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Archived: BMI Three Shires Hospital Requires improvement

The provider of this service changed - see new profile


Inspection carried out on 17, 18, 26 June and 13 July 2015

During a routine inspection

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  • We found some out of date medications and equipment in the outpatients department.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 carried out on 17 September 2013

During a routine inspection

We spoke with three people who had recently undergone surgery at BMI Three Shires Hospital. They all told us that they were very happy with the treatment they had received. They told us that their consultants had clearly explained everything and they had received adequate pain relief.

We found that the hospital had ensured that people gave their consent before undergoing treatment. We saw that people had care plans that staff followed that met people�s needs.

We found that staff were supported and trained to provide care for people undergoing surgery.

We found that the hospital had good systems in place to monitor the quality of the service and maintained their records in accordance with the regulations.

Inspection carried out on 6 February 2013

During a routine inspection

Three Shires Hospital provides care and treatment for adults and children. This inspection focused on the services provided to children only. We found that Three Shires Hospital do not provide overnight care for children, therefore all the surgical treatments were provided as a daycase.

We spoke with staff who were knowledgeable about the care of children. We saw that Three Shires Hospital had processes in place to look after children before, during and after their treatment.

Inspection carried out on 13 November 2012

During a routine inspection

We spoke with two people who were in-patients at the hospital, they told us they were looked after very well. We looked at the care they had received and found that the hospital had systems in place to ensure that they had been treated safely.

Inspection carried out on 21 March 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

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