You are here

Archived: BMI Three Shires Hospital Requires improvement

The provider of this service changed - see new profile

Inspection Summary


Overall summary & rating

Requires improvement

Updated 3 December 2015

We carried out an announced inspection visit of BMI Three Shires Hospital LTD. on 17, 18 June and 13 July 2015 and an unannounced inspection on 27 June 2015.

The imaging department is operated by a separate provider via a joint venture agreement with BMI, therefore this department was not inspected as part of the outpatient core service.

We inspected the following four core services:

  • Surgery

  • Outpatients

  • Services for Children and Young People

  • Termination of pregnancy

Our key findings were as follows:

Are services safe at this hospital?

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

  • Staff were encouraged to report incidents and there was an incident reporting system in place that staff were aware of.

  • Feedback from incidents was varied and we were not reassured that staff learnt from all reported incidents.

  • Not all staff in the outpatients department were aware of the new Duty of Candour regulations.

  • Out of hours, there was only the Resident Medical Officer (RMO) in the hospital at any one time who was an Advanced Life Support (ALS) provider.

  • Despite procedures being in place to check the cleanliness of rooms in outpatients, we found equipment and some rooms and equipment that were not clean. Check lists were signed, but not specific to tasks undertaken.

  • Although there were up to date records to demonstrate that a system was in place to maintain equipment in outpatients the system was not effective.

  • We found some out of date medications and equipment in the outpatients department.

  • Medications were stored safely and securely to prevent theft, damage or misuse, including Controlled Drugs.

  • Services were generally clean and equipment was cleaned between patients; however we noted that in outpatients some areas did not appear to have been cleaned thoroughly.

  • There were adequate hand-washing facilities and soap dispensers, hand hygiene foam and paper towels for staff and patients to use. ‘However, we observed a number of staff not always washing or sanitising their hands when moving between theatre and recovery.

  • There were clear strategies for minimising the risk to adult patients. Staff demonstrated a good understanding of the assessed risks and how to avoid these. ‘The hospital did not admit or treat patients who were anticipated as requiring critical care support and had an appropriate transfer policy in place with the local trust in the event that a patient became critically ill and needed to be transferred.’

  • The hospital had a screening system in place to ensure that patients were assessed pre-operatively to ensure their suitability for surgery and used an early warning system to alert them should a patient’s condition deteriorate in the post-operative phase.

  • Surgical procedures were carried out by a team of consultant surgeons and anaesthetists registered with the General Medical Council (GMC). The consultants were mainly employed by other organisations (usually in the NHS) in substantive posts and had practising privileges (the right to practice in a hospital) with BMI Three Shires Hospital.

  • The Resident Medical Officer (RMO) provided out-of-hours medical cover 24 hours a day and as part of their practising privileges agreement, consultants were required to be contactable whilst they had patients under their care in the hospital. Staff said that consultants could be contacted out of hours.

  • There was a system in place for planning and monitoring the number of staff and mix of staff needed to meet patients’ needs in the wards and theatre.

  • The records showed that there were no vacancies within the outpatient department or in patient wards. There was very little agency staff use in all departments.

  • Staff were aware of their role and responsibilities with regards to safeguarding and the majority of staff were up to date with adult’s safeguarding training. However, some staff, including the hospital leads for safeguarding, were unsure what level of training had been provided with regards to both adult and children’s safeguarding when we spoke with them. The hospital subsequently confirmed that some staff were trained to level 2 or 3.

  • Adult nurses, who did not have the appropriate level of safeguarding training, often looked after children.

  • The hospital did not have a system to identify children or young person who may be at risk of abuse.

  • Staff and managers told us they were up to date with their mandatory training. Overall compliance was 86% which was in line with the hospital’ target of 85%.

  • Patient records were up to date; risk assessments had been completed and documented for patients undergoing surgery, including the 5 Steps to Safer Surgery safety checklists.

Are services effective at this hospital?

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

  • Surgical and outpatient care delivered was evidence based and in line with nationally agreed policies and practice.

  • We saw assessments of people’s needs were comprehensive and included the assessment of pain. However, this was not the case in children’s services, where pain assessments were poorly completed.

  • There was an audit programme in place, being undertaken in all services, except children and young people’s services. There was recording and reporting of some patient outcomes.

  • There was evidence of good multidisciplinary working across the hospital.

  • Services could be provided over seven days to reflect demand.

  • The role of the Medical Advisor Committee (MAC) included ensuring that consultants were skilled, competent and experienced to perform the treatments undertaken. These were reviewed annually.

  • There was a process in place for checking General Medical Council and Nursing and Midwifery Council registration, as well as other professional registrations.

  • There was a lack of formal supervision for nursing staff.

  • Most staff had yearly appraisals.

  • Staff were confident about seeking consent from patients and staff had received training on the Mental Capacity Act 2005.

  • Senior staff and those working within children’s services were not aware of processes around Fraser Guidelines but did recognise the Gillick competency assessment.

Are services caring at this hospital?

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

  • Patients were treated with dignity and respect.

  • We observed good interaction between patients and staff. Staff explained procedures and gave appropriate information to patients to help them to understand and be involved in decisions concerning their treatment. Initial consultations and pre-admissions assessments were thorough and included consideration of patients’ emotional well-being.

  • Most patients spoke positively about the care provided by staff. Patients we spoke with commended staff saying they were friendly and very attentive.

  • The hospital sought feedback from patients about the service via a BMI questionnaire and the Friends and Family Test. The results were positive as 84% of patient said they would recommend the hospital as a good place to go for treatment.

  • There was no mechanism for eliciting feedback from children and young people or their carers, but this was planned to be implemented in the future.

  • Privacy and dignity was respected and protected.

Are services responsive at this hospital?

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

  • The patients we spoke with told us that access to the hospital was good and did not have any concerns in relation to their admission, waiting times or discharge arrangements.

  • Information about services provided at the hospital was provided in a way patients understood and appreciated. Staff told us that should a patient have communication problems they were able to address their individual needs. However, not all staff were aware that the hospital had access to an interpreting service.

  • Staff said they were able to accommodate people’s religious needs both pre and post operatively. They said they could contact the local community that offered support for example, church, mosque, temple or synagogue.

  • There was information on the process for making complaints for patients. The hospital had received 54 complaints between April 2014 and April 2015, with 9 related to consultants, 5 related to clinical care and the rest shared between medical care, costs and arrangements surrounding admission and discharge. All had been acknowledged and responded to within the industry standard timeframes.

Are services well led at this hospital?

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

  • There was a governance structure in place, with committees such as the governance and risk team feeding into the medical advisory committee (MAC) and hospital senior management team. The governance and risk committee was also responsible for clinical governance in the hospital. However, the terms of reference for the committee structure were ambiguous.

  • The Clinical Governance Committee, did not discuss in detail appropriate categorisation of incidents, or if suitable action had been taken following incidents. Appropriate action following incidents was not always taken in both the CG and MAC.

  • We saw evidence of anaesthetists and consultant surgeons being reviewed and discussed at the MAC. Consultants had their practising privileges suspended by the Executive Director if they did not provide the relevant information in a timely manner. Temporary privileges could be granted, if for example a specialist opinion from a consultant was required, who did not have privileges.

  • We were not assured that the senior management team had sufficient control of or oversight of risk within the hospital. The hospital had a risk register in place; however two risks identified did not have an effective method of measuring the likelihood and impact of the identified risk.

  • Appraisal rates were at 78% in May 2015, compared to 39% at the end of 2014. Staff said that the hospital’s values were discussed during their appraisals. However, staff were not familiar with the vision for services.

  • There was no vision or strategy for the children’s service.

  • We found there were no risks identified on the risk register for the children and young people’s service.

  • There was no one person who had clear responsibility for leading the service for children and young people.

  • There was no monitoring of registered nurses skills and competencies which led to staff with no paediatric training caring for children.

  • Senior managers confirmed that they did not identify children and young people within the completed audits. This meant that we could not be assured that risks were assessed, monitored and mitigated against.

  • Staff spoke positively about the high quality care and services they provided for patients and were proud to work for the hospital. Staff reported that all their managers, including the Executive Director were visible. Staff told us that senior management were supportive and staff felt able to raise concerns.

  • Audits were being undertaken in all services, except children and young people’s services, to measure the quality of the service.

  • Feedback was collected from patients, except young people’s services. It was collected and the results shared with the staff. Patient feedback was positive.

We saw several areas of outstanding practice including:

  • Excellent multidisciplinary working across the hospital, to ensure that patients received appropriate and timely care.

  • A caring and responsive approach to patients after their surgery.

  • The daily hospital ‘Huddle’ for exchanging information.

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

Importantly, the provider must:

  • Ensure that all equipment used by the service is clean, stored correctly and properly maintained.

  • Ensure that equipment checks in place are carried out efficiently in accordance with the hospitals policy or to identify all concerns.

  • Ensure effective systems are in place to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users, including ensuring that the risk register is reflective of service risks.

In addition the provider should:

  • Ensure all incidents are recorded and staff receive feedback and learn from incidents.

  • Ensure staff are aware of the new Duty of Candour regulations

  • Ensure all staff sanitise their hands before entering the theatre area.

  • Ensure that staff receive formal supervision and appropriate competencies.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 3 December 2015

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

  • Staff were encouraged to report incidents and there was an incident reporting system in place that staff were aware of.

  • Feedback from incidents was varied and we were not reassured that staff learnt from all reported incidents.

  • Not all staff in the outpatients department were aware of the new Duty of Candour regulations.

  • Out of hours, there was only the Resident Medical Officer (RMO) in the hospital at any one time who was an Advanced Life Support (ALS) provider.

  • Despite procedures being in place to check the cleanliness of rooms in outpatients, we found equipment and some rooms and equipment that were not clean. Check lists were signed, but not specific to tasks undertaken.

  • Although there were up to date records to demonstrate that a system was in place to maintain equipment in outpatients the system was not effective.

  • We found some out of date medications and equipment in the outpatients department.

  • Medications were stored safely and securely to prevent theft, damage or misuse, including Controlled Drugs.

  • Services were generally clean and equipment was cleaned between patients; however we noted that in outpatients some areas did not appear to have been cleaned thoroughly.

  • There were adequate hand-washing facilities and soap dispensers, hand hygiene foam and paper towels for staff and patients to use. However, we observed a number of staff not always washing or sanitising their hands when moving between theatre and recovery.

  • There were clear strategies for minimising the risk to adult patients. Staff demonstrated a good understanding of the assessed risks and how to avoid these. The hospital did not admit or treat patients who were anticipated as requiring critical care support and had an appropriate transfer policy in place with the local trust in the event that a patient became critically ill and needed to be transferred.

  • The hospital had a screening system in place to ensure that patients were assessed pre-operatively to ensure their suitability for surgery and used an early warning system to alert them should a patient’s condition deteriorate in the post-operative phase.

  • Surgical procedures were carried out by a team of consultant surgeons and anaesthetists registered with the General Medical Council (GMC). The consultants were mainly employed by other organisations (usually in the NHS) in substantive posts and had practising privileges (the right to practice in a hospital) with BMI Three Shires Hospital.

  • The Resident Medical Officer (RMO) provided out-of-hours medical cover 24 hours a day and as part of their practising privileges agreement, consultants were required to be contactable whilst they had patients under their care in the hospital. Staff said that consultants could be contacted out of hours.

  • There was a system in place for planning and monitoring the number of staff and mix of staff needed to meet patients’ needs in the wards and theatre.

  • The records showed that there were no vacancies within the outpatient department or in patient wards. There was very little agency staff use in all departments.

  • Staff were aware of their role and responsibilities with regards to safeguarding and the majority of staff were up to date with adult’s safeguarding training. However, some staff, including the hospital leads for safeguarding, were unsure what level of training had been provided with regards to both adult and children’s safeguarding when we spoke with them. The hospital subsequently confirmed that some staff were trained to level 2 or 3.

  • Adult nurses, who did not have the appropriate level of safeguarding training, often looked after children.

  • The hospital did not have a system to identify children or young person who may be at risk of abuse.

  • Staff and managers told us they were up to date with their mandatory training. Overall compliance was 86% which was in line with the hospital target of 85%.

  • Patient records were up to date; risk assessments had been completed and documented for patients undergoing surgery, including the 5 Steps to Safer Surgery safety checklists.

Effective

Requires improvement

Updated 3 December 2015

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

  • Surgical and outpatient care delivered was evidence based and in line with nationally agreed policies and practice.

  • We saw assessments of people’s needs were comprehensive and included the assessment of pain. However, this was not the case in children’s services, where pain assessments were poorly completed.

  • There was an audit programme in place, being undertaken in all services, except children and young people’s services. There was recording and reporting of some patient outcomes.

  • There was evidence of good multidisciplinary working across the hospital.

  • Services could be provided over seven days to reflect demand.

  • The role of the Medical Advisor Committee (MAC) included ensuring that consultants were skilled, competent and experienced to perform the treatments undertaken. These were reviewed annually.

  • There was a process in place for checking General Medical Council and Nursing and Midwifery Council registration, as well as other professional registrations.

  • There was a lack of formal supervision for nursing staff.

  • Most staff had yearly appraisals.

  • Staff were confident about seeking consent from patients and staff had received training on the Mental Capacity Act 2005.

  • Senior staff and those working within children’s services were not aware of processes around Fraser Guidelines but did recognise the Gillick competency assessment.

Caring

Good

Updated 3 December 2015

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

  • Patients were treated with dignity and respect.

  • We observed good interaction between patients and staff. Staff explained procedures and gave appropriate information to patients to help them to understand and be involved in decisions concerning their treatment. Initial consultations and pre-admissions assessments were thorough and included consideration of patients’ emotional well-being.

  • Most patients spoke positively about the care provided by staff. Patients we spoke with commended staff saying they were friendly and very attentive.

  • The hospital sought feedback from patients about the service via a BMI questionnaire and the Friends and Family Test. The results were positive as 84% of patient said they would recommend the hospital as a good place to go for treatment.

  • There was no mechanism for eliciting feedback from children and young people or their carers, but this was planned to be implemented in the future.

  • Privacy and dignity was respected and protected.

Responsive

Good

Updated 3 December 2015

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

  • The patients we spoke with told us that access to the hospital was good and did not have any concerns in relation to their admission, waiting times or discharge arrangements.

  • Information about services provided at the hospital was provided in a way patients understood and appreciated. Staff told us that should a patient have communication problems they were able to address their individual needs. However, not all staff were aware that the hospital had access to an interpreting service.

  • Staff said they were able to accommodate people’s religious needs both pre and post operatively. They said they could contact the local community that offered support for example, church, mosque, temple or synagogue.

  • There was information on the process for making complaints for patients. The hospital had received 54 complaints between April 2014 and April 2015, with 9 related to consultants, 5 related to clinical care and the rest shared between medical care, costs and arrangements surrounding admission and discharge. All had been acknowledged and responded to within the industry standard timeframes.

Well-led

Inadequate

Updated 3 December 2015

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

  • There was a governance structure in place, with committees such as the governance and risk team feeding into the medical advisory committee (MAC) and hospital senior management team. The governance and risk committee was also responsible for clinical governance in the hospital. However, the terms of reference for the committee structure were ambiguous.

  • The Clinical Governance Committee, did not discuss in detail appropriate categorisation of incidents, or if suitable action had been taken following incidents. Appropriate action following incidents was not always taken in both the CG and MAC.

  • We saw evidence of anaesthetists and consultant surgeons being reviewed and discussed at the MAC. Consultants had their practising privileges suspended by the Executive Director if they did not provide the relevant information in a timely manner. Temporary privileges could be granted, if for example a specialist opinion from a consultant was required, who did not have privileges.

  • We were not assured that the senior management team had sufficient control of or oversight of risk within the hospital. The hospital had a risk register in place; however two risks identified did not have an effective method of measuring the likelihood and impact of the identified risk.

  • Appraisal rates were at 78% in May 2015, compared to 39% at the end of 2014. Staff said that the hospital’s values were discussed during their appraisals. However, staff were not familiar with the vision for services.

  • There was no vision or strategy for the children’s service.

  • We found there were no risks identified on the risk register for the children and young people’s service.

  • There was no one person who had clear responsibility for leading the service for children and young people.

  • There was no monitoring of registered nurses skills and competencies which led to staff with no paediatric training caring for children.

  • Senior managers confirmed that they did not identify children and young people within the completed audits. This meant that we could not be assured that risks were assessed, monitored and mitigated against.

  • Staff spoke positively about the high quality care and services they provided for patients and were proud to work for the hospital. Staff reported that all their managers, including the Executive Director were visible. Staff told us that senior management were supportive and staff felt able to raise concerns.

  • Audits were being undertaken in all services, except children and young people’s services, to measure the quality of the service.

  • Feedback was collected from patients, except young people’s services. It was collected and the results shared with the staff. Patient feedback was positive.
Checks on specific services

Services for children & young people

Inadequate

Updated 3 December 2015

The service for children and young people required improvement in were safe, caring, effective and responsive.

There service was rated inadequate with regards to it being well led.

The hospital did not have a system to identify children or a young person who may have been at risk of abuse. The children’s nurses said they were unaware if staff who worked with children and young people were trained, with regards to safeguarding, at the appropriate level. Although some safeguarding systems were in place and staff knew how to respond to safeguarding concerns.

The records identified inconsistencies in the recording of the resuscitation equipment checks. We saw the checklist was not checked and completed daily. We found that the registered nurses were unaware of the shortfall in the checking of equipment and did not ensure the equipment was safe for use by children and young people.

Not all children and young and young people had their weight and height recorded on admission.

Staff said they were encouraged to report any incidents which were then discussed at staff meetings. There was consistent feedback and learning from incidents reported. Staff were aware of the Duty of Candour, ensuring patients received an apology when something went wrong.

The environment was visibly clean and staff followed the hospital policy on infection control.

Staffing levels were adequate for the service provision. The hospital had processes in place to attend to risks associated with emergencies.

Relatives told us how their children received good care. They said their children were treated with dignity, respect and compassion. The records showed that staff involved children and their parents/relative in decisions about their care and treatment. Relatives said they were supported and reassured if they were anxious or concerned.

The hospital did not gather children, young people or their relatives’ feedback on the service provided. This meant the hospital was unable to action patient experiences to improve the service.

The children and young people services were responsive to their needs. Children and young people were admitted to and discharged from the hospital at appropriate times. Patients with a learning disability were provided with the necessary support. Staff had access to translation services although this did not extend to a sign language interpreter.

Rooms provided by the hospital were not specifically set up for children from a safety point of view. However, there were no children or young people on the wards during our inspection, so we were unable to verify the changes which might have been made to those rooms were they to be used by a child or young person.

Complaints were dealt with in line with hospital policy.

We found that children and young people’s services required improvement to be well-led. Staff were not aware of the vision or strategy for the service.

The governance processes had a focus on risk and quality for the hospital. However, this did not identify the objectives for the children and young people service. We found there were no risks identified on the risk register. Senior managers confirmed they did not identify children and young people within the completed audits. This meant that we could not be assured that risks were assessed, monitored and mitigated against. Policies and procedures were accessible to staff. The service held a monthly internal paediatric forum meeting.

Within the service there was a culture of support and respect for each other. Staff were open and transparent about issues and concerns and felt this was positive for making improvements to the service.

There was positive awareness among staff of the expectations for patient care.

Outpatients and diagnostic imaging

Requires improvement

Updated 3 December 2015

Safety concerns were not consistently identified or addressed quickly enough. Cleanliness, hygiene and infection prevention and control risks were not adequately assessed and managed.

Potential risks to patients due to the environment and equipment were not adequately identified, including on the resuscitation trolleys.

Systems, processes and standard operating procedures were not always reliable or appropriate to keep patients safe.

Monitoring whether safety systems were implemented was not effective. We found incidences of out of date medicine and FP10 prescription pads that were stored inappropriately.

There was limited evidence of how practice was audited against current evidence-based guidance, standards and best practice. There was no monitoring of patient outcomes of care and treatment. Participation in external audits and benchmarking was limited.

Not all staff had the right qualifications, skills, knowledge and experience to do their job. There were gaps in support arrangements for staff, such as supervision. Staff were supported to participate in training and development.

Multi-disciplinary teams worked well together to provide effective care. Nursing staff did not always have the complete information they needed before providing care and treatment.

Consultants had their own patient records and were able to access diagnostic results without any delays. Consent to care and treatment was obtained in line with legislation and guidance, including the Mental Capacity Act 2005 (MCA) by the consultants.

There was a lack of awareness by nursing staff regarding the MCA and why they would need to know this information. Limited numbers of staff had received MCA and Deprivation of Liberty Safeguards (DoLS) training.

Feedback from patients was positive about the way staff treated them. Patients were treated with dignity, respect and kindness during all interactions with staff. Patients were involved in their care and in making decisions, with any support needed. They received information in a way that they could understand, including the risks and benefits of potential surgery. Patients’ privacy and confidentiality was respected at all times.

Care and treatment was coordinated with other services and other providers. Access to care was managed to take account of patient needs, including those with urgent needs. Services ran on time and patients were kept informed of any disruption/delays to their care or treatment. Complaint information or how to raise a concern was available for patients. Complaints and concerns were always taken seriously, responded to in a timely way and listened to.

Surgery

Good

Updated 3 December 2015

Surgical services were safe, caring, effective and responsive.

There was improvement required with regards to the hospital overall, being well-led.

There were integrated governance arrangements in place to minimise risk to patients and ensure shared learning. However, the terms of reference and what happened in practice differed.

The Clinical Governance Committee, (CG) did not discuss in detail appropriate categorisation of incidents, or if suitable action had been taken following incidents. Appropriate action following incidents was not always taken in both the CG and Medical Advisory Committee (MAC.)

There was no evidence that reports circulated prior to meetings had been read and the minutes showed that there was a subsequent lack of action.

The risk register did not show corporate risks that may affect the hospital.

The risk assessment process failed to consider the impact and likelihood of the risk happening.

Incidents were reported and dealt with appropriately and themes and outcomes were communicated to staff. Patient areas were visibly clean, tidy and appropriately equipped.

Patients were assessed, treated and cared for in line with professional guidance. There were effective arrangements in place to monitor and manage pain.

Patient surgical outcomes were monitored and reviewed through formal national and local audit.

There was sufficient competent medical and nursing staff on duty to meet the needs of patients. Nursing, medical and other healthcare professionals were caring and patients were extremely positive about their care and experiences. Patients were treated with dignity and respect.

Complaints were acknowledged, investigated and responded to in a timely manner. Information about the hospitals complaints procedure was available for patients and their relatives. The service reviewed and acted on feedback about the quality of care received.

Staff had limited awareness of the hospital’s new vision. There were good arrangements for monitoring the quality of the service provided. There was strong leadership and an open culture where staff felt valued.

Termination of pregnancy

Insufficient evidence to rate

Updated 3 December 2015

The hospital carried out only four terminations of pregnancy in 2014. Therefore this small service was inspected but not rated.

The hospital complied with The Abortion Act 1967, (as amended) The Abortion Regulations 1991, theAbortion (Amendment) (England) Regulations 2002 and the DoH Required Standard Operating procedures (RSOPS).