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BMI Three Shires Hospital Good

The provider of this service changed - see old profile


Inspection carried out on 27 to 28 June 2018, 3 and 10 July 2018

During a routine inspection

BMI Three Shires Hospital is operated by BMI Healthcare. The hospital opened in 1982 as a private elective surgery hospital. The hospital is registered for 53 beds. Facilities include five operating theatres, an ambulatory care unit, and outpatient facilities.

The hospital provides surgery, medical care, services for children and young people, and outpatients. We inspected surgery, medicine, outpatients and services for children and young people.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 27 and 28 June 2018 along with an unannounced visit to the hospital on 3 July 2018 and 10 July 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 main service provided by this hospital was surgery. Where our findings on surgery – for example, management arrangements – also apply to other services, we do not repeat the information but cross-refer to the surgery core service.

Services we rate

This is the first time BMI Three Shires has been inspected since it registered in June 2015. We rated it as good overall.

Summary of main findings:

  • There were systems in place to keep patients protected from avoidable harm, including the reporting and investigation of incidents. Learning from incidents was cascaded to staff.

  • Staffing levels were sufficient to meet the needs of patients and there was an effective multidisciplinary approach to care and treatment. Staff worked well together to benefit patients.

  • Staff were proud of the hospital and were committed to providing the best possible care for their patients. We observed positive interactions between staff and patients. All patients spoke highly of the care they had received.

  • The hospital was focused on providing quality care and had a defined strategy, which was aligned to its vision. Staff were committed to providing a positive patient experience.

  • Services had a vision and strategy for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community.

  • Staff told us they felt appreciated and supported by service leaders and said they were visible and approachable, this included the executive director.

  • There were governance structures in place to ensure that risk and quality were regularly reviewed and actions were taken to address performance issues, where indicated.

  • There was a complaints management process with a culture of being open and honest with patients. There was a complaints policy and complaints were taken seriously and investigated.

  • When things went wrong, staff apologised and gave patients honest information and suitable support.

  • Patients’ views and experiences were gathered and acted on to shape and improve the services and culture.

  • Staff ensured that patients’ privacy and dignity was maintained at all times.


  • Arrangements were in place for the management of medicines, however we saw incidences where patients were not always given their medication as prescribed.

  • Not all staff within surgery services received relevant resuscitation training at the level appropriate to their role, including in the use of emergency equipment.

  • The records maintained by the cancer breast nurse were not assessed or audited which meant that we could not be assured the hospital had oversight to validate the information contained was legible, accurate and up to date.

  • Although the service managed patient safety incidents well, staff within the oncology unit did not always recognise incidents and report them appropriately.

  • Although the hospital had an audit and risk management structure there were no specific audits regarding breast cancer patients. Compliance to risk assessments, including the use of NEWS2 and sepsis guidance were not audited either.

  • Consultants provided the interaction between their patients and the NHS multi-disciplinary team (MDT) meetings. However, the minutes from these meetings were not provided to the hospital.

  • Not all entries in patient records had been signed and dated by the consultant.

  • The hospital had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. However, we found some risks had not been escalated to the risk register where relevant and some risks were not monitored or acted upon.

  • The service and the hospital had identified risks to children and young people but were not recorded on risk registers.

We found areas of practice that require improvement in surgery:

  • Not all staff received relevant resuscitation training at the level appropriate to their role, including in the use of emergency equipment.

  • Not all patients were given all medication as prescribed.

  • Action plans were not routinely completed where audit results had fallen below required rates.

  • Some risk assessments were carried out on patients. However, the service did not audit its compliance to risk assessments, including use of NEWS2 or compliance to sepsis guidance.

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 one requirement notice that affected surgery services. Details are at the end of the report.

Heidi Smoult

Deputy Chief Inspector of Hospitals