• Hospital
  • Independent hospital

The Shirley Oaks Hospital

Overall: Good read more about inspection ratings

Poppy Lane, Shirley Oaks Village, Croydon, Surrey, CR9 8AB (020) 8655 5500

Provided and run by:
Circle Health Group Limited

Latest inspection summary

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Background to this inspection

Updated 15 January 2020

BMI Shirley Oaks Hospital is operated by BMI Healthcare Limited. It is a private hospital in Croydon, Surrey. The hospital primarily serves the communities of the Surrey and South East London. It also accepts patient referrals from outside this area.

At the time of the inspection, a new manager had recently been appointed and was in the process of registering with the CQC to be the registered manager.

Overall inspection


Updated 15 January 2020

BMI Shirley Oaks Hospital is one of the 52 hospitals which operate under the umbrella of BMI Healthcare. The hospital has 42 beds and provides a range of services for patients who require surgery or treatment for medical related conditions. There is an outpatient consultation department made up of 10 consultation rooms and two treatment rooms. A full range of diagnostic services are available, including x-ray, MR and CT scanners.

Patients who use the hospital facilities may have medical insurance, be self-payers or be booked through the NHS under arrangement made through the clinical commissioning groups.

  • Patients were treated with respect, kindness and compassion. Staff were mindful to respect each person’s dignity and took into account their individual needs and choices. Services were planned in a way which took into account the needs of people regardless of their point of referral.

  • The hospital had enough staff with the right skills and abilities to provide the treatment and care for patients. Training, including safety related subjects were provided to staff. The skills and competencies of individuals were assessed by line managers as part of the appraisal process. Consultants who used the hospital did so under the agreement of practising practices and were required to provide evidence to support this, including professional qualifications and training completed.

  • Staff had been trained in safeguarding adult’s and the arrangements to safeguard vulnerable adults were clearly communicated and understood by staff. Consent and mental capacity was understood by staff and patient needs with this regard was fully considered. Nursing staff were confident to challenge consultants when they could not read information written on consent forms.

  • The areas in which treatment and care was provided were visibly clean and tidy. Staff were supported to apply effective infection prevention and control practices and staff adherence to these measures were monitored.

  • The environment was suitable for the services provided and were accessible to those who may have had reduced mobility. Areas which required restricted access were managed safely. Resuscitation equipment was accessible and was subject to regular checks. Staff were identified on each shift to be members of the emergency response team.

  • Medicines were safely managed in line with professional standards. There was oversight of antimicrobial prescribing and medicines optimisation by the on-site pharmacy team. Patients were assessed for pain and given pain relief medicines in a timely manner.

  • There was a well-defined system to report incidents, which staff were fully aware of and confident to use. Incidents were reviewed following a formal process and where learning was identified, this was shared with staff.

  • Staff had access to a range of professional guidance, corporate and local policies and procedures to guide them in their work. Treatment and care to patients was delivered in line with professional practices. Monitoring of standards were measured through a range of audits, with results presented through performance dashboards. These were compared with other hospitals within the group.

  • The individual needs of patients including their nutritional needs were fully considered and taken into account in planning their treatment and care. There was access to technical aids to support care and equipment used for treatment was available and subject to safety testing. A translation service was available and was regularly used.

  • Staff felt valued and respected by one another. The leadership of individual areas within the hospital was suitable. Lines of reporting were clearly defined, and staff understood their responsibilities. Managers had the right experience, skills and commitment to ensure the hospital operated safely and effectively. Governance arrangements ensured oversight and scrutiny of performance and risks. Leaders recognised the value of learning and ensured information was communicated to staff.


  • Although the hospital had done a lot of work to improve the completion of consent forms with consultants, there remained times where consultants writing was not clear enough.

  • Patient outcomes data collection was limited and therefore there was a lack of information to identify and support improvements.

  • Clinical hand wash basins were not yet available in-patient rooms.

  • The interpreting service was not wholly reliable and where it was known in advance of the need for a interpreter, staff did not pre-arrange this.

  • Appointment times in outpatient’s were not always provided to the specified time. The service was not actively monitoring start and finish times of individual consultation sessions and therefore did not know where frequent delays were occurring.

Dr Nigel Acheson

Deputy Chief Inspector of Hospitals (London and the South)