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

Reports


Inspection carried out on 18 to 20 September 2018

During a routine inspection

Bupa Cromwell Hospital is operated by Medical Services International Limited. The hospital has 118 inpatient beds and 19 day case beds. Facilities include five operating theatres, a four-bed level three care unit, endoscopy unit, outpatient and diagnostic facilities.

The hospital provides surgery, critical care, medical care, services for children and young people, and outpatients and diagnostic imaging. We inspected all of these six services.

We inspected this service using our comprehensive inspection methodology. We carried out the unannounced inspection on 18 to 20 September 2018.

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 services provided by this hospital were at the Bupa Cromwell Hospital.

Services we rate

Our rating of this hospital improved. We rated it as good overall.

We found mainly good practice in all the key questions for all the six services we inspected. However, we rated critical care as requires improvement.

The hospital had made significant improvements in the services of medical care and children and young people; both these services had previously been rated as requires improvement. Medical care was rated as outstanding overall.

We found the following areas of good practice across all services:

  • The service had improved the systems in place for reporting, investigating and learning from incidents and serious adverse events. There was an open culture of reporting, and learning was shared with staff to make improvements.

  • There was sufficient staff with the right skills, training and support to meet the needs of patients and provide effective multidisciplinary care in all the services.

  • Staff used a standardised sepsis screening tool and sepsis care pathway. Our review of records showed staff used an early warning score system to monitor patients for signs of deterioration and responded appropriately.

  • The service followed best practice when prescribing, giving, recording and storing medicines. Patients received the right medication at the right dose at the right time.

  • The hospital used current evidence-based guidance and quality standards to plan the delivery of care and treatment to patients. There were effective processes and systems in place to ensure guidelines and policies were updated and reflected national guidance and improvement in practice.

  • We observed staff treated patients and their families with compassion and care to meet their holistic needs.

  • The hospital planned, developed and provided services in a way that met and supported the needs of the population that accessed the service, including those with complex or additional needs. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were excellent.

  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff.

  • Managers had implemented systems to strengthen governance, performance and risk management arrangements across the hospital since the last inspection.

  • Managers across the services promoted a positive culture that supported and valued staff. The majority of staff told us they felt listened to and well supported by managers and colleagues and were confident to raise any concerns they had.

  • The hospital engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.

We found areas of outstanding practice

Medical care:

  • Staff provided compassionate individualised care. Staff provided extensive support to patients and their relatives and worked hard to meet the holistic needs of their patients through emotional and practical measures.

  • The hospital provided extensive emotional support and resources to patients and their families. The oncology and chemotherapy day unit had a qualified Macmillan cancer counsellor and patients really valued the service.

  • We saw numerous examples of individualised care and progress made through the involvement of relatives, for example with patients who had suffered a brain injury.

Outpatients:

  • The hospital worked with a sight loss charity to provide a braille map for partially sighted and blind patients to enable them to navigate the hospital safely and independently.

  • Patients were provided with a single point of contact via a patient care coordinator. This was their point of contact throughout their visit. They were responsible for looking after the patients’ welfare, and checking them in with the consultants’ reception desk. They also kept the patient up to date with any changes or delays.

  • The hospital held cultural sessions for both international patients and staff prior to admission to the hospital. This was to ensure both patients and staff understood cultural expectations, enhanced the patient experience and so they did not offend each other.

We found areas of practice that require improvement:

Medical care:

  • Clinical equipment was not regularly serviced and sharps bins were not always dated in a timely manner to indicate when they were assembled.

  • Some staff from a certain ethnic group had experience bullying from patients within the same ethnic group. Senior managers were aware of this and told us they had addressed the issue with patients and emphasized the organisation had zero tolerance on abuse or victimization.

Surgery:

  • Equipment in some patient rooms was covered in dust.

  • The service had a high number of unplanned readmissions within 28 days of surgery.

  • The service used two different patient pain score measures; one for theatres and one on the wards.

  • There was no service level strategy in place.

  • Junior nurses felt neglected by the executive team and did not speak highly of the culture.

Critical care

  • Not all equipment was safety tested and always cleaned and labelled appropriately.

  • Staff did not always adhere to infection prevention and control standards.

  • The rate of bank or agency staff did not always comply with recommendations by Core Standards for Intensive Care Units.

  • The premises did not comply with Core Standards for Intensive Care Units but the hospital had building plans for a new unit.

  • Intensive Care National Audit Research Centre (ICNARC) data showed there were more unit acquired infections in blood compared to similar units.

  • ICNARC data showed the risk adjusted acute hospital mortality was above calculated expected acute hospital mortality.

  • Not all staff knew about the principles of Deprivation of Liberty Safeguards (DoLS) and how to apply them in a critical care setting.

  • The service did not always meet the needs of people. The facilities for patients’ relatives were not appropriate, but there were building plans for a new unit to correct this by 2019.

  • Intensive Care National Audit Research Centre (ICNARC) data showed there were more unplanned readmissions within 48 hours from discharge compared to similar units.

  • ICNARC data showed there were more out of hours discharges to the ward compared to similar units.

Services for children and young people

  • Staff did not receive any specific training on potential needs of people with learning disability and autism. This was not in line with best practice.

  • We observed some staff in clinical areas did not adhere to bare below the elbow dress code.

  • We found that the clinical audit programme was limited to mainly nurse led audit and the service did not audited their consent practice.

  • There was limited monitoring of clinical outcomes.

  • Though clinical guidelines were available on the intranet, the process to search correct information was cumbersome.

  • There was no learning disability link nurse.

  • The children’s service was at an early stage of establishing a formal governance structure and this needed to become well embedded.

Outpatients

  • Not all patient records were completed to log patient interactions, assessments, medications prescribed and treatment provided by the consultant.

  • Cleaning schedules for consulting rooms were not always completed as required.

  • Infection prevention and control (IPC) audits were below the target, and action plans were incomplete.

  • The hospital did not audit evidence based care and treatment outcomes, therefore they could not benchmark against other providers.

  • Information and assistance posters were only displayed in English.

  • Cancellation rates and do not attend (DNA) rates were not monitored due to secretaries booking and cancelling appointments and not working onsite to be able to record this.

  • Patients with dementia, learning difficulties and mental health conditions were not able to be flagged via patient records.

  • The management and governance team did not always ensure action plans were up to date as a result of audits that had taken place.

Diagnostic imaging

  • The service controlled infection risk well. However, some areas did not have documentation to check they were cleaned effectively.

  • The service had suitable premises and equipment and looked after them well. However, there were no separate waiting areas for children in the waiting areas for x-ray, CT, PETCT, MRI and ultrasound. This could result in exposure to inappropriate adult conversation.

  • There was a lack of health promotion material available across the diagnostic department

  • There was a lack of audit to ensure the correct exposures for plain film x-ray were used.

Nigel Acheson

Deputy Chief Inspector of Hospitals

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)