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BMI Sarum Road Hospital Good

All reports

Inspection report

Date of Inspection: 7 November 2012
Date of Publication: 4 December 2012
Inspection Report published 4 December 2012 PDF

The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care (outcome 16)

Meeting this standard

We checked that people who use this service

  • Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.

How this check was done

We looked at the personal care or treatment records of people who use the service, carried out a visit on 7 November 2012, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We talked with people who use the service and talked with staff.

Our judgement

The provider had an effective system to regularly assess and monitor the quality of service that people receive.

Reasons for our judgement

As provider BMI Healthcare Limited carried out audits of the service to monitor clinical performance, infection control, patient satisfaction and other aspects of patient care.

The service kept a record of all clinical governance issues. There was also a record of any lessons that had been learnt as a result of any of the incidents. For example a root cause analysis meeting had been held to discuss a patient infection. This had included a study of the patient’s record and a review of the hospital’s processes. A root cause analysis is a process which allows organisations to understand areas requiring improvement in patient care and identifies actions to minimise the chance of recurrence for future patients.

We looked at the minutes for management team meetings and clinical risk manager’s meetings. One of the incidents discussed was escalated to the Medical Advisory Committee (MAC). We were able to see that incidents discussed at management meetings were taken, if relevant, to the MAC and possible improvements and changes were discussed and implemented.

The provider took account of complaints and comments to improve the service. We followed a complaint which had been made regarding post operative care. We saw that this had been discussed at the MAC and new procedures had been introduced. All patients now had a named nurse both during their admission and post operatively. This meant that people felt supported and able to discuss their needs or ask questions. Physiotherapy support had also been introduced for certain post operative patients to give them advice and exercise if relevant. We observed a person being escorted into theatre by a nurse who was later the person’s recovery nurse, ensuring continuity of care. One person told us, “They were very attentive in anaesthetic and in my aftercare.”

People who use the service, their representatives and staff were asked for their views about their care and treatment and they were acted on. We saw results of the latest patient satisfaction survey. There had been a full analysis of the results and comments from the survey had been acted upon. One person had commented that their late admission had been at a time when the chef was not in the building and they had not been able to have a meal. We spoke to the chef who told us that if they know of late admissions they made sure that a meal was left for nursing staff to serve. There was always a selection of food available in the ward kitchen for unexpected admissions and for people who felt hungry during the night.

Staff told us that they had the opportunity to provide feedback about the service and how it could be improved. One member of staff told us about the oncology care pathway they had on trial. Staff were encouraged to feedback their opinions and to suggest changes or improvements.