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BMI The Ridgeway Hospital Requires improvement


Inspection carried out on 19 to 20 and 28 March 2018

During an inspection looking at part of the service

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 carried out on 19, 20 and 29 April 2016

During a routine inspection

BMI The Ridgeway Hospital is an independent hospital and part of BMI Healthcare Limited. It provides care and treatment to both privately-funded patients, and to NHS patients, which is free at the point of use.

The hospital provides surgery, medical care, including oncology, outpatient and diagnostic services, and some limited privately-funded services to children and young people. Specialties include general surgery, orthopaedic surgery, ear, nose and throat procedures, gynaecology, haematology, oncology treatment, ophthalmology, oral and maxillo-facial surgery, reconstructive and cosmetic surgery, podiatry and urology services.

The hospital has an outpatient department, which includes diagnostic and screening services, including an open MRI scanner. There is a large physiotherapy department, which includes a hydrotherapy pool and fully equipped therapy gymnasium.

There are 49 beds, of which 34 are for inpatients, 12 for day-case patients, and four within the oncology suite – the Webster Suite. There are three operating theatres, each with their own anaesthetic rooms, and operating from 9am to 9pm on Mondays to Fridays and 9am to 6pm on Saturdays.

We carried out a comprehensive announced inspection of The Ridgeway Hospital on 19 and 20 April 2016, and an unannounced inspection on 29 April 2016.

We inspected and reported on the following four core services:

  • Medical care
  • Surgery
  • Services for children and young people
  • Outpatients and diagnostic imaging

The overall rating for BMI The Ridgeway Hospital was requires improvement. Our key findings were as follows:

Are services safe?

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

We rated safety overall as requires improvement:

  • The surgical safety checklists were not fully completed at all times, and this had not been identified by the hospital’s routine audit.
  • There was a lack of assurance of the servicing and maintenance of surgical equipment.
  • Some entries in patient records, including within prescription charts, were not legible or fully completed.
  • The hospital was mostly clean and infection control protocols followed. There were, however, some dusty areas in the recovery room. There was some inattention from staff required to be bare below the elbow in clinical areas. Some areas of the hospital were showing signs of age and wear and tear and cleaning made more difficult as a result.
  • Not all clinical staff who had a degree of contact with children were trained to the appropriate level of child safeguarding.


  • Staff acted upon the principles of the duty of candour. They were open, honest, and would apologise to patients when things went wrong.
  • The majority of staff were trained to recognise and respond to suspicions of abuse of vulnerable people. Not all staff who had some degree of contact with children were trained to the appropriate level. The director of nursing had the overall responsibility for safeguarding people, and was trained to the appropriate level.
  • There was a good culture of incident reporting among the staff, and learning from adverse events. However, the reporting system for staff to record incidents was still paper-based. Incidents were transposed to a database for analysis and this double-entry was inefficient.
  • There was a safe level of both nursing, medical staff and support staff, with a good mix and range of skills and experience. The hospital had a resident medical officer available 24 hours a day, every day. There was minimal use of agency staff and a regular team of bank staff to fill vacant shifts.
  • There were almost no hospital-acquired infections.
  • Patient care was safe, and there was no avoidable harm to patients. Staff recognised and responded quickly to any deteriorating patients.

Are services effective?

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

We rated effectiveness overall as good.

  • There were good outcomes for patients, with most on a par with the NHS and some slightly better.
  • There was pro-active care and programmes to increase patients’ chances of an enhanced recovery from orthopaedic surgery.
  • The oncology operational policy had been devised by a member of the oncology team at The Ridgeway Hospital and was to be shared across the organisation.
  • Patients gave valid informed consent where they were able to do so. There were assessments and procedures following legal requirements for patients who might have reduced mental capacity to make their own decisions.
  • The hospital participated in relevant national audit and research programmes.
  • There were minimal unplanned readmissions and inter-hospital transfers in an emergency.
  • There were low levels of surgical site infections.
  • There was an active programme of revalidation for nurses, and the hospital monitored all aspects of employment and practising rights for medical staff. These were up-to-date.
  • There were appropriately trained staff to safely care, treat and provide support for children.
  • The hospital provided evening outpatient appointments and diagnostic imaging was available seven days a week.


  • The hospital employee system was not able to provide accurate data for employed staff appraisals, and some departments were consequently showing poor results. This had been recognised in the hospital's risk register.
  • The endoscopy unit did not meet the Joint Advisory Group (JAG) on gastrointestinal endoscopy accreditation.
  • There was no skill set against which to assess staff working with children.

Are services caring?

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

We rated caring overall as outstanding.

  • There was a strong patient-centred culture. All staff across the hospital were highly motivated to provide the best care and to patients, and this was highly valued by patients, staff and the leadership.
  • Patients were given care and compassion that treated them as individuals, and respected and protected their human rights, including their privacy and dignity. All staff had empathy and understanding, and were supportive and positive.
  • There was a high level of patient satisfaction with the service, including the Friends and Family Test results. All the feedback we received from patients about their care and support was positive and highly complimentary.
  • There was good emotional support for patients, particularly when they were anxious or nervous. Staff recognised and responded to these patients with understanding, compassion and kindness.
  • The hospital respected patients had different needs. People were treated as individuals and the care they were given took account of their culture, religious, social and personal needs. All the staff wanted patients to have care that exceeded their expectations.

Are services responsive?

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

We rated responsiveness overall as good.

  • Services were planned to meet local needs and provide timely and convenient independent medical care to both private and NHS patients.
  • People were treated as individuals. This included taking time to support people living with dementia and meeting different levels of need.
  • There was good physical access to and around the hospital for patients and visitors.
  • Good bed management led to few cancelled or delayed operations. Surgery services met most referral to treatment times (monitored for NHS patients).
  • The hospital was commissioned and established to treat non-emergency patients and provide elective medical and surgical services. Within this, there were no exclusion criteria for patients.
  • There was an appropriate response to complaints, and all staff made aware of any comments, including compliments or criticism from patients and visitors. There was learning and action taken from any complaints or negative comments.


  • Patients and visitors reported issues with a lack of available parking spaces at busy times.
  • Some patients reported finding the hospital noisy during the night.

Are services well-led?

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

We rated well-led overall as requires improvement.

  • There was a detailed strategic vision for the hospital, although the key risks did not flow through the strategy or the future plans. Children and young people were not included in the strategic plan.
  • The governance work did not show how audit work and the risk register were delivering improvements in safe and quality care. There were gaps in the audit work that meant some issues were not being picked-up or addressed. There was poor recording of the audit results at the clinical governance meetings and little evidence to show they had been considered, or of any value.
  • The action tracker was too large and had become difficult to manage effectively. On the risk register, there were no dates to show when risks had been included, so they could not be examined for how long matters were taking to resolve.
  • There were no quality measures to assess the performance or outcomes of children and young people’s services.


  • There was strong, visible and approachable leadership throughout the hospital and good engagement with staff and patients.
  • Staff told us they felt well supported by their immediate managers, and the senior leadership team. There was a strong culture of delivering kind and compassionate patient care.

We saw several areas of outstanding practice including:

  • There was outstanding care provided to surgical and medical inpatients and day-case patients, including oncology patients, and outpatients. Patients told us they could not fault the kindness, compassion and sensitivity of staff.
  • There was an outstanding service to patients from the pharmacy team when medicines were prescribed to take home. Patients were given their medicines within an hour, and this therefore meant they were not delayed in going home.
  • The senior management team were visible, approachable and supportive to both staff and patients. Engagement with staff and patients was welcomed in a positive and constructive manner.
  • The organisation had an extensive and detailed patient satisfaction questionnaire. This provided useful information for the hospital and the wider provider organisation. It enabled the hospital to look for, and implement, improvements to patient care.
  • The oncology operational policy had been devised by a member of the oncology team at The Ridgeway Hospital and was to be shared across the organisation.
  • The provider had various staff recognition schemes, which made staff feel proud, valued and encouraged them to improve services for patients.

However, there were also areas where the provider needed to make improvements.

Importantly, the provider must:

  • Ensure all surgical safety checklists are fully completed, and audit routines are able to provide full assurance.
  • Review the medical equipment asset register to be able to provide assurance that all medical equipment is serviced and maintained as required.
  • Ensure all surgical patient records are legible and complete and written in accordance with policy.
  • Ensure within governance, all audit work, the risk register and action tracker provide assurance that the governance systems are delivering safe, effective, and quality care and treatment.
  • Ensure all staff who have some degree of contact with children are appropriately trained in level two safeguarding children.
  • Ensure all staff involved in assessing and planning care for children and young people are trained in level three safeguarding children.
  • Develop a competency framework to assess the paediatric skills and training competencies for registered adult nurses and other clinical staff who may be required to work with children and young people. Young people must be risk assessed for care on the adult pathway by either a paediatric nurse or an adult nurse with paediatric competencies.
  • Ensure the children and young people’s service is being assessed and monitored through audit work, the risk register and patient experience, to provide assurance that the governance systems are delivering safe, effective and quality care and treatment.

In addition the provider should:

  • Continue the programme of refurbishment, replacement, and remedial works to ensure all areas of the hospital and its equipment are safe, compliant with clinical requirements, and able to be cleaned effectively.
  • Review practice to ensure all staff are bare below the elbow when in clinical areas.
  • Continue to update patient rooms to provide shower facilities.
  • Ensure all areas within the operating theatre recovery room are free from dust at all times.
  • Review the storage and security of chemicals and products that should be locked away.
  • Arrange for a regular review of antibiotic prescribing and key performance indicators for pharmacy staff to achieve. Provide the medical advisory committee with an annual report on antimicrobial stewardship.
  • Ensure the business continuity plans are satisfactory for the services provided and there are simulation exercises at the required intervals.
  • Invest in an electronic incident reporting system for staff to record incidents at source, to make reporting more efficient and timely.
  • Display the excellent harm-free care (NHS safety thermometer) results on the ward, as is best practice.
  • Review the electrical testing of all surgical equipment to ensure the records are accurate and all equipment has been tested as and when required.
  • Make sure the service level agreement with the local NHS acute hospital trust for emergency transfers of patients is updated and current.
  • Ensure all staff have had their annual performance review and there are systems to demonstrate this.
  • Look to provide pharmacist advice for staff out-of-hours.
  • Allow patients to respond to staff knocking on doors before entering.
  • Continue to investigate how to deliver improved parking facilities.
  • Ensure patients are not disturbed by unnecessary noise at night.
  • Confirm the correct weight criteria for young people’s suitability for surgical treatment on the adult pathway.
  • Improve feedback to staff following incidents in the outpatients’ department.
  • Review and improve clinical waste management systems in the outpatients’ department.
  • Ensure patient consent forms are fully completed and contain sufficient detail in line with hospital policy.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 21 January 2014

During a routine inspection

All patients were fully informed about their treatments or procedures. People told us they had all their questions answered and felt involved in the decision making around their care. All patients had signed consent forms. We found that the discharge of patients was planned and discussed appropriately.

People we spoke with told us they were happy with the care and treatment they received from the staff. We were told the staff were caring and professional and treated people in a respectful manner.

The hospital took steps to ensure it was a safe place for people to receive treatment. All staff undertook training in adult protection and contact information was available to staff should they have a need to report a concern.

Staff attended regular courses to ensure they were up to date with the required mandatory training. They also had opportunities to undertake courses to develop their professional skills.

The hospital had effective systems to monitor and manage risk. Processes were in place that audited the quality of service delivered and there were opportunities for staff to contribute their ideas or raise concerns.

The hospital had an effective complaints procedure in place that was well advertised to patients. Regular feedback was also sought from patients.

Inspection carried out on 28 February 2013

During a routine inspection

We spoke to three patients and reviewed their care records. We also spoke with nine members of staff and reviewed other documentation. Patients said that the care they had received at the hospital was �Excellent�, �Brilliant� and that staff were �Attentive.� Patients also felt fully informed of their treatment options and the care that they were receiving.

People�s needs were assessed and care and treatment was planned and delivered in line with their individual care plan. We reviewed the records of three patients and found these to be appropriately documented and updated.

People were cared for in a clean, hygienic environment. The hospital has systems in place to ensure that infection control is monitored. Appropriate cleaning procedures are in place to prevent the spread of infection.

People were cared for, or supported by, suitably qualified, skilled and experienced staff. Staff recruitment is robust and new staff feel supported in their new roles. Training and development is available for all new staff.

People were made aware of the complaints system. This was provided in a format that met their needs. The patients we spoke to were aware of how to complain but had not needed to.

Inspection carried out on 22 February 2012

During a routine inspection

Patients told us they were satisfied with their care and treatment and were treated with respect by hospital staff.

Information was provided prior to admission and good clear information given about procedures and the services the hospital provided.

Patients said they felt safe whilst visiting the hospital or staying for treatment.

Staff were described as professional, caring and encouraging.

Staff told us they were well supported by their colleagues and managers within the hospital and received appropriate supervision and appraisals.

We were told that an open culture was encouraged and people felt confident about reporting concerns or issues that needed addressing to improve the service or protect the patients.

The management of the hospital undertook to regulallrly audit all aspects of the service and take action to address identified shortfalls.

The registered provider BMI Healthcare provided regular external visits and audits to promote safety and good practice.

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