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Inspection Summary


Overall summary & rating

Good

Updated 24 April 2018

BMI Syon Clinic is operated by BMI. Facilities include consulting rooms, a physiotherapy suite and diagnostic and imaging facilities.

The hospital provides outpatients and diagnostic imaging services.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 10th and 11th January 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.

We rated this hospital as good overall.

  • Incidents were reported and investigated through a clinic wide electronic system. Lessons learnt were shared effectively with all staff electronically and through team meetings. Themes were identified and there was no blame culture.

  • The clinic was a safe, clean environment and risk was minimised by regular cleaning and infection control monitoring.

  • The clinic had recently introduced a facility for storing records which meant that records were available for all patient appointments. Provider data suggested only 28% of appointments had all available records previously.

  • Sufficient staffing levels were maintained to keep patients safe.

  • There were clear business continuity protocols in place and staff knew what to do in case of emergency.

  • The clinic followed national and BMI guidelines and procedures which were kept updated.

  • We saw evidence that staff gained consent from patients and followed procedures correctly.

  • Patients gave good feedback about the care provided; they reported that staff were helpful and supportive.

  • Patients said that they were well informed about their care

  • We observed friendly interactions between patients and staff

  • Patients were able to access the service and make appointments quickly at flexible times. There was efficient flow through the clinic and a wide range of specialties available.

  • Staff described adjustments they made to meet the needs of patients they cared for.

  • There were same-day clinics so that patients could have their appointment and imaging done in one visit.

  • Learning from complaints was shared and managers improved the service in response to them.

  • There was positive leadership and managers understood the challenges facing the clinic and devised strategies to overcome them and improve the service.

  • The clinic had a clear vision and staff understood their roles in achieving the overall strategy.

  • There was a positive and supportive working culture at the clinic, staff spoke highly of their managers and felt able to raise problems and concerns if they needed to.

However:

  • There had been an Ionising Radiation (Medical Exposure) Regulation (IR[ME]R) reportable incident in imaging in the 12 months prior to inspection where a patient had undergone an unnecessary second scan due to poor record keeping and clinical communication.

  • There was limited auditing of the clinical performance of the clinic so managers were reliant on patient complaints to identify clinical concerns

  • There was not a clear power failure protocol in the imaging department

  • There was limited staff and public engagement to obtain wider involvement in improving the service.

Amanda Stanford

Deputy Chief Inspector of Hospitals

Inspection areas

Safe

Good

Updated 24 April 2018

We rated safe as requires improvement because:

  • Incidents were reported and investigated through a clinic wide electronic system. Lessons learnt were shared effectively with all staff electronically and through team meetings. Themes were identified and there was no blame culture.

  • The clinic was a safe, clean environment and risk was minimised by regular cleaning and infection control monitoring.

  • The clinic had recently introduced a facility for storing records which meant that records were available for all patient appointments, up from 28% previously.

  • Sufficient staffing levels were maintained to keep patients safe.

However:

  • There had been an Ionising Radiation (Medical Exposure) Regulation (IR[ME]R) reportable incident in imaging in the 12 months prior to inspection where a patient had undergone an unnecessary second scan due to poor record keeping and clinical communication.

Effective

Good

Updated 24 April 2018

We do not rate effective for outpatients. We found that:

  • The clinic followed national and BMI guidelines and procedures which were kept updated.

  • There was limited auditing of the clinical performance of the clinic

  • We saw evidence that staff gained consent from patients and followed procedures correctly.

Caring

Good

Updated 24 April 2018

We rated caring as good because:

  • Patients gave good feedback about the care provided; they reported that staff were helpful and supportive.

  • Patients said that they were well informed about their care

  • We observed friendly interactions between patients and staff

Responsive

Good

Updated 24 April 2018

We rated responsive as good because:

  • Patients were able to access the service and make appointments quickly at flexible times. There was efficient flow through the clinic and a wide range of specialties available.

  • Staff described adjustments they made to meet the needs of patients they cared for.

  • There were same day clinics so that patients could have their appointment and imaging done in one visit.

  • Learning from complaints was shared and managers improved the service in response to them.

Well-led

Good

Updated 24 April 2018

We rated well-led as good because:

  • Managers understood the challenges facing the clinic and devised strategies to overcome them and improve the service.

  • The clinic had a clear vision and staff understood their roles in achieving the overall strategy.

  • There was a positive and supportive working culture at the clinic, staff spoke highly of their managers and felt able to raise problems and concerns if they needed to.

However:

  • There was limited staff and public engagement to obtain wider involvement in improving the service.
Checks on specific services

Outpatients and diagnostic imaging

Good

Updated 24 April 2018

  • Incidents were reported and investigated through a clinic wide electronic system. Lessons learnt were shared effectively with all staff electronically and through team meetings. Themes were identified and there was no blame culture.

  • The clinic was a safe, clean environment and risk was minimised by regular cleaning and infection control monitoring.

  • The clinic had recently introduced a facility for storing records which meant that records were available for all patient appointments. Provider data suggested only 28% of appointments had all available records previously.

  • Sufficient staffing levels were maintained to keep patients safe.

  • There were clear business continuity protocols in place and staff knew what to do in case of emergency.

  • The clinic followed national and BMI guidelines and procedures which were kept updated.

  • We saw evidence that staff gained consent from patients and followed procedures correctly.

  • Patients gave good feedback about the care provided; they reported that staff were helpful and supportive.

  • Patients said that they were well informed about their care

  • We observed friendly interactions between patients and staff

  • Patients were able to access the service and make appointments quickly at flexible times. There was efficient flow through the clinic and a wide range of specialties available.

  • Staff described adjustments they made to meet the needs of patients they cared for.

  • There were same-day clinics so that patients could have their appointment and imaging done in one visit.

  • Learning from complaints was shared and managers improved the service in response to them.

  • There was positive leadership and managers understood the challenges facing the clinic and devised strategies to overcome them and improve the service.

  • The clinic had a clear vision and staff understood their roles in achieving the overall strategy.

  • There was a positive and supportive working culture at the clinic, staff spoke highly of their managers and felt able to raise problems and concerns if they needed to.

However:

  • There had been an Ionising Radiation (Medical Exposure) Regulation (IR[ME]R) reportable incident in imaging in the 12 months prior to inspection where a patient had undergone an unnecessary second scan due to poor record keeping and clinical communication.

  • There was limited auditing of the clinical performance of the clinic so managers were reliant on patient complaints to identify clinical concerns

  • There was not a clear power failure protocol in the imaging department

  • There was limited staff and public engagement to obtain wider involvement in improving the service.