However, when we looked at a small sample of incidents, we found two that had been incorrectly categorised and should have been graded as serious.

  • Incidents were not always investigated thoroughly before being closed.

  • No one in the hospital, including the senior team, had undergone root cause analysis training.

  • Theatre staff did not follow best practice national guidelines according to the Association for Perioperative Practice, or the BMI policy for peri-operative swab, instruments and needle counts. Swabs, instrument and needle counts were not displayed on a white board in the operating theatre, whilst the operation was taking place, although this had been rectified at our unannounced visit on 14 October 2015.

  • Potential risks to patients due to the environment and equipment were not adequately identified, including throughout planned refurbishment of the outpatient department which did not meet relevant Health Building Notes (HBN).

  • In outpatients, taps did not comply with HBN 00 -10 Part C: Sanitary Assemblies.

  • Sharps were not always treated in line with best practice.

  • Services were generally clean and equipment was cleaned between patients; however we noted that in outpatients some areas did not appear to have been cleaned thoroughly.

  • In the operating theatre, we found a piece of clean equipment stored in the dirty utility room, which did not comply with the recommendations of HBN 00 – 09.

  • We observed the cleaning and decontamination of dirty endoscopes in the same room where clean endoscopes were stored. This posed a risk of cross contamination between dirty and clean endoscopes. There was no risk assessment in place to mitigate this.

  • We were told that major operations were not commenced after 7pm and minor after 7.30pm. The staff were not aware of any formal policy to support this. However, we found this was not the case and patients were returning to the ward during the night shift when fewer staff were available.

  • Staffing levels, skill mix and caseloads were not always planned and reviewed by the senior ward staff, so that people received safe care and treatment at all times.

  • An early warning score system was used to alert staff, should a patient’s condition start to deteriorate.

  • Surgical procedures were carried out by a team of consultant surgeons and anaesthetists registered with the General Medical Council (GMC). The consultants were mainly employed by other organisations (usually in the NHS) in substantive posts and had practising privileges (the right to practice in a hospital) with BMI The Manor Hospital.

  • Staff were aware of their role and responsibilities with regards to safeguarding and 100% of staff were up to date with adult’s safeguarding and level one safeguarding children’s training.

  • Patient records were up to date; risk assessments had been completed and documented for patients undergoing surgery, including the 5 Steps to Safer Surgery safety checklists. However, we found that records were not stored securely throughout the hospital.

Are services effective at this hospital?

By effective, we mean that people’s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence.

  • Some staff were accessing out of date policies. For example, The

  • The endoscopy department did not have Joint Accreditation Group (JAG) or a Global rating score (GRS) or a similar system for collecting data for endoscopy patients.

  • All patients were given standard fasting instructions aligned with the recommendations of the Royal College of Anaesthetists. However, despite this, due to admission times and eventual theatre attendance, patients were often fasting longer than required.

  • We saw assessments of people’s needs were comprehensive and included the assessment of pain.

  • There was recording and reporting of some patient outcomes, including pain. However, there was no audit plan for the outpatients department.

  • The role of the Medical Advisory Committee (MAC) included ensuring that consultants were skilled, competent and experienced to perform the treatments undertaken. These were reviewed annually.

  • There was a process in place for checking General Medical Council and Nursing and Midwifery Council registration, as well as other professional registrations.

  • There was a lack of formal supervision for nursing staff.

  • Competencies for nursing staff in various areas such as bladder scanning and medicine competencies were not up to date.

  • Staff were confident about seeking consent from patients and staff had received training on the Mental Capacity Act 2005.

Are services caring at this hospital?

By caring we mean that staff involve and treat patients with compassion, dignity and respect.

  • Patients were treated with dignity and respect.

  • We observed good interaction between patients and staff. Staff explained procedures and gave appropriate information to patients to help them to understand and be involved in decisions concerning their treatment. Initial consultations and pre-admissions assessments were thorough and included consideration of patients’ emotional well-being.

  • Most patients spoke positively about the care provided by staff. Patients we spoke with commended staff saying they were friendly and very attentive.

  • The hospital sought feedback from patients about the service using a BMI questionnaire and the Friends and Family Test. The results were positive as 84% of patients said they would recommend the hospital as a good place to go for treatment.

Are services responsive at this hospital?

By responsive we mean that services are organised so they meet people’s needs.

  • Information about services provided at the hospital was provided in a way patients understood and appreciated. Staff told us that should a patient have communication problems they were able to address their individual needs. However, not all staff were aware that the hospital had access to an interpreting service.

  • The patients we spoke with told us that access to the hospital was good and did not have any concerns in relation to their admission, waiting times or discharge arrangements.

  • Staff said they were able to accommodate people’s religious needs both pre and post operatively. They said they could contact the local community that offered support for example, church, mosque, temple or synagogue.

  • National waiting time targets for referral to treatment (RTT) times in surgery were within 18 weeks (admitted pathway). The hospital met the target of 90% of admitted patients beginning treatment within 18 weeks of referral, for each month in the reporting period, July 2014 to June 2015.

  • There was information on the process for making complaints for patients. There were few complaints; all were responded to within industry standard timeframes.

Are services well led at this hospital?

By well-led, we mean that the leadership, management and governance of the organisation, assure the delivery of high-quality person-centred care, supports learning and innovation, and promotes an open and fair culture.

  • There was a governance structure in place, with committees such as the governance and risk team feeding into the medical advisory committee (MAC) and hospital senior management team. The governance and risk committee was also responsible for clinical governance in the hospital.

  • The clinical governance committee, discussed incidents in general. Some had been categorised incorrectly. Appropriate action following incidents was not always taken in both the CG and MAC.

  • We were not assured that the senior management team had sufficient control of or oversight of risk within the hospital. The hospital had a risk register in place; however, it was limited and key risks were not assessed and registered.

  • We saw evidence of anaesthetists and consultant surgeons being reviewed and discussed at the MAC. Consultants had their practising privileges suspended by the Executive Director if they did not provide the relevant information in a timely manner.

  • Appraisal rates were at 100%.

  • Staff spoke positively about the high quality care and services they provided for patients and were proud to work for the hospital.

  • Staff reported that all their managers, including the Executive Director were visible. Staff told us that senior management were supportive and staff felt able to raise concerns.

There were areas of poor practice where the provider needs to make improvements.

Importantly, the provider must:

  • Ensure enough staff with the appropriate skills are available to care for patients.

  • Ensure that all equipment used by the service is clean and stored correctly.

  • Ensure sharps are disposed of correctly.

  • Ensure clean and dirty equipment is not stored in the same area.

  • Ensure the new outpatient room conforms to building regulations.

  • Ensure hand wash sinks conform to building regulations.

  • Ensure that there is a sufficient supply of personal protective equipment in all consultation rooms.

  • Ensure that equipment checks in place are carried out efficiently in accordance with the hospitals policy or to identify all concerns.

  • Ensure that incidents are categorised correctly and fully investigated before being closed.

  • The provider must ensure effective systems are in place to assess, monitor and improve the quality and safety of the services provided; including undertaking relevant audits to monitor and improve patient outcomes.

  • Ensure effective systems are in place to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users, including ensuring that the risk register is reflective of service risks.

In addition the provider should:

  • Ensure records are always stored securely.

  • Ensure root cause analysis training is undertaken for at least senior staff.

  • Ensure all incidents are recorded and staff receive feedback and learn from incidents.

  • Ensure that staff receive formal supervision and appropriate competencies

  • Ensure staff receive training to care for patients with dementia.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 10 October 2013

During a routine inspection

During our inspection of BMI The Manor Hospital on 10 October 2013, we saw that people who use the service were provided with suitable and sufficient information including pre-admission and discharge packs. People told us the information was very useful. They said they'd received good explanations about their care and treatment and felt fully informed. They told us they felt well looked after throughout the course of their care and treatment and this had included undergoing an assessment process before and on arrival at the service.

Our review of their care files confirmed this. We saw that the explanations provided to people including the risks and benefits involved in any procedures were well documented. People had received a review of their medical histories and allergies in all the cases we looked at and were having specific risk factors reviewed and updated regularly.

The people we spoke with said they found staff to be friendly and competent. The staff we spoke with said they were completing a program of training relevant to their roles and received appraisals of their competencies and development. The documentation we looked at confirmed this.

We saw that the service appeared clean during our inspection. However, we found that some infection control processes and practices were lacking.

People told us they had no complaints about the service. We saw the service had a complaints process in place and people's complaints were responded to appropriately.

Inspection carried out on 22 January 2013

During a routine inspection

We visited BMI The Manor on 22 January 2013 and found the environment welcoming and relaxed, with friendly staff.

We spoke with two of the seven patients during our visit, and one person�s relative. All those we spoke with told us they were very happy with their experience at the hospital and the care provided. One person said they were very scared of hospitals, and that staff at BMI The Manor had been �....very good to them� to ease their anxiety. We observed positive, friendly interactions between staff, patients and relatives, and saw people were treated respectfully at all times.

We spoke with staff on duty in most areas within the service, who told us they enjoyed working there.

We saw the service had processes in place to manage people�s assessment and care needs, as well as obtaining consent for treatment or surgical procedures. The two people we spoke with said they had been fully informed about their treatment and what they should expect to happen during their stay.

Inspection carried out on 15 November 2011

During a routine inspection

People we spoke with said that their experience at the hospital had been as they had expected as they had received clear information prior to attending. They said that the nurses and the doctors explained procedures clearly and that they had answered all of their questions.

We were told by the people that we spoke with that all of the staff at the hospital, whatever their role, were polite and friendly. They said that the nursing staff were respectful of their privacy and that they were treated with dignity. They said that the nurses responded very quickly to the call bell. One said, "The staff are excellent, I can't complain at all". Another told us, "The nurses are very attentive".

People told us that they had been asked to complete a patient satisfaction survey and to include any additional information they wanted to with regard to the service that they had received

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