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BMI The Ridgeway Hospital Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 19 July 2018

BMI, The Ridgeway Hospital is operated by BMI Healthcare Limited . The hospital provides outpatient, diagnostics, surgery and medical care including oncology and endoscopy services to adults and children and young people (CYP). Treatment is provided to privately funded and NHS patients.

Specialities offered by the service for inpatients and outpatients include gynaecology, ears, nose and throat (ENT), breast and cosmetic surgery, chemotherapy and oncology, paediatric services, refractive eye surgery, and other laser surgery.

We inspected this service using our focused inspection methodology. We carried out an unannounced inspection on 19 and 20 March 2018, and a further unannounced inspection on the 28 March 2018.

We focused on specific parts of the service which were highlighted as concerns to the CQC from staff and members of the public. Additionally, we focused our inspection on areas previously identified as needing improvement in our last inspection. The key questions we asked during this focused unannounced inspection were, was it ‘Safe’ in surgery, and children’s and young people’s and was it ‘Well Led’ in medicine, surgery and children’s and young people’s.

Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate. As this was a focused inspection, new ratings were only awarded for the key questions that were inspected. The overall rating for the service was not changed.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

We found areas of practice, which required improvement in surgery, medicine and children and young peoples services.

  • Issues such as sickness and performance management within the theatre department, had compromised staff morale and the running of the department.

  • Infection control practices were not always in line with policy and guidance.

  • Resuscitation and anaesthetic equipment was not always checked in line with hospital policy.

  • Staffing shortages across pharmacy meant not all audits were completed. This impacted on the providers awareness of the safety of the service it delivered.

  • Not all staff had completed their mandatory training within the timeframes expected by the hospital.

  • The hospital did not have an in-date service level agreement with the local NHS Trust, for emergency transfer of children and young people and adults.

  • Not all staff in the endoscopy unit took part in the World Health Organisations surgical safety checklist in a fully compliant manner and patient checks were not fully completed prior to medication being given.

  • Chemotherapy team meetings were not held regularly and we could not be assured that there was an effective governance framework to support the service.

  • The out of hours and on-call arrangements for chemotherapy services were not safely arranged.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with requirement notices that affected surgery, children and young people and medicine. Details are at the end of the report.

Amanda Stanford

Deputy Chief Inspector of Hospitals.

Inspection areas


Requires improvement

Updated 19 July 2018

Are services safe?

We rated safe as requires improvement because:

  • There was a disparity with the reporting culture in theatres and on the wards.

  • Systems and processes were in place to protect patients and staff from healthcare associated infection but not all staff in all the departments adhered to practice.

  • The endoscopy unit did not have accreditation from the Joint Advisory Group (JAG) on Gastrointestinal Endoscopy standards for endoscopy services.

  • Some bedrooms and corridors were still carpeted as the refurbishment programme had been halted. We were told funds had been released for this to commence after the time of our inspection.

  • The storage of intravenous (IV) fluids was not always safe.

  • There were no audits of medicine reconciliations, which meant the service, could not be assured of safe practices around medicines administration.

  • The pharmacy department was small and cramped and staff told us they found it a challenging environment to work in.
  • Not all staff had completed their mandatory training within the timeframes expected by the hospital.
  • The current service level agreement with the local trust, for the emergency transfer of patients was still in draft format.

  • Systems and processes in some areas of the hospital had not been used successfully to manage sickness and poor performance.



Updated 19 July 2018



Updated 19 July 2018



Updated 19 July 2018


Requires improvement

Updated 19 July 2018

We rated well-led as requires improvement because:

  • We did not see evidence the organisation used performance management processes effectively when working with underperforming staff.

  • The service had identified the lack of Joint Advisory Group on Gastrointestinal Endoscopy (JAG) accreditation standards for endoscopy services as a weakness. We were not assured progress towards this was monitored effectively.

  • The Oncology and Cancer Services meeting group had met once since November 2016. Processes to manage operational challenges such as out of hours were not in place.

  • There was a lack of processes to ensure that all employees who were involved in invasive procedures in the endoscopy department carried out good safety practice, as set out in the National Safety Standards for invasive procedures (NatSSIPs).


  • The hospital had a clear vision and a set of values, which had quality and safety as a priority.

  • There was a strong representation for children and young people reflected in the strategy and vision for this core service

  • The hospital had a straightforward and effective governance and risk management structure, which had been put in place since our last inspection. This included structures and quality measures for children and young people.
Checks on specific services

Medical care (including older people’s care)


Updated 19 July 2018

Medical care services were a small proportion of hospital activity. The main service provided was surgery.

Where arrangements were the same, we have reported findings in the surgery section.

We inspected the well led domain only and rated this as requires improvement.

Services for children & young people

Requires improvement

Updated 19 July 2018

Children and young people’s 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.

During this inspection, we inspected and rated the service as requires improvement in safe and well led.

Outpatients and diagnostic imaging


Updated 6 September 2016

We rated outpatient and diagnostic imaging overall as good because:

  • Staff were aware of their responsibility to report incidents and had a good understanding of the Duty of Candour.

  • Departments were visibly clean and well organised with completed cleaning schedules in place.

  • Medicines were stored and managed safely in accordance with national guidelines.

  • Patient records were accessible when required, they were stored and managed safely in the departments ensuring confidentiality was maintained.

  • Staff were able to identify their responsibilities in respect of safeguarding patients and had received appropriate training.

  • Staffing levels and skills were reviewed by the head of department to ensure people were safe and services were efficient.

  • Staff followed national and local guidelines to ensure patients received effective care. They had a good understanding of their role in protecting people from unnecessary radiation exposure.

  • We observed effective, patient centred, multidisciplinary team working and there were good relationships between all members of the team.

  • All patients were extremely positive and complimentary about the care they received at the hospital. They said they were kept informed with verbal and written information, which was easy to understand. They received telephone calls from their doctor following treatment to ensure they had no complications or concerns.

  • Staff were passionate and proud of the care they provided and worked hard to improve patient experiences.

  • Targets for referral to treatment times for NHS patients at the hospital had always been met in the reporting period and extra clinics were provided in departments if required.

  • The length of appointments were monitored and adjusted to avoid long waiting times for patients and all patients we spoke with reported being seen quickly and sometimes ahead of their appointment time.

  • A multidisciplinary team approach was taken to resolve complaints and staff were involved in this process.

  • Staff said the senior management team were very visible and approachable.

  • The heads of department were supportive and knowledgeable and kept staff up to date with developments and changes.

  • Patient and staff opinions were sought and service improvements were made because of these.

  • All staff said they felt valued and were proud to work at the hospital.


  • Staff reported they did not always receive feedback from reported incidents.

  • There was a lack of assurance regarding the servicing and maintenance of equipment.

  • The temporary closure of a treatment room had caused some delays in the outpatient department.

  • The governance work did not show how audit work and the risk register were delivering improvements in safe and quality care.

  • Some patients we spoke with commented there was insufficient parking at the hospital.


Requires improvement

Updated 19 July 2018

Surgery was the main activity of the hospital and staffing was managed jointly with medical care.

We inspected and rated surgery as requires improvement in safe, and well-led.