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BMI Southend Private Hospital Good

The provider of this service changed - see old profile

Inspection Summary


Overall summary & rating

Good

Updated 10 December 2018

BMI Southend Private Hospital is operated by BMI Southend Private Hospital Limited. The hospital offers day case surgery and an outpatients department. There are no overnight beds. Facilities include two operating theatres, a ward and recovery area and an outpatient department.

The hospital provides minor surgical procedures under local anaesthetic only – the majority being ophthalmic surgery. As well as the ophthalmic work the hospital also offers minor orthopaedic, podiatry and dermatology surgery and minor cosmetic procedures such and laser skin and hair removal. We inspected all services.

We inspected this service using our comprehensive inspection methodology. We carried out an unannounced inspection on 9 October 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 service level.

Services we rate

We rated this hospital as good overall.

We found good practice in relation to surgery and outpatient care:

  • The service ensured it had enough staff who completed mandatory and safeguarding training to keep people safe.

  • The environment and equipment were suitable for use and staff ensured patients were protected from infection by using the appropriate infection, prevention and control measures.

  • Risk assessments were completed for people who used the service and confidentiality was protected with well organised and managed individual care records.

  • Staff knew how and when to record incidents and there were systems to identify, monitor and share learning from incidents.

  • The service delivered evidence based care according to national guidance, performed local audits and measured patient outcomes.

  • Staff were competent for their roles and were encouraged to develop further.

  • Complaints were low and dealt with in a timely manner and according to corporate policy.

  • The service ensured that patients were treated with kindness, dignity, respect and compassion and supported in making decisions about their treatment.

  • The service was well-led, with effective leadership, management and governance of the organisation.

  • Senior staff supported learning and innovation, and promoted an open and fair culture.

  • There were clear and effective processes for managing risks, issues and performance.

We found areas of practice that require improvement in surgery and outpatient services:

  • Some medical records within the outpatient department lacked legibility.

  • The service did not meet the 90% target for patients admitted within 18 weeks of referral for seven out of the 12 months reviewed and were lower than the England average.

  • The service did not follow its own procedure with regard to 48-hour post-operative follow up telephone calls.

Following this inspection, we told the provider that it should make improvements, even though a regulation had not been breached, to help the service improve. Details are at the end of the report.

Amanda Stanford

Deputy Chief Inspector of Hospitals

Inspection areas

Safe

Good

Updated 10 December 2018

Are services safe?

We rated safe as Good because:

  • There were effective processes in place to plan, deliver and oversee compliance with mandatory training.

  • There were effective systems and processes in place to identify safeguard vulnerable patients from abuse.

  • The service had systems and processes in place to prevent and control the spread of infection.

  • Equipment in outpatient areas was clean and regularly maintained.

  • Staff effectively assessed patients for the risk of clinical deterioration.

  • There was adequate nursing and medical staffing in place.

  • Medicines were stored securely, well organised and all within expiry dates.

  • There were effective processes in place to identify, report and share learning from clinical and non-clinical incidents.

However, we also found the following issues that the service provider needs to improve:

  • A small number of medical records within the outpatient department lacked legibility.

  • The corporate policy ‘procedure for the management of medicines when temperatures are out of range’ was overdue for review in May 2018.

Effective

Good

Updated 10 December 2018

Are services effective?

We rated effective as Good because:

  • Polices were evidence based and referenced national guidance.
  • The service carried out several local audits to ensure compliance with key procedures and policies.
  • There were systems and processes in place to ensure that staff were competent within their role.
  • There were systems and processes in place to facilitate effective communication amongst staff and other healthcare professionals.
  • Staff obtained and documented consent, where clinically appropriate.

However, we also found the following issue that the service provider needs to improve:

  • The service record audit of June 2018 identified that only 35% of patient’s records showed ‘evidence of being completed 48 hours post discharge follow-up telephone call’.

Caring

Good

Updated 10 December 2018

We rated caring as Good because:

  • Friends and family test data was consistently positive.

  • Patients described the service as ‘efficient’ and praised staff for their care.

  • Patients received adequate information prior to treatment to enable them to make informed decisions about their care.

Responsive

Good

Updated 10 December 2018

Are services responsive?

We rated responsive as Good because:

  • The service offered flexibility of appointments to NHS-funded and self-funding patients.
  • Staff received training in dementia awareness and had access to a telephone translation line to meet the individual needs of patients.
  • The service offered access to consultation and treatment in a timely manner for both NHS-funded and self-funding patients.
  • The service acknowledged and responded to complaints in a timely manner.

However, we also found the following issue that the service provider needs to improve:

  • Information supplied following our inspection showed the service failed to meet the target of 90% for NHS patients admitted within 18 weeks of referral for seven out of the 12 months reviewed (August 2017 to July 2018). The lowest percentage being 64.4% in April 2018. They achieved an overall 84.6% for the 12-month period.

Well-led

Good

Updated 10 December 2018

We rated well-led as Good because:

  • There was a clear leadership structure in place within the outpatient department.

  • The service had a clear vision in place. Staff were aware of the vision and passionate about providing the best patient care possible.

  • Staff described an open, supportive and transparent culture, feeling valued in their role.

  • Risks were regularly reviewed both locally and service wide.

Checks on specific services

Outpatients

Good

Updated 10 December 2018

Outpatient services were a small proportion of hospital activity. The main service was surgery. Where arrangements were the same, we have reported findings in the surgery services section.

We rated this services as good because it was safe, effective, caring, responsive and well-led.

Surgery

Good

Updated 10 December 2018

Surgery was the main activity of the hospital. Where our findings on surgery also apply to other services, we do not repeat the information but cross-refer to the surgery section.

We rated this service as good because it was safe, effective, caring, responsive and well-led.