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Bupa Cromwell Hospital Requires improvement

We are carrying out checks at Bupa Cromwell Hospital. We will publish a report when our check is complete.


Inspection carried out on 29 November 2016 to 1 December 2016

During a routine inspection

Bupa Cromwell Hospital is operated by Medical Services International Limited. The hospital was purpose built in 1981 and acquired by Bupa in 2008. Facilities includes 114 beds and four suites, five operating theatres, a seven -bedded level three critical care unit, MRI and X-ray, outpatient and diagnostic facilities.

In the reporting period July 2015 to June 2016, the hospital treated 155,735 patients. The majority of these (89%) were outpatient attendance, 11,166 (7%) were inpatient and 6,689 (4%) were day-case discharges.

Of these, 49% of the patients were UK insurance, 23% self pay, 17% Embassy patients and 1% were NHS patients.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 29 November 2016 – 1 December 2016, along with an unannounced visit to the hospital on 6 December 2016.

The Bupa Cromwell Hospital provides

  • Medical care

  • Surgical care

  • Critical care

  • Services for children and young people

  • Outpatients and diagnostic imaging

We inspected all services provided at this hospital during our visit.

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.

Services we rate

Overall we rated The Bupa Cromwell Hospital as requires improvement because,

  • There were issues with the environment and infection control prevention (IPC). In the dialysis day unit, there was no sluice directly attached to the ward. During the course of inspection, we observed bags of dirty linen being left in the entrance of the unit, to be collected by domestic staff. In the neurology ward’s sluice, linen bags were found incorrectly disposed of in the green recycling bin. In both the dialysis unit and the oncology wards, there was no documentation of daily or weekly cleaning of equipment, although we did see evidence that green ‘I am clean’ stickers were in use. Some patients that we spoke to felt that the cleaning standards had dropped since their last visit. In patients’ en-suite bathrooms, bars of soap were provided for hand washing.

  • Not all portable equipment we checked had been recently serviced and labelled to indicate the next review date. We found seven pieces of equipment in the dialysis day unit that had stickers on them that exceeded review date, as well as one item on the neurology ward, two items in the general/cardiac ward and two pieces of equipment in the iodine suites. The hospital later provided us with records to indicate that service reviews had taken place on most of these items of equipment, but stickers were used inconsistently at the time of the inspection to indicate that they were safe to use.

  • In the dialysis day unit, we found 11 boxes of disposable equipment that had expired. Senior staff told us that some of this was waiting to be returned, and some was for teaching purposes. However, these boxes were not segregated or marked to indicate as such.

  • Nursing staff did not always check medication fridge temperatures daily, such as on the general/cardiology ward and oncology ward. Appropriate actions were not always taken when these were out of normal range. On some of the wards, room temperatures had consistently exceeded recommended levels of 25 degrees centigrade. No actions had been taken even though nursing staff told us that they had contacted building services.

  • Across the hospital, 90% of all staff had completed basic life support training and 90% had completed intermediate life support training. However, there was no effective system in place to ensure that competencies of staff in the dialysis day unit were checked on a regular basis.

  • Bank and agency usage of both nurses and healthcare assistants (HCAs) in the hospital inpatient departments was higher than the average of other independent acute hospitals that CQC holds this type of data for (July 2015 to June 2016). In the same period, bank and agency usage varied between 25.9% to 44.7% for nurses, and 29.4% to 56.4% for HCAs. However, staff told us that they tried to use the same bank and agency staff where possible, so that they were familiar with local protocols and procedures. The hospital provided evidence that indicated that regular members of bank staff were usually used in most cases, rather than agency staff who were unfamiliar with the unit.

  • Although guidance stated that RMOs should only cover a 48-hour shift at the hospital in an emergency, we found several instances of this in rotas dated between August and December 2016 for medical and paediatric services.

  • There was one paediatric resuscitation trolley shared between two theatres, which was not safe.

  • The hospital operational policy said shifts should be coordinated to ensure there was always an EPLS trained nurse on duty in paediatrics. However, the paediatric service was not always achieving this.

  • The service had closed its paediatric intensive care unit the week before our inspection. However, there were no formal plans in place on what to do in the event of a deteriorating patient.

  • Starfish ward and the paediatric outpatient department were not always meeting the Royal College of Nursing's guidelines with regards to children’s nurses being on each shift.

  • Staff were unable to show us how to access policies and evidenced based guidelines on the hospital's online system. Some staff said the system was not user friendly.

  • There was a lack of clinical audit within the paediatric department and the service was not participating in any national audits.

  • There were no on-call anaesthetists in place in recovery. This contravenes the Royal College of Surgeon (RCOS) and Association of Anaesthetists of Great Britain and Ireland (AAGBI) guidelines.

  • Handover from the ward to the theatres was done by telephone which caused some delay and sometimes issues with getting the right patient.

  • The recovery area was cramped and lacked natural light.

  • Some incidents indicated that the WHO surgical checklist was not embedded into day-to-day practice.

  • The hospital participated in six national audits. The medical service submitted data to the British Cardiovascular Intervention Society (BCIS) but did not participate in any other national audits related to medical care or end of life care. This was due to the fact that the hospital provided a limited number of services to a comparatively smaller patient base than NHS hospitals. This meant that it was limited in terms of the national audits that it could submit data to. The hospital had started to submit data to Private Healthcare Information Network (PHIN) in order to perform benchmarking functions, although this project remained in the early stages. There was a plan for local audit for the coming year, although many had not yet taken place at time of inspection.

  • The angiography department was not undertaking the recommended amount of percutaneous coronary interventions (PCIs) per year. However, discussions were underway with high volume NHS Institutions to explore 'job-share' partnerships that would allow non-medical staff (nurses/physiologists) to gain further experience. The hospital also hoped to encourage NHS Waiting list initiative programmes to increase the volume of procedures performed in the hospital.

  • Many training records for staff competencies within medicine services were inconsistent and unclear, with no assured mechanism in place for senior staff to ensure staff in the dialysis day unit were up to date with required training.

  • The palliative care clinical nurse specialist (CNS) had no formal supervision structure.

  • We found issues with the environment in the endoscopy department. Although only one patient underwent a procedure at a time, we found several patients present in the unit in various stages of preparation or recovery on the days of the inspection. We found that the waiting and recovery areas were cramped, with no effective means of separation as curtains were not routinely drawn across bays. Relatives could sit with patients but were usually discouraged due to the lack of space, as patients could spend up to three hours in recovery. On the day of inspection, a patient in a gown was waiting in the corridor post-procedure as there was only one changing room.

  • There was a lack of space in some other areas of the hospital, too. The dialysis day unit had no waiting room. Patients were called from the downstairs reception. Staff told us that limited space in the unit meant that relatives often had to wait in reception due to limited space by the beds or chairs in the facility.

  • In many areas of the hospital, patient information leaflets were not standardly available in languages other than English, although the hospital told us that any information could be readily translated as required.

  • There was no learning disability link nurse for support when children, young people or families might be living with a learning disability.

  • There was no clearly defined strategy in place for children and young people’s service or to develop end of life care (EOLC) services within the hospital.

  • Some staff described the environment as very corporate and business focused. They felt more could be done to support both patients and staff, making them the centre of care.

  • We were not assured the service had taken appropriate provisions to ensure they could care for the deteriorating patient before closing the paediatric intensive care unit.

  • We were not assured risks were being appropriately managed. There were a number of risks we identified within medicine, surgery and paediatric services, which were not on the services risk register and the critical care risk register had not timeline or action plan.

However, we also found good practice in relation to surgery:

  • There were embedded procedures in place to ensure staff learned and received feedback from incidents and complaints.

  • The infection control link nurse, the infection control team and staff both in the theatres and on the wards worked hard to ensure that infection control and good hygiene practices were maintained despite the lack of space.

  • There was a multidisciplinary approach to ensuring patients were adequately nourished, including input from both dietitians and speech and language therapists (SALTs).

  • Consultant surgeons only received privileges to perform surgery that they were skilled, competent and experienced to perform.

  • There were several regular multidisciplinary team (MDT) meetings within the service.

  • Patients' cultural, social and religious needs were all determined in the pre-assessment stage.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with two requirement notices that affected children and young people core services. Details are at the end of the report.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 22 October 2013

During a routine inspection

During our inspection visit we visited the imaging and outpatient departments, Adult Intensive Care Unit (ITU), two adult wards and the operating theatres. We spoke with patients and staff in the wards and imaging departments. We also spoke with the hospital’s Registered Manager, the Director of Nursing, the Medical Director and the infection control specialist nurse. The specialist adviser accompanying us specialised in peri-operative care.

The patients we spoke with were positive about their experiences at the hospital. One person said “it’s like a quality hotel” and another said that there was sufficient time to discuss his treatment. They all said the hospital was clean and they would make a complaint if they needed to. We reviewed the 2013 quarter 3 patient feedback information (404 respondents). 97% of people would recommend the hospital to others.

Patients’ needs were assessed and care and treatment was planned and delivered in line with their individual plans. This included risk assessment, multi-disciplinary team work and patients’ involvement with their care. Surgical processes were safely managed. Before receiving any treatment staff ensured that patients understood and consented to the procedure.

There were effective systems in place to reduce the risk and spread of infection. Staff had received infection control training and there was a team to support and advise staff as well as policies to guide clinical practice. Staff were trained and received appraisal and supervision that was appropriate to their role. This included an induction process for all staff.

There was an effective complaints system which included investigation, response and action planning. We saw that staff were focussed on providing safe and responsive care for their patients.

Inspection carried out on 26 June 2012

During a routine inspection

People we spoke with were satisfied with their care and treatment at the hospital. Many described aspects of their care as “excellent”. They reported that they were treated with respect. People understood the treatment that they or their children were undergoing and had been involved in making decisions about their care. They felt that they could give feedback about the service and ask for more information.

People who did not speak English as their first language told us that they had had a good experience at the hospital. They had had as much information as they needed and could ask for more. They had always been able to use the interpreter service when they needed it, or their doctors spoke Arabic with them.

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