North Bristol Private Hospital

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

This is the first assessment for this service. This key question has been rated good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We scored the service as 3. The evidence showed a good standard. The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team.

Staff felt respected, supported and valued. They were focused on the needs of patients receiving care and could explain how they were working to deliver high quality care.

We saw a culture where staff worked well together in cohesive teams and leaders were available to staff if they had any issues. A response from the staff survey stated, ‘thank you to the management for all the hard work to make our environment a safe and comfortable place’. Staff we spoke to said they were happy to raise issues with the management team and that there was an open door policy. The service had a staff feedback box and staff said they had the opportunity to contribute ideas for improving the service.

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders had a good understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care. The service had employed an external consultant to be part of their Medical Advisory Committee, to ensure that this committee had the right people with the right experience to inform the service.

Leaders were visible in the service and approachable for patients and staff.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Managers and staff had access to the feedback from patients, carers and staff and used it to make improvements.

Patients and staff could meet with members of the provider’s senior leadership team to give feedback.

The service encouraged staff and patients to speak up. There was a freedom to speak up and whistleblowing policy which were in date and recently reviewed. The Theatre Manager was the dedicated freedom to speak up champion. Staff had commented on the supportive environment at the organisation and said they felt able to escalate any concerns to the medical and / or the hospital director. If staff felt unable to speak up, there was clear signposting to an independent charity which could provide confidential advice.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Managers put reasonable adjustments in place for staff members to help them carry out their role. We observed that for some of the housekeepers, English was not their first language. The service had included instructions for operating machinery, such as the washing machines, in English and the home language of the housekeepers in order to help them out and to avoid any confusion.

We scored the service as 3. The evidence showed a good standard. The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

There was a defined governance structure within the service and staff at all levels were clear about their roles, responsibilities and accountability. The Registered Manager had been in post for 6 months at the time of inspection and was improving how the service was audited. They were able to clearly articulate their plans and what they aimed to achieve in terms of development and performance.

The provider held regular clinical governance and Medical Advisory Committee “MAC” meetings where clinical governance was discussed. Issues raised from the clinical governance meeting were shared with staff.

Governance around practicing privileges was reviewed regularly. We reviewed practicing privilege files and saw that all the required information and insurance indemnity certificates had been received.

Risks and performance were discussed at clinical governance, MAC and quality meetings. The service had a risk register that assessed and rated the risks to the business. Staff concerns matched those on the risk register and we clearly saw the management implemented mitigation measures to minimise risk. The risks and mitigation measures were also communicated effectively to staff. We discussed the risk register with the registered manager who had comprehensive oversight of issues which accurately reflected those recorded.

The service had a business continuity plan and plans for unexpected events. The plans clearly state the action to take in case of an emergency and whom to contact depending on the threat level of the event. The service had emergency lighting, back-up generators and clear evacuation points.

The service had just started to hold all staff weekly meetings to enable managers to share relevant information with staff and provide a forum for staff to feedback directly to the management team. All staff were expected to attend if they were working.

Staff undertook or participated in local clinical audits. The audits were sufficient to provide assurance and staff acted on the results when needed.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners.

The service worked in partnership with General Practitioners (“GP”) when necessary to ensure the patient had the necessary tests and was medically fit for the surgical procedure. The service also ensured the patient’s GP was informed of any procedure undertaken at the clinic. The medical director also worked at other cosmetic organisations and would share any learning between the different service providers.

We scored the service as 3. The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation.

Staff of all levels were supported to learn and develop, and managers encouraged them to suggest further training they wished to pursue. The registered manager was looking at changing learning providers so that staff were supported and enabled to take further learning opportunities.

All staff were committed to improving services and we saw evidence of this during inspection and following review of clinical governance and MAC meeting minutes.