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Inspection carried out on 19,20,26 July 2016

During a routine inspection

We carried out a comprehensive inspection of BMI Mount Alvernia Hospital on the 19, 20 and 26 July 2016 as part of our national programme to inspect and rate all independent hospitals. We inspected the core services of surgical services, medical services, out-patient and diagnostic imaging services as these incorporated the activity undertaken by the provider, BMI Healthcare Limited at this location.

We rated all four core services as good overall.

Are services safe at this hospital/service

Incidents were reported, investigated and learning evidenced. Reports were communicated to all staff.

Patients were cared for in a visibly clean environment that was well maintained. There were arrangements to prevent the spread of infection and compliance with these was monitored. There were no outbreaks of serious infection reported.

There were processes for assessing and responding to patient risk. The service had enough staff with the skills and experience to care for the number of patients and their level of need. The majority of staff had completed the provider’s mandatory training programme. Staff were aware of their responsibilities with regard to the protection of people in vulnerable circumstances.

There were adequate supplies of appropriate equipment that was properly maintained to deliver care and treatment and staff were competent in its use. Staff demonstrated good medicines storage, management and administration.

There was room for improvement with safety in surgery where we found that the side of the patient due to be operated on was not always clearly or accurately documented on daily operating lists. We also found that staff did not consistently adhere to the World Health Organisation Safe Surgery checklist.

We also found not all staff had not attended major incident or business continuity training.

Are services effective at this hospital/service

We found care and treatment reflected current national guidance. There were formal systems in place for collecting comparative data regarding patient outcomes.

Staff worked with other health professionals in and out of the hospital to provide services for patients. Patients were cared for by staff who had undergone specialist training for the role and who had their competency reviewed.

There were arrangements that enabled patients to access advice and support seven days a week, 24 hours per day. There was comprehensive assessment of patient needs. This included clinical needs, physical health, nutrition and hydration needs. Patients received adequate pain relief.

Patients provided informed, written consent before commencing their treatment. Where patients lacked capacity to make decisions, staff were able to explain what steps to take to ensure relevant legal requirements were met.

There was a proactive audit programme that included national, corporate, hospital and departmental audits. Results were shared throughout the hospital and collated to identify themes.

Are services caring at this hospital/service

Staff provided sensitive, caring and individualised personal care to patients. Staff supported patients to cope emotionally with their care and treatment as needed.

Patients commented positively about the care provided from all staff they interacted with. Staff treated patients courteously and with respect. Patients felt well informed and involved in their procedures and care, including their care after discharge.

Patients and their relatives were involved in their care and were given adequate information about their diagnosis and treatment. Families were encouraged to participate in the personal care of their relatives with support from staff.

We observed patients treated with compassion, care and dignity. Patient feedback was positive and staff demonstrated commitment to continuous improvement.

Are services responsive at this hospital/service

There were a variety of mechanisms to provide psychological support to patients and their supporters. This range of service meant that each patient could access a service that was relevant to their particular needs. For example those with spiritual needs, those requiring bariatric equipment, patients whose first language was not English, or support for people living with dementia or learning disabilities.

The services were delivered in a way that met the needs of the local population and allowed patients to access care and treatment when they needed it. Waiting times, delays and cancellations were minimal and well managed. Patients told us staff were responsive to their needs.

Complaints management was a priority in the hospital. The process was transparent and open with learning communicated across the hospital.

Are services well led at this hospital/service

There were clear organisational structures and roles and responsibilities. The senior management team were highly visible and accessible across the hospital. Staff described an open culture and said managers were approachable at all times.

Staff spoke highly about their departmental managers and the support they provided to them and patients. All staff said managers supported them to report concerns and their managers would act on them. They told us their managers regularly updated them on issues that affected the separate departments and the whole hospital.

There were good governance, risk and quality systems and processes that staff understood. The committee structure supported this with reports disseminated and discussed appropriately. Staff from all departments had a clear ambition for their services and were aware of the vision of their departments.

Staff asked patients to complete satisfaction surveys on the quality of care and service provided. Departments used the results of the survey to improve services. The hospital had a risk register which was reviewed at the governance committee meetings. However, the risk register was not divided into separate departments.

The management team had an understanding of the Workforce Race Equality Standard (WRES) as there is a national requirement to produce key data relating to race quality in the workplace. BMI had started to collect data nationally which they currently held, for example the numbers of staff from black and ethnic minority groups. The management team was in the process of implementing reporting processes to capture the data to enable them to fully comply with WRES reporting requirements.

However there were areas of where the provider needs to make improvements.

The provider must:

  • Ensure that staff are trained to the appropriate level for safeguarding children. Children attend the hospital as patients and visitors.

The provider should:

  • Provide each individual department with a separate and relevant risk register.
  • Enable all staff to attend major incident or business continuity training and attend simulation exercises.
  • The outpatient department should adequately risk assess environment and equipment.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 11, 12, 13 and 22 November 2014

During a routine inspection

We carried out a comprehensive inspection of BMI Mount Alvernia Hospital on the 19, 20 and 26 July 2016 as part of our national programme to inspect and rate all independent hospitals. We inspected the core services of surgical services, medical services, out-patient and diagnostic imaging services as these incorporated the activity undertaken by the provider, BMI Healthcare Limited at this location.

We rated all four core services as good overall.

Are services safe at this hospital/service

Incidents were reported, investigated and learning evidenced. Reports were communicated to all staff.

Patients were cared for in a visibly clean environment that was well maintained. There were arrangements to prevent the spread of infection and compliance with these was monitored. There were no outbreaks of serious infection reported.

There were processes for assessing and responding to patient risk. The service had enough staff with the skills and experience to care for the number of patients and their level of need. The majority of staff had completed the provider’s mandatory training programme. Staff were aware of their responsibilities with regard to the protection of people in vulnerable circumstances.

There were adequate supplies of appropriate equipment that was properly maintained to deliver care and treatment and staff were competent in its use. Staff demonstrated good medicines storage, management and administration.

There was room for improvement with safety in surgery where we found that the side of the patient due to be operated on was not always clearly or accurately documented on daily operating lists. We also found that staff did not consistently adhere to the World Health Organisation Safe Surgery checklist.

We also found not all staff had not attended major incident or business continuity training.

Are services effective at this hospital/service

We found care and treatment reflected current national guidance. There were formal systems in place for collecting comparative data regarding patient outcomes.

Staff worked with other health professionals in and out of the hospital to provide services for patients. Patients were cared for by staff who had undergone specialist training for the role and who had their competency reviewed.

There were arrangements that enabled patients to access advice and support seven days a week, 24 hours per day. There was comprehensive assessment of patient needs. This included clinical needs, physical health, nutrition and hydration needs. Patients received adequate pain relief.

Patients provided informed, written consent before commencing their treatment. Where patients lacked capacity to make decisions, staff were able to explain what steps to take to ensure relevant legal requirements were met.

There was a proactive audit programme that included national, corporate, hospital and departmental audits. Results were shared throughout the hospital and collated to identify themes.

Are services caring at this hospital/service

Staff provided sensitive, caring and individualised personal care to patients. Staff supported patients to cope emotionally with their care and treatment as needed.

Patients commented positively about the care provided from all staff they interacted with. Staff treated patients courteously and with respect. Patients felt well informed and involved in their procedures and care, including their care after discharge.

Patients and their relatives were involved in their care and were given adequate information about their diagnosis and treatment. Families were encouraged to participate in the personal care of their relatives with support from staff.

We observed patients treated with compassion, care and dignity. Patient feedback was positive and staff demonstrated commitment to continuous improvement.

Are services responsive at this hospital/service

There were a variety of mechanisms to provide psychological support to patients and their supporters. This range of service meant that each patient could access a service that was relevant to their particular needs. For example those with spiritual needs, those requiring bariatric equipment, patients whose first language was not English, or support for people living with dementia or learning disabilities.

The services were delivered in a way that met the needs of the local population and allowed patients to access care and treatment when they needed it. Waiting times, delays and cancellations were minimal and well managed. Patients told us staff were responsive to their needs.

Complaints management was a priority in the hospital. The process was transparent and open with learning communicated across the hospital.

Are services well led at this hospital/service

There were clear organisational structures and roles and responsibilities. The senior management team were highly visible and accessible across the hospital. Staff described an open culture and said managers were approachable at all times.

Staff spoke highly about their departmental managers and the support they provided to them and patients. All staff said managers supported them to report concerns and their managers would act on them. They told us their managers regularly updated them on issues that affected the separate departments and the whole hospital.

There were good governance, risk and quality systems and processes that staff understood. The committee structure supported this with reports disseminated and discussed appropriately. Staff from all departments had a clear ambition for their services and were aware of the vision of their departments.

Staff asked patients to complete satisfaction surveys on the quality of care and service provided. Departments used the results of the survey to improve services. The hospital had a risk register which was reviewed at the governance committee meetings. However, the risk register was not divided into separate departments.

The management team had an understanding of the Workforce Race Equality Standard (WRES) as there is a national requirement to produce key data relating to race quality in the workplace. BMI had started to collect data nationally which they currently held, for example the numbers of staff from black and ethnic minority groups. The management team was in the process of implementing reporting processes to capture the data to enable them to fully comply with WRES reporting requirements.

However there were areas of where the provider needs to make improvements.

The provider must:

  • Ensure that staff are trained to the appropriate level for safeguarding children. Children attend the hospital as patients and visitors.

The provider should:

  • Provide each individual department with a separate and relevant risk register.
  • Enable all staff to attend major incident or business continuity training and attend simulation exercises.
  • The outpatient department should adequately risk assess environment and equipment.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 11 November 2013

During an inspection to make sure that the improvements required had been made

All eight people we spoke with informed us that they had been asked to provide full details of their medical history prior to their admission. One person told us “Yes, I am satisfied that staff are aware of my medical history.” Another person told us, “I have an issue that the anaesthetist needs to know about. The letter has been put on my file for the surgeon and the anaesthetist.” One person told us that they had noticed that staff had checked that their information was in their file.

We found evidence in records and feedback from all grades of staff and senior management which suggested that robust actions had been taken to respond to the concerns about the record-keeping of medical staff. For example, the Quality and Risk month end report for September showed that action had being taken to ensure that people admitted to the hospital had been appropriately assessed based on a full medical history. One member of staff told us, “There is no issue in relation to consultant record keeping in theatre”.

We also saw records which showed that the service had forwarded Notifications of incidents to the Care Quality Commission. These records corresponded with our records of notification received.

Inspection carried out on 21, 22 May 2013

During an inspection to make sure that the improvements required had been made

We inspected this service in December 2012 and January 2013 and found that the provider had failed to comply with the essential standards of quality and safety for the following outcomes: consent, care and welfare, cleanliness and infection control, suitability of premises, suitability and availability of equipment, staffing, supporting workers and assessing and monitoring the quality and safety of the service.

We took enforcement action to ensure that the provider protected people’s safety and welfare in relation to the following outcomes: consent, care and welfare, cleanliness and infection control, staffing and assessing and monitoring the quality and safety of the service.

We asked the provider to send us an action plan, specifying how and by when they would achieve compliance with the following outcomes: suitability of the premises, suitability and availability of equipment and supporting workers.

An inspection on 21 and 22 May 2013 was carried out to check whether the provider had taken appropriate action to protect people’s safety and welfare and to achieve compliance.

During this inspection we spoke with nine patients who used the service. Their comments were all positive. Patient's comments included; “It is brilliant” and “Very good”.

We found that the provider had taken action to change systems and practices and to monitor the effectiveness of these changes in order to protect patients from risks associated with their care and treatment. However, we found that some patients remained at risk because not all the staff and/or consultants had followed the provider’s policies or ensured that safe practices had been implemented on every occasion.

Since the last inspection the provider had amended their statement of purpose. The provider informed us that they had ceased to provide services or carry out surgery for patients below the age of 18 years. We saw that the statement of purpose reflected this change to the services provided at this location.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of this inspection. Their name appears because they were still a registered manager on our register at the time of the inspection.

Inspection carried out on 19 December 2012 and 8 January 2013

During an inspection in response to concerns

Most people we spoke with were happy with the care and treatment they were receiving. The majority of people we spoke to had been admitted for planned surgery and were otherwise quite well. When we talked to them they told us about how nice the nurses were and how good the food was. As far as they were concerned there was no cause for complaint.

However, the staff we spoke to and the documents and reports we saw highlighted very serious failings. Medical, surgical and some nursing practices at BMI Mount Alvernia hospital were so poor that people were put at significant risk. This risk was, on some occasions, life threatening.

One of the most serious concerns was the care of children admitted for surgery. Staff were untrained and had very limited experience of caring for sick and post operative children.

The hospital management team were dismissive of staff concerns and blocked action to improve the situation.

The provider, BMI Healthcare Limited, was not aware of the shortfalls and had not identified any concerns about this hospital.

Inspection carried out on 15 September 2011

During a routine inspection

We carried out interviews with four patients during our visit to Mount Alvernia. We were told that staff at the hospital treated them respectfully and involved them in their own care. We spoke with people who had experienced both day care and in-patient (overnight) care at the hospital, and all reported high levels of satisfaction, with comments such as "Superb care" and "Excellent care - I can't fault them" being typical.

People told us their needs were reflected in their care plans, and they said they were kept informed about the treatment they were having. When asked, the people we spoke to said that they felt safe at this hospital, and confirmed there were sufficient staff to assist them in a timely way. Overall those people we spoke to commented very favourably on the service they had received at this hospital, and whilst they did not have any complaints, all four confirmed they would know how to make a complaint if they had one.

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