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Inspection carried out on 23, 24 July and 02 August 2019

During a routine inspection

BMI Thornbury is operated by BMI Healthcare Limited and cares for adults and children undergoing a wide range of surgical procedures and those requiring other medical interventions. The hospital has a dedicated cancer unit offering both chemotherapy and supportive therapies to patients. Diagnostic imaging services include a 161 slice CT scanner and a 1.5T MRI scanner. A new digital mammography unit has been installed.

BMI Thornbury Hospital offers a level two critical care facility for those patients requiring additional monitoring and support. The hospital attracts consultants and is located close to a local NHS trust. The hospital offers a wide range of services including orthopaedics, general surgery, gynaecology, spinal surgery, urology, oncology, ophthalmology, ear nose and throat services, cosmetic surgery and physiotherapy.

We inspected this service using our comprehensive inspection methodology. We carried out an unannounced visit to the hospital on 23 and 24 July 2019, and on 02 August 2019.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

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

The main service provided by this hospital was surgery. Where our findings on surgery – for example, management arrangements – also apply to other services, we do not repeat the information but cross-refer to the surgery service level.

Services we rate

Our rating of this hospital improved. We rated it as Good overall. The rating for Safe stayed the same as requires improvement. Effective improved from requires improvement to good. Caring, responsive and well-led stayed the same and were rated as good.

We rated each core service - surgery, medical care, services for children and young people, outpatients and diagnostic services - as good overall. Critical care was rated as requires improvement.

The ratings for surgery, medical care and critical care stayed the same. The ratings for services for children and young people improved from requires improvement to good. Outpatients and diagnostic services were inspected as one service at the last CQC inspection. At this inspection we rated them separately.

Although the hospital was rated a good overall, we found some issues that the service provider needs to improve.

Following this inspection, we told the provider it must take some actions to comply with the regulations and it should make other improvements, even though a regulation had not been breached, to help the service improve. We issued the provider with three requirement notices. These were related to Regulations 12 (safe care and treatment) and 17 (good governance) in the critical care unit, and Regulation 15 (premises and equipment) in relation to the hospital fire safety corrective action plan Details are at the end of the report.

Ann Ford

Deputy Chief Inspector of Hospitals (North East)

Inspection carried out on 24 – 26 November, 4, 17 December 2015

During a routine inspection

BMI Thornbury Hospital is operated by BMI Healthcare Group. Facilities at the hospital included four operating theatres and an endoscopy suite and a four bedded critical care unit. The hospital is registered with the Care Quality Commission (CQC) for 64 beds.

We inspected the hospital as part of our independent hospital inspection programme. The inspection was conducted using the CQC’s comprehensive inspection methodology. It was a routine planned inspection. We inspected the following five core services at the hospital: medicine, surgery, critical care, services for children and young people, and outpatients and diagnostic imaging. We carried out the announced part of the inspection on 24, 25 and 26 November and 4 December 2015. We also carried out an unannounced visit on 17 December 2015.

We rated the hospital as requires improvement overall. Services for children and young people and critical care services were rated as requires improvement. Medicine, surgery and outpatients and diagnostic imaging services were all rated as good. For the hospital overall we rated the safe and effective key questions as requires improvement. The effective, caring and responsive key questions were all rated as good.

Are services safe at this hospital

We rated the safe key question as requires improvement overall. We found that patient records were not fully completed. We found that the resuscitation trolley for children on the Fulwood Suite was not well organised to allow staff to find equipment quickly in an emergency and syringes to inflate resuscitation masks were not immediately available on the ward or in outpatient areas. We had concerns about the management of the deteriorating patient and emergency situations in the critical care unit. Early warning scores were not recorded and patients did not have easy access to call bells. This meant that there could be a delay in identifying and responding to a deteriorating patient. The critical care unit was cramped. We were not assured that there were adequate arrangements in place to mitigate the risks associated with the critical care environment.

The hospital was visibly clean. There were audits of infection prevention and control practices. Staff did not always follow infection prevention and control practices. Incidents were reported and there were robust processes for sharing learning with staff. Staff were aware of the duty of candour. There had been no never events or serious incidents in the reporting period July 2014 to June 2015. The resident medical officer (RMO) was based in the hospital and provided medical cover 24 hours a day. We reviewed RMO cover and found it was sufficient. Staffing levels and projected occupancy ratios were reviewed daily. Mandatory training was in place for all employed staff and training compliance rates were high. Staff received mandatory training in the safeguarding of vulnerable adults and children and the nursing and medical staff we spoke to were generally aware of their safeguarding responsibilities and of appropriate safeguarding pathways to use to protect vulnerable adults and children. The Director of Clinical Services was the named safeguarding lead for the hospital. However, we saw no evidence in staff files that paediatric nurses had level three safeguarding training. The hospital has subsequently confirmed that this training is in place. For medical staff, mandatory training records were not completed or checked with substantive employers. We reviewed files for six consultants working under practising privileges and saw no evidence that recent training compliance was logged. There was a deteriorating patient pathway and a clinical escalation policy in place. There was a formal arrangement for patients to be transferred to the local NHS hospital if their clinical condition could not be safely managed at the hospital. The hospital would use the Embrace paediatric transfer service to transfer children whose clinical condition had deteriorated but there was no formal arrangement with the Embrace service.

Are services effective at this hospital

We rated the effective key question as requires improvement overall. We saw that pain scores were not routinely recorded in some areas and that some policies we reviewed were out of date. Some staff had not undergone annual appraisals. The hospital did not complete audits for children and young people and there was no data collected on the outcomes for children and young people following surgery. Staff in theatres had not all completed Paediatric Intermediate Life Support Training as required.

Patients were cared for in accordance with evidence based practice. Policies were mostly developed nationally. Clinical indicators were monitored corporately and compared with similar hospitals in the company through the production of a monthly quality dashboard. The hospital participated in a number of national audits to measure patient outcomes such as Patient Reported Outcome Measures and the National Joint Registry. There had been 19 unplanned readmissions to the hospital within 29 days of discharge in the period July 2014 to June 2015. This rate was “similar to expected” compared with other independent acute hospitals. Consultants were granted practising privileges to work at the hospital. Practising privileges are when authority is granted to a doctor or dentist to provide patient care in the hospital by a hospital’s governing board. Staff appraisal rates varied across the hospital This had been recognised by senior management and there were plans in place to address this. There were consent procedures in place and training rates for Mental Capacity Act training were good.

Are services caring at this hospital

We rated the caring key question as good overall. Patients were cared for compassionately and with dignity and respect. Patients and relatives spoke positively about care and treatment and felt involved in the planning of their care. Staff gave examples of providing emotional care to patients. We observed positive interaction between staff and patients. The hospital had a high score (above 85%) in the Friends and Family Test but response rates were low (less than 30%). The hospital’s internal patient surveys showed generally high (above 90%) levels of patient satisfaction, particularly in relation to the quality of care.

Are services responsive at this hospital

We rated the responsive key question as good overall. Services were planned to meet the needs of local people and individual patients. There were plans to develop the endoscopy and oncology services and the endoscopy service was working towards achieving Joint Advisory Group (JAG) accreditation. The cancer care (oncology) service had been awarded the Macmillan Quality Environment Mark (MQEM) following an external assessment visit in October 2015. There were clear inclusion/exclusion criteria for accepting surgical patients. Patient discharge was planned so that patients were discharged with the right level of care and support. Referral to treatment times data for the reporting period July 2014 to June 2015 showed that the hospital had routinely exceeded the targets for admitted and non-admitted patients to be seen or treated within 18 weeks. The hospital had not cancelled any operations in the three months prior to the inspection. The number of complaints made about the hospital had increased in recent years. However, complaint volumes were benchmarked against other hospitals in the company and this showed that the number of complaints received at Thornbury Hospital were low when compared with other similar hospitals. There were systems in place to share findings and learning from complaints with staff.

Are services well led at this hospital

We rated the well led key question as good overall.

There was a vision and strategy in place at the hospital, which the majority of staff could articulate. The hospital had an action plan in place detailing further actions to be taken up to 2016 to continue to engage staff and provide ongoing training in line with the vision and strategy. There was vision and strategy in place at service level and staff could generally articulate this. The hospital had a governance structure, with a clinical governance committee in place. The clinical governance committee fed into the Medical Advisory Committee (MAC). The hospital fed into the corporate governance arrangements via the hospital’s executive group. We reviewed the hospital’s risk register. There were no risks that had been opened prior to 2015 and all risks had mitigating actions and review dates identified.

The monitoring systems to ensure that doctors working in the hospital under practising privileges were safe to practise were not robust. We reviewed six files for doctors working under practising privileges. Appraisals were out of date in all files we reviewed and Disclosure and Barring Service checks were either missing or out of date in five of the files we reviewed. Senior managers were aware of these issues and we saw evidence that they were working to address this. Systems to ensure that nurses had valid professional registration were also not robust. Staff generally described the leadership and culture within the hospital positively. Staff told us they were able to raise their views and opinions with their managers and were asked to share their ideas and to make service improvements. The hospital had formed a patient satisfaction group and had made a number of changes to improve patient experience in response to themes identified in patient feedback.

The service for children and young people did not have robust systems in place to identify and mitigate risk. For example, the risk of the resuscitation equipment not being stored appropriately and some staff not knowing how to use it had not been identified. There had been an abrupt change in leadership in the outpatient team and senior managers acknowledged that work was needed to develop the vision and a positive culture in this service.

We observed outstanding practice in the hospital’s daily “comms cell” meetings which were held between the hospital’s senior management team and the heads of department. Comms cell meetings were used to discuss matters such as patient admissions, staffing, risk and incidents. Information from comms cell meetings was then cascaded to staff through departmental meetings. Comms cell meetings were supported by comms cell boards in the main staff areas that displayed information on incidents, audit outcomes, clinical audit data and staffing. The comms cells ensured there was a robust system of communication in place in the hospital.

However, there were also areas of poor practice where the provider needs to make improvements.

Importantly, the provider must:

  • Ensure that comprehensive patient records are maintained, particularly in relation to recording pre-assessment, risk assessment, consent and early warning scores.
  • Ensure that paediatric resuscitation equipment is stored appropriately, all required equipment is immediately accessible and staff know how to use paediatric resuscitation masks.
  • Ensure that all staff adhere to the hospital policy for the administration of controlled drugs.
  • Ensure that there are appropriate arrangements in place to manage the risks associated with the critical care environment, including ensuring patients have access to call bells and managing emergency situations in the critical care unit.
  • Ensure that staff follow infection prevention and control practices.
  • Ensure that, in relation to the service for children and young people, there are in operation effective governance, reporting and assurance mechanisms that provide timely information so that risks can be identified, assessed and managed.
  • Ensure that there is a robust process for ensuring that medical and nursing staff have the skills, competency, professional registration and good character to practise in the hospital, including evidence of current professional registration, up-to-date appraisal and training and Disclosure and Barring Service checks (DBS).
  • Ensure that theatre staff involved in the care and treatment of children have child-specific training, as recommended by the Royal College of Anaesthetists.

In addition the provider should:

  • Ensure that daily controlled drug stock checks are done when the critical care unit is open.
  • Run a simulation of a patient collapsing in the bathroom in the critical care unit.
  • Ensure that a system of pain scoring is used in the critical care unit.
  • Ensure that cover is available for staff working in the critical care unit to have a break.

  • Review and formalise arrangements for paediatric transfer.
  • Ensure that the BMI corporate policy is adhered to concerning children’s nurse staffing in outpatients.
  • Consider formally monitoring and auditing waiting times, clinic cancellation and patients that do not attend for outpatient appointments.
  • Consider developing a suitable ‘did not attend’ policy concerning outpatient appointments.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 10 December 2013

During a routine inspection

We talked with four patients during our inspection visit. Patient�s confirmed that staff had talked through their procedure with them and had kept them up date with aspects of their care following surgery. Some comments captured included �[The doctor] explained the procedure, risks and benefits�, �Excellent care, excellent staff �can�t do enough for you� and �Nurses are really good, quick to respond to the call bell.�

We found people�s care needs had been met.

We found people were protected against the risks of unsafe or unsuitable premises.

We found people�s needs had been met by sufficient numbers of appropriate staff.

We found there was a complaints process in place.

We found people were protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records had been maintained.

Inspection carried out on 16 May 2013

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

We haven�t been able to speak to patients because this inspection was to follow up a specific compliance action relating to a specific aspect of practice within the operating theatres. In the inspection conducted 22nd February 2013 we talked with patients who confirmed they had received a very good standard of care from the staff who looked after them.

We found the location had ensured effective processes had been introduced to ensure people were protected from unsafe or unsuitable equipment within the operating theatres because practice relating to the changing of anaesthetic breathing circuits adhered to best practice guidance.

Inspection carried out on 22 February 2013

During a routine inspection

People told us they were asked for their consent and involved in making decisions about their care. We reviewed care records which showed that consent forms had been completed appropriately.

People told us they received a good standard of care. We reviewed care records which showed that people's needs were assessed and care and treatment was delivered in line with their individual care plan.

People told us they were given drinks and nutrition as soon as was possible after surgery. We also reviewed records, and spoke to staff, which showed that people were provided with a choice of suitable and nutritious food and drink.

We found that anaesthetic ventilator circuits were not changed in accordance with the recommendations of the specialist professional body. People were therefore not protected from unsafe or unsuitable equipment. We felt this had a minor impact on people who used the service and a compliance action was set.

We reviewed records and personal files which showed that people were cared for by suitably qualified, skilled and experienced staff. We also found there was an appropriate system for the granting of practicing privileges.

People who used the service were asked for their opinion through surveys and staff were involved in the management of quality in the hospital. We also found there were systems in place to regularly assess and monitor the quality of service that people received.

Inspection carried out on 29 February 2012

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

During our inspection visit in November 2011 we talked to people who use the service at this location. Comments were positive about aspects of their care.

For example, people spoke positively about the staff and care provided and said comments such as �It�s first class here�, �I feel well looked after� and �the staff are really good and helpful�. Please see the last report for this location for full details of people�s views.

Inspection carried out on 29 November 2011

During a routine inspection

As part of our inspection we talked with a number of patients. They spoke positively about the staff and care provided and told us that staff treated them with respect. Everyone we spoke with felt they were involved in their care and in making decisions about their treatment. We received comments such as �It�s first class here� and �I knew what to expect from what they told me�.

Everyone we spoke with felt they had received sufficient information about their treatment and we received comments such as �When I spoke to the doctor I wasn�t sure about the surgery so he gave me more time to think about it�, �Really good information� and �You can always ask questions and if the staff don�t know they will find out and get back to you�.

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