Archived: Burcot Hall Hospital

Updated 29 June 2021

Burcot Hall is an independent hospital, based in Bromsgrove, Worcestershire.

The service was registered under the current provider in September 2020 and is an independent hospital that offers a diverse range of surgical procedures, such as orthopaedics. The service has not yet been inspected.

Whilst primarily offering surgical cosmetic procedures, since the pandemic, they have had contracts with the NHS acute hospitals. They were carrying out work to reduce the waiting lists at the acute trusts for, orthopaedics (both under Local Anaesthesia (LA) and General Anaesthesia (GA), vascular, max fax and plastics.

The hospital has four surgical theatres and 30 inpatient beds. There is a registered manager in post.

Updated 29 June 2021

Burcot Hall is an independent hospital, based in Bromsgrove, Worcestershire.

The service was registered under the current provider in September 2020 and is an independent hospital that offers a diverse range of cosmetic and weight loss surgical procedures. The service has not yet been inspected.

Whilst primarily offering surgical cosmetic procedures largely privately funded by patients. Since the pandemic, they have had contracts with some NHS acute hospitals. They have been carrying out work to reduce the waiting lists at the acute trusts for, orthopaedic surgeries (both under Local Anaesthesia (LA) and General Anaesthesia (GA), vascular, maxillofacial and plastic surgeries.

The hospital has four surgical theatres and 30 inpatient beds. There is a registered manager in post.

We carried out this unannounced focused inspection because we had received information of concern about the safety and quality of the services. The information of concern related to the following areas:

• Assessing and responding to risk.
• Infection prevention and control.
• Mandatory training
• Staffing provision (medical and nursing)
• Leadership.
• Culture.
• Governance systems.
• At the time of our inspection Burcot Hall Hospital Ltd the registered provider did not employ any staff or provide any regulated services directly. All staff and support services were being provided by another provider. After our inspection a service level agreement was put in place to ensure the accountability lay with Burcot Hall Hospital Ltd.

We did not rate the service at this inspection. This was a focused inspection; based on risk, we only inspected certain key lines of enquiries in the domains; safe and well led.

We found:

• The service did not always make sure all staff completed mandatory training in key skills.
• Staff did not always use control measures to protect patients, themselves and others from infection. However, they kept equipment and the premises visibly clean.
• Not all risks were removed or minimised. Staff completed and updated risk assessments for each patient. Staff identified and acted upon patients at risk of deterioration.
• Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date and easily available to all staff providing care. However, records were not always stored securely.
• Leaders did not have all the necessary skills and abilities to run the service. They did not always understand and manage the priorities and issues the service faced. They were visible and approachable in the service for patients and staff.
• Leaders operated some governance processes, throughout the service and with partner organisations. Staff at all levels were clear about their roles and accountabilities. However, there were not regular opportunities to meet, discuss and learn from the performance of the service.
• Leaders and teams did not use systems to manage performance effectively. They identified and escalated relevant risks and issues and identified actions to reduce their impact, however, they were not always communicated effectively. We could not be assured that the changes, practices and systems would be embedded.

However,

• The service had enough nursing and support staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix, and gave bank and agency staff a full induction.
• The service had enough medical staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment.
• The service generally managed patient safety incidents well. Staff recognised and reported incidents and near misses. Managers investigated incidents, however, not all lessons learnt were communicated effectively. When things went wrong, staff apologised and gave patients honest information and suitable support.

Updated 29 June 2021

We found:

• The service did not always make sure all staff completed mandatory training in key skills.
• Staff did not always use control measures to protect patients, themselves and others from infection. They kept equipment and the premises visibly clean.
• Not all risks were removed or minimised. Staff completed and updated risk assessments for each patient. Staff identified and acted upon patients at risk of deterioration.
• Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date and easily available to all staff providing care. However, records were not always stored securely.
• Leaders did not have all the necessary skills and abilities to run the service. They did not always understand and manage the priorities and issues the service faced. They were visible and approachable in the service for patients and staff.
• Leaders operated some governance processes, throughout the service and with partner organisations. Staff at all levels were clear about their roles and accountabilities. However, there were not regular opportunities to meet, discuss and learn from the performance of the service.
• Leaders and teams did not use systems to manage performance effectively. They identified and escalated relevant risks and issues and identified actions to reduce their impact, however, they were not always communicated effectively. We could not be assured that the changes, practices and systems would be embedded.

However,

• The service had enough nursing and support staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix, and gave bank and agency staff a full induction.
• The service had enough medical staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment.
• The service generally managed patient safety incidents well. Staff recognised and reported incidents and near misses. Managers investigated incidents, however, not all lessons learnt were communicated effectively. When things went wrong, staff apologised and gave patients honest information and suitable support.