BMI Mount Alvernia Hospital › sites › default › files › new_reports › AAAF66… · There was comprehensive assessment of patient needs. This included clinical needs, physical

This report describes our judgement of the quality of care at this location. It is based on a combination of what wefound when we inspected and a review of all information available to CQC including information given to us frompatients, the public and other organisations

Ratings

Overall rating for this location Good –––

Are services safe? Requires improvement –––

Are services effective? Good –––

Are services caring? Good –––

Are services responsive? Good –––

Are services well-led? Good –––

Mental Health Act responsibilities and Mental Capacity Act and Deprivation of LibertySafeguardsWe include our assessment of the provider’s compliance with the Mental Capacity Act and, where relevant, MentalHealth Act in our overall inspection of the service.

We do not give a rating for Mental Capacity Act or Mental Health Act, however we do use our findings to determine theoverall rating for the service.

Further information about findings in relation to the Mental Capacity Act and Mental Health Act can be found later inthis report.

BMIBMI MountMount AlverniaAlvernia HospitHospitalalQuality Report

Harvey Road,Guildford,Surrey.GU1 3LX.Tel:01483 570122Website:www.bmihealthcare.co.uk/hospitals/bmi-mount-alvernia-hospital

Date of inspection visit: 19,20,26 July 2016Date of publication: 11/11/2016

1 BMI Mount Alvernia Hospital Quality Report 11/11/2016

Letter from the Chief Inspector of Hospitals

We carried out a comprehensive inspection of BMI Mount Alvernia Hospital on the 19, 20 and 26 July 2016 as part of ournational programme to inspect and rate all independent hospitals. We inspected the core services of surgical services,medical services, out-patient and diagnostic imaging services as these incorporated the activity undertaken by theprovider, BMI Healthcare Limited at this location.

We rated all four core services as good overall.

Are services safe at this hospital/service

Incidents were reported, investigated and learning evidenced. Reports were communicated to all staff.

Patients were cared for in a visibly clean environment that was well maintained. There were arrangements to preventthe spread of infection and compliance with these was monitored. There were no outbreaks of serious infectionreported.

There were processes for assessing and responding to patient risk. The service had enough staff with the skills andexperience to care for the number of patients and their level of need. The majority of staff had completed the provider’smandatory training programme. Staff were aware of their responsibilities with regard to the protection of people invulnerable circumstances.

There were adequate supplies of appropriate equipment that was properly maintained to deliver care and treatmentand staff were competent in its use. Staff demonstrated good medicines storage, management and administration.

There was room for improvement with safety in surgery where we found that the side of the patient due to be operatedon was not always clearly or accurately documented on daily operating lists. We also found that staff did notconsistently adhere to the World Health Organisation Safe Surgery checklist.

We also found not all staff had not attended major incident or business continuity training.

Are services effective at this hospital/service

We found care and treatment reflected current national guidance. There were formal systems in place for collectingcomparative data regarding patient outcomes.

Staff worked with other health professionals in and out of the hospital to provide services for patients. Patients werecared for by staff who had undergone specialist training for the role and who had their competency reviewed.

There were arrangements that enabled patients to access advice and support seven days a week, 24 hours per day.There was comprehensive assessment of patient needs. This included clinical needs, physical health, nutrition andhydration needs. Patients received adequate pain relief.

Patients provided informed, written consent before commencing their treatment. Where patients lacked capacity tomake decisions, staff were able to explain what steps to take to ensure relevant legal requirements were met.

There was a proactive audit programme that included national, corporate, hospital and departmental audits. Resultswere shared throughout the hospital and collated to identify themes.

Are services caring at this hospital/service

Staff provided sensitive, caring and individualised personal care to patients. Staff supported patients to copeemotionally with their care and treatment as needed.

Summary of findings


Patients commented positively about the care provided from all staff they interacted with. Staff treated patientscourteously and with respect. Patients felt well informed and involved in their procedures and care, including their careafter discharge.

Patients and their relatives were involved in their care and were given adequate information about their diagnosis andtreatment. Families were encouraged to participate in the personal care of their relatives with support from staff.

We observed patients treated with compassion, care and dignity. Patient feedback was positive and staff demonstratedcommitment to continuous improvement.

Are services responsive at this hospital/service

There were a variety of mechanisms to provide psychological support to patients and their supporters. This range ofservice meant that each patient could access a service that was relevant to their particular needs. For example thosewith spiritual needs, those requiring bariatric equipment, patients whose first language was not English, or support forpeople living with dementia or learning disabilities.

The services were delivered in a way that met the needs of the local population and allowed patients to access care andtreatment when they needed it. Waiting times, delays and cancellations were minimal and well managed. Patients toldus staff were responsive to their needs.

Complaints management was a priority in the hospital. The process was transparent and open with learningcommunicated across the hospital.

Are services well led at this hospital/service

There were clear organisational structures and roles and responsibilities. The senior management team were highlyvisible and accessible across the hospital. Staff described an open culture and said managers were approachable at alltimes.

Staff spoke highly about their departmental managers and the support they provided to them and patients. All staff saidmanagers supported them to report concerns and their managers would act on them. They told us their managersregularly updated them on issues that affected the separate departments and the whole hospital.

There were good governance, risk and quality systems and processes that staff understood. The committee structuresupported this with reports disseminated and discussed appropriately. Staff from all departments had a clear ambitionfor their services and were aware of the vision of their departments.

Staff asked patients to complete satisfaction surveys on the quality of care and service provided. Departments used theresults of the survey to improve services. The hospital had a risk register which was reviewed at the governancecommittee meetings. However, the risk register was not divided into separate departments.

The management team had an understanding of the Workforce Race Equality Standard (WRES) as there is a nationalrequirement to produce key data relating to race quality in the workplace. BMI had started to collect data nationallywhich they currently held, for example the numbers of staff from black and ethnic minority groups. The managementteam was in the process of implementing reporting processes to capture the data to enable them to fully comply withWRES reporting requirements.

However there were areas of where the provider needs to make improvements.

The provider must:

• Ensure that staff are trained to the appropriate level for safeguarding children. Children attend the hospital aspatients and visitors.

The provider should:

Summary of findings


• Provide each individual department with a separate and relevant risk register.• Enable all staff to attend major incident or business continuity training and attend simulation exercises.• The outpatient department should adequately risk assess environment and equipment.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Summary of findings


Our judgements about each of the main services

Service Rating Summary of each main service

Medical care

Good –––

We found the medical services at BMI Mount Alverniato be good. This was because:

• The hospital had systems and processes in place tokeep patients free from harm.

• Infection prevention and control practices were inline with national guidelines.

• Areas we visited were visibly clean, tidy and fit forpurpose. The environment was light, airy andcomfortable. The oncology unit was awarded theMacmillan Quality Environment Mark, whichidentifies and recognises cancer environments thatprovide high levels of support and care for peopleaffected by cancer. It had been developed inpartnership with patients living with cancer and theDepartment of Health. It is a core component of theEnglish Cancer Reform Strategy.

• The hospital provided end of life care training andhad an on going education programme which wasattended by staff.

• The palliative care team worked with ward staff toprovide holistic (the treating the whole ofsomething and not just a part) care for patients withpalliative and end of life care needs in line withnational guidance. This meant a multidisciplinaryapproach was maintained.

• Staff kept medical records accurately and securelyin line with the Data Protection Act 1998.

• Medicines were stored in locked cupboards andadministration was in line with relevant legislation.

• The endoscopic services demonstrated compliancewith British Society of Gastroenterology (BSG)guidelines. The service was working toward JointAdvisory Group (JAG) on gastrointestinal (GI)endoscopy accreditation incorporating theendoscopy global rating scale, which is the qualityimprovement and assessment tool for the GIendoscopy service.

• Oncology services demonstrated compliance withNational Institute for Health and Care Excellence(NICE) guidelines.

Summary of findings


• The medical services had an appropriate level ofcompetent staff.

• Staff completed appraisals regularly and managersencouraged them to develop their skills further.

• Staff interacted with patients in a kind and caringmanner. Patients told us they felt relaxed whenhaving their treatment.

• The hospital and its staff recognised that provisionof high quality, compassionate end of life care to itspatients was the responsibility of all clinical staffthat looked after patients at the end of life.

• Staff at the hospital provided focused care for dyingand deceased patients and their relatives. Thehospital had an end of life care link person.Facilities were provided for relatives and thepatient’s cultural, religious and spiritual needs wererespected.

• Managers were visible, approachable and effective.This had resulted in a well-led service that had aclear vision and strategy to provide a streamlinedservice for medical and end of life care patients.

• The hospital had a clinical governance committeeand medical advisory committee (MAC) bothresponsible for ensuring there were robust systemsand processes in place in relation to governanceand assurance.

However

• The safeguarding lead was not trained to level 3 forsafeguarding children as per national guidelines.

• Staff had not attended major incident or businesscontinuity training, or attended any simulationexercises.

• The risk register was hospital wide and not dividedinto separate departments.

Surgery

Good –––

We rated the surgical services at Mount AlverniaHospital as good because:

• The hospital had good systems and processes inplace to keep patients free from harm. There was agood track record on safety.

• Staff understood the incident reporting process andtheir responsibilities to report, investigate andlearn.

Summary of findings


• There were processes for assessing and respondingto patient risk and safe protocols for patienttransfer. There was a comprehensive assessment ofpatient needs. There were sufficient skilled andexperienced staff to care for patients.

• The hospital worked to current national guidance.The hospital participated in national audits and hada proactive programme of hospital anddepartmental audits. Results andrecommendations were shared throughout thehospital with change and learning evidenced.

• Patients were treated with compassion, care anddignity. They were well supported and providedwith good information.

• Services were provided to meet the needs of thelocal population and allow access to care andtreatment. There were minimal delays orcancellations for treatment and these were wellmanaged.

• Complaints were investigated and discussed openlywith staff.

• The organisational and committee structuressupported good governance systems andprocesses. Staff described an open culture withinthe hospital and were clear on roles andresponsibilities.

• The hospital collected patient feedback anddemonstrated ongoing work by all staff towardscontinuous improvement in the patient experience.

However:


• The side of the patient due to be operated on wasnot always clearly or accurately documented ondaily operating lists.

• Staff had not attended major incident or businesscontinuity training, or attended any simulationexercises.

• The risk register was not compiled so thatdepartment risks could be identified.

Outpatientsanddiagnosticimaging

Good –––We found the outpatient and diagnostic imagingservices at BMI Mount Alvernia to be good. This wasbecause:

Summary of findings


• The hospital had good systems and process in placeto keep patients from harm.

• A wide variety of modern equipment was availablefor staff to deliver a range of services andexaminations.

• Staff managed medicines in line with best practiceand stored them securely.

• The hospital had a comprehensive auditprogramme in place to monitor services andidentify areas for improvement.

• The outpatient and diagnostic imagingdepartments had sufficient numbers ofappropriately trained competent staff to providetheir services.

• Staff dealt with patients in a kind, caring andconsiderate manner. Patients were happy with thecare they received.

• The hospital was responsive to the needs of thelocal populations. Appointments could be accessedin a timely manner and at a variety of timesthroughout the day.

• Results of investigations were available quickly anddouble checked by members of staff.

• Managers were visible, approachable and effective.• The hospital had a clinical governance committee

and medical advisory committee both responsiblefor ensuring there were robust systems andprocesses in place in relation to governance andassurance.

However:

• Children attended the outpatient department, butneither the safeguarding lead nor any staff hadattended level three safeguarding children trainingas per national guidelines.

• The assessment and response to risk was notmanaged consistently throughout outpatient anddiagnostic imaging services.

Summary of findings


Contents

PageSummary of this inspectionBackground to BMI Mount Alvernia Hospital 11

Our inspection team 11

Why we carried out this inspection 11

How we carried out this inspection 11

Information about BMI Mount Alvernia Hospital 12

The five questions we ask about services and what we found 14

Detailed findings from this inspectionOverview of ratings 17

Outstanding practice 76

Areas for improvement 76

Action we have told the provider to take 77

Summary of findings


BMI Mount Alvernia Hospital

Services we looked atMedical care; Surgery; Outpatients and diagnostic imaging.

BMIMountAlverniaHospital

Good –––


Background to BMI Mount Alvernia Hospital

Mount Alvernia Hospital is an independent hospital whichis part of BMI Healthcare Limited. It is situated inGuildford, Surrey. Mount Alvernia Hospital wasestablished in 1935 by a Group of Franciscan Sisters, andacquired by BMI Healthcare in 2005. The hospital initiallyconcentrated on community and maternity servicesalthough the latter were stopped in the eighties. It hassince grown to provide a wide range of acute clinicalservices in recent years and significant investment in thehospital has seen the development of many new servicesincluding cancer services.

BMI Mount Alvernia Hospital has 76 beds, most of whichare private rooms with en-suite bathrooms. The hospitalhas a diagnostics facility including CT, MRI, full field digitalmammography, nuclear medicine, radiotherapy and amobile PET CT service as well as on-site pathology with

additional services provided by a third party provider. Thehospital has a suite of three main theatres supported byan ambulatory care unit with endoscopy theatresattached.

We inspected this hospital as part of our nationalprogramme to inspect and rate all independenthealthcare providers. We inspected four core services atthe hospital which incorporated all the activityundertaken. These were surgical services, medicalservices, which included end of life services andoutpatient and diagnostic services.

The registered manager of the hospital is Nick Fox whohas been in post for two years at the hospital. Theprovider’s nominated individual for this service isElizabeth Sharp. The controlled Drug Accountable Officeris Nick Fox.

Our inspection team

Our inspection team was led by:

Inspection Lead: Vanessa Ward, Inspection Manager,Care Quality Commission

The team included CQC inspectors and a variety ofspecialists:

• Including a surgeon, a theatre nurse, a nurse withexperience of managing outpatient departments inindependent hospitals and a radiographer.

Why we carried out this inspection

We carried out a comprehensive inspection of BMI MountAlvernia Hospital on the 19, 20 and 26 July 2016 as part ofour national programme to inspect and rate allindependent hospitals. We inspected the core services of

surgical services, medical services, out-patient anddiagnostic imaging services as these incorporated theactivity undertaken by the provider, BMI HealthcareLimited at this location.

How we carried out this inspection

We reviewed a wide range of documents and data werequested from the provider. This included policies,minutes of meetings, staff records and results of surveys

and audits. We placed comment boxes at the hospitalprior to our inspection which enabled staff and patientsto provide us with their views. We received 21 commentsfrom patients.

Summaryofthisinspection

Summary of this inspection


We carried out an announced inspection on the 19 and20 July 2016 and an unannounced visit on the 26 July2016.

We interviewed the management team. We spoke with awide range of staff including nurses, resident medicalofficer, radiographers and administrative and supportstaff totalling 82 personnel.

We also spoke with 14 patients and two relatives whowere using the hospital.

We observed care in the outpatient and imagingdepartments, in operating theatres and on the wards andreviewed patient records. We visited all the clinical areasat the hospital.

Information about BMI Mount Alvernia Hospital

There were 5,377 inpatient and day case episodes of carerecorded at BMI Mount Alvernia Hospital in the reportingperiod (April 2015 to March 2016); of these 9% were NHSfunded and 91% other funded. 10% of all NHS fundedpatients and 20% of all other funded patients stayedovernight at the hospital during the same reportingperiod.

There were 23,466 outpatient total attendances in thereporting period (Apr 15 to Mar 16); of these 5% were NHSfunded and 95% were other funded.

The ten most common medical procedures between April2015 to March 2016 were Image-guided injection(s) intojoint(s) (319), Diagnosticoesophago-gastro-duodenoscopy(OGD) includes forcepsbiopsy, biopsy urease test and dye spray(192), Insertion ofportocath/vasoport unit (108), Diagnostic colonoscopy,includes forceps biopsy (106), Removal of portocath/port-a-cath/vasoport unit (60), Ultrasound guidedbiopsy/(ies) (55), Ultrasound guided drainage of fluidcollection (45), Epidural injection (lumbar) (44),Diagnostic oesophago-gastro-duodenoscopy andimmediate colonoscopy includes forceps biopsies, biopsytest and dye spray (43), Transformational epidural (41).

The ten most commonly performed surgical proceduresbetween April 2015 and March 2016 were Diagnosticendoscopic examination of bladder (incl any biopsy)(276), Excision of lesion of skin orsubcutaneous tissue -up to 3 (154), Rhinoplasty - cosmetic only (98), Facet jointinjection (under x-ray control) - 5 to 6 joints (91),Hysteroscopy (including biopsy, dilatation, curettage andresection of polyp(s) +/- contraceptive coil insertion) (87),Primary total hip replacement with or without cement(74),Bladder instillation of pharmacologic agent

(including cystoscopy) (71), Excision of lesion of skin orsubcutaneous tissue - up to 3 (70), Arthroscopicmeniscectomy (incl debridement)(67), Biopsy of skin orsubcutaneous tissue (62).

There were 195 doctors and dentists with practisingprivileges at the hospital. Between April 2015 and March2016 29% of these carried out over 100 episodes of careduring 2015, 31% carried out between 10-99, and 25%between one and nine episodes of care. This meant that15% did not carry out any procedures during the sameperiod. During the same period eight doctors or dentistshad had their practising privileges removed and two hadhad their practising privileges suspended.

There were 45.8 full time equivalents (FTE) registered staffemployed, including nurses, 18.2 FTE support staffincluding care assistants and operating departmentpractitioners (ODP), and 92.5 FTE other staff.

233 clinical incidents occurred in surgery, inpatients orother services at the hospital in the reporting period (April2015 to March 2016). Out of the 233 clinical incidents 94%occurred in surgery or inpatients and 6% in otherservices. The hospital reported no incidents as severe ordeath. For the time period, April 2015 to March 2016assessed rates of clinical incidents (per 100 bed days)were increasing and higher than other independent acuteproviders we hold this type of data for. This could beattributed to the hospital making a significant effort topromote a culture of reporting and learning during thistime.

During April 2015 to March 2016, there were no seriousincidents or never events at the hospital. Never events areserious incidents that are wholly preventable and havethe potential to cause serious patient harm or death.There were 149 other clinical incidents within this year.




The rate of clinical incidents (per 100 inpatientdischarges) has risen from the beginning of the period.No safeguarding concerns have been reported sinceJanuary 2015.

In the same year, there were no unexpected deaths andno were no reported cases of serious infection such asMRSA.

Inpatient VTE screening rates were 100% in the reportingperiod (April 15 to March 16). With no incidents of hospitalacquired VTE or PE in the reporting period (April 2015 toMarch 2016).

There have been no safeguarding concerns reported toCQC in the reporting period (April 2015 to March 2016).

CQC directly received three complaints in the reportingperiod (April 2015 to March 2016).

The hospital received 25 complaints in the reportingperiod (April 2015 to March 2016) which is a decreasefrom 2014/15. One complaint has been referred to theOmbudsman or ISCAS (Independent Healthcare SectorComplaints Adjudication Service) this relates to a patientwho used the service in 2013. The assessed rate ofcomplaints (per 100 day case and inpatient attendances)is significantly lower than the other independent acutehospitals we hold this type of data for.




The five questions we ask about services and what we found

We always ask the following five questions of services.

Are services safe?Incidents were reported, investigated and learning evidenced.Reports were communicated to all staff.

Patients were cared for in a visibly clean environment that was wellmaintained. There were arrangements to prevent the spread ofinfection and compliance with these was monitored. There were nooutbreaks of serious infection reported.

There were processes for assessing and responding to patient risk.The service had enough staff with the skills and experience to carefor the number of patients and their level of need. The majority ofstaff had completed the provider’s mandatory training programme.Staff were aware of their responsibilities with regard to theprotection of people in vulnerable circumstances.

There were adequate supplies of appropriate equipment that wasproperly maintained to deliver care and treatment and staff werecompetent in its use. Staff demonstrated good medicines storage,management and administration.

There was room for improvement with safety in surgery where wefound that the side of the patient due to be operated on was notalways clearly or accurately documented on daily operating lists. Wealso found that staff did not consistently adhere to the World HealthOrganisation Safe Surgery checklist.

We also found that staff had not attended major incident orbusiness continuity training, or attended any simulation exercises.

Requires improvement –––

Are services effective?We found care and treatment reflected current national guidance.There were formal systems in place for collecting comparative dataregarding patient outcomes.

Staff worked with other health professionals in and out of thehospital to provide services for patients. Patients were cared for bystaff who had undergone specialist training for the role and who hadtheir competency reviewed.

There were arrangements that enabled patients to access adviceand support seven days a week, 24 hours per day. There wascomprehensive assessment of patient needs. This included clinicalneeds, physical health, nutrition and hydration needs. Patientsreceived adequate pain relief.

Good –––




Patients provided informed, written consent before commencingtheir treatment. Where patients lacked capacity to make decisions,staff were able to explain what steps to take to ensure relevant legalrequirements were met.

There was a proactive audit programme that included national,corporate, hospital and departmental audits. Results were sharedthroughout the hospital and collated to identify themes.

Are services caring?Staff provided sensitive, caring and individualised personal care topatients. Staff supported patients to cope emotionally with theircare and treatment as needed.

Patients commented positively about the care provided from allstaff they interacted with. Staff treated patients courteously and withrespect. Patients felt well informed and involved in their proceduresand care, including their care after discharge.

Patients and their relatives were involved in their care and weregiven adequate information about their diagnosis and treatment.Families were encouraged to participate in the personal care of theirrelatives with support from staff.

We observed patients treated with compassion, care and dignity.Patient feedback was positive and staff demonstrated commitmentto continuous improvement.

Good –––

Are services responsive?There were a variety of mechanisms to provide psychologicalsupport to patients and their supporters. This range of servicemeant that each patient could access a service that was relevant totheir particular needs. For example those with spiritual needs, thoserequiring bariatric equipment, patients whose first language was notEnglish, or support for people living with dementia or learningdisabilities.

The services were delivered in a way that met the needs of the localpopulation and allowed patients to access care and treatment whenthey needed it. Waiting times, delays and cancellations wereminimal and well managed. Patients told us staff were responsive totheir needs.

Complaints management was a priority in the hospital. The processwas transparent and open with learning communicated across thehospital.

Good –––




Are services well-led?There were clear organisational structures and roles andresponsibilities. The senior management team were highly visibleand accessible across the hospital. Staff described an open cultureand said managers were approachable at all times.

Staff spoke highly about their departmental managers and thesupport they provided to them and patients. All staff said managerssupported them to report concerns and their managers would acton them. They told us their managers regularly updated them onissues that affected the separate departments and the wholehospital.

There were good governance, risk and quality systems andprocesses that staff understood. The committee structure supportedthis with reports disseminated and discussed appropriately. Stafffrom all departments had a clear ambition for their services andwere aware of the vision of their departments.

Staff asked patients to complete satisfaction surveys on the qualityof care and service provided. Departments used the results of thesurvey to improve services. The hospital had a risk register whichwas reviewed at the governance committee meetings. However, therisk register was not divided into separate departments.

The management team had an understanding of the WorkforceRace Equality Standard (WRES) as there is a national requirement toproduce key data relating to race quality in the workplace. BMI hadstarted to collect data nationally which they currently held, forexample the numbers of staff from black and ethnic minority groups.The management team was in the process of implementingreporting processes to capture the data to enable them to fullycomply with WRES reporting requirements.

Good –––




Overview of ratings

Our ratings for this location are:

Safe Effective Caring Responsive Well-led Overall

Medical care Good Good Good Good Good Good

Surgery Requiresimprovement Good Good Good Good Good

Outpatients anddiagnostic imaging

Requiresimprovement Good Good Good Good Good

Overall Requiresimprovement Good Good Good Good Good

Detailed findings from this inspection


Safe Good –––

Effective Good –––

Caring Good –––

Responsive Good –––

Well-led Good –––

Information about the serviceMedical care services provided by Mount Alvernia Hospitalare medical inpatient care, end of life care, endoscopy andoncology day care.

In the period April 2015 to March 2016 inpatientattendances were 1,251. Inpatient accommodation isprovided over three floors in individual rooms with theirown bathrooms, three of which can convert to twinoccupancy. There were 12 beds each in St Clare ward(mixed medical and surgical), St Elthelbert (surgical) and StFrancis ward. St Clare ward was the main ward forinpatients. At the time of inspection St Francis was not inuse.

The hospital’s endoscopy unit and ambulatory care unitboth had six beds. Endoscopy involves looking inside thebody for medical reasons using an endoscope. Anendoscope is an instrument used to examine the interior ofa hollow organ or cavity of the body. From April 2015 toMarch 2016, the hospital performed 276 endoscopicprocedures.

The oncology unit, based in St Martha’s, covers diagnostics,intravenous and oral chemotherapy instillations. Oncologyis a branch of medicine that deals with the prevention,diagnosis and treatment of cancer. Treatment can includethe use of chemotherapy, which is the treatment of diseaseby the use of chemical substances, especially by cytotoxicand other drugs. The hospital administered 1,473 episodesof chemotherapy April 2015 to March 2016.

End of life care encompasses all care given to patients whoare considered to be in the last 12 months of life, patientswhose death is imminent and care after death. End of lifecare services are provided by ward staff and the director of

nursing is the end of life care lead for the hospital. Wardstaff are supported by the palliative care team arrangedthrough a service level agreement with the local acute trustwhich started in March 2016. The palliative care teamconsist of a clinical nurse specialist who visits the hospitaltwo days a week and telephone support is available 9am to5pm seven days a week. Palliative care consultants deliverconsultant led care. The consultants provide medicaladvice and support when present at the hospital and bytelephone via the on-call rota when not.

The majority of patients seen for palliative and end of lifecare are patients with a primary diagnosis of cancer. FromApril 2015 to June 2016, ten deaths had been reported atthe hospital. Eight deaths were recognised as end of lifecare patients and were under the care of the palliative careteam.

The hospital clinical team is made up of medical staff,nurses and a resident medical officer (RMO) who is on duty24 hours a day. A senior nurse is available at all times toassist patients following discharge and arrange admissionsfor patients who require hospitalisation for unplannedmedical and surgical treatments.

The oncology service is provided by specialist nurses,consultants, physiotherapists and therapists. Patients aresupported from diagnosis, through surgery, chemotherapyand followed up for up to five to ten weeks post treatment.A 24 hour oncology triage/helpline is provided. Supportivetherapies, spiritual support and supportive care for end oflife are available.

The hospital does not provide care for those patients whorequire higher dependency (known as level 2) critical care.

Medicalcare

Medical care

Good –––


Patients assessed as higher risk of developingpostoperative complications or who may require enhancedinterventions and monitoring are referred to a suitablefacility.

During our inspection we visited St Clare inpatient ward, StMartha (oncology unit), ambulatory care unit andendoscopy.

We spoke with 13 members of staff and observed the careprovided by medical, nursing and support staff in thedepartments visited. We spoke with three patients and oneof their relatives. We reviewed information received frommembers of the public who contacted us separately to tellus about their experiences. We evaluated results of patientsurveys and other performance information about thehospital.

Summary of findingsWe found the medical services at BMI Mount Alvernia tobe good. This was because:

• The hospital had systems and processes in place tokeep patients free from harm.

• Infection prevention and control practices were inline with national guidelines.

• Areas we visited were visibly clean, tidy and fit forpurpose. The environment was light, airy andcomfortable. The oncology unit was awarded theMacmillan Quality Environment Mark, whichidentifies and recognises cancer environments thatprovide high levels of support and care for peopleaffected by cancer. It had been developed inpartnership with patients living with cancer and theDepartment of Health. It is a core component of theEnglish Cancer Reform Strategy.

• The hospital provided end of life care training andhad an ongoing education programme which wasattended by staff.

• The palliative care team worked with ward staff toprovide holistic (the treating the whole of somethingand not just a part) care for patients with palliativeand end of life care needs in line with nationalguidance. This meant a multidisciplinary approachwas maintained.

• Staff kept medical records accurately and securely inline with the Data Protection Act 1998.

• Medicines were stored in locked cupboards andadministration was in line with relevant legislation.

• The endoscopic services demonstrated compliancewith British Society of Gastroenterology (BSG)guidelines. The service was working toward JointAdvisory Group (JAG) on gastrointestinal (GI)endoscopy accreditation incorporating theendoscopy global rating scale, which is the qualityimprovement and assessment tool for the GIendoscopy service.

• Oncology services demonstrated compliance withNational Institute for Health and Care Excellence(NICE) guidelines.

Medicalcare

Medical care

Good –––


• The medical services had an appropriate level ofcompetent staff.

• Staff completed appraisals regularly and managersencouraged them to develop their skills further.

• Staff interacted with patients in a kind and caringmanner. Patients told us they felt relaxed whenhaving their treatment.

• The hospital and its staff recognised that provision ofhigh quality, compassionate end of life care to itspatients was the responsibility of all clinical staff thatlooked after patients at the end of life.

• Staff at the hospital provided focused care for dyingand deceased patients and their relatives. Thehospital had an end of life care link person. Facilitieswere provided for relatives and the patient’s cultural,religious and spiritual needs were respected.

• Managers were visible, approachable and effective.This had resulted in a well-led service that had aclear vision and strategy to provide a streamlinedservice for medical and end of life care patients.

• The hospital had a clinical governance committeeand medical advisory committee (MAC) bothresponsible for ensuring there were robust systemsand processes in place in relation to governance andassurance.

However:


• Not all staff had attended major incident or businesscontinuity training, or attended any simulationexercises.

• The risk register was hospital wide and not dividedinto separate departments.

Are medical care services safe?

Good –––

We rated medical services good. This was because:

• The hospital provided us with the incidents reportedwith evidence of learning achieved and the resultingchanges in practice that took place. Staff gave usexamples of how they reported incidents and thefeedback they received. Staff informed us that they wereencouraged to report incidents to enable learning as anorganisation.

• Patients were cared for in a visibly clean environmentthat was well maintained. There were arrangements toprevent the spread of infection and compliance withthese was monitored. There were no outbreaks ofserious infection reported.

• There were adequate supplies of appropriateequipment that was properly maintained to deliver careand treatment and staff were competent in its use.

• Staff demonstrated good medicines storage,management and administration. There were systemsthat ensured patient’s medicines were given safely,on-time and according to the consultant prescription.Medicines were stored securely as per nationalguidelines.

• We found that patient’s records were complete andaccurate and there were systems to identify patientswhose condition may be deteriorating to allow earlyintervention.

• The hospital had sufficient numbers of appropriatelytrained staff to provide safe care to patients. Themajority of staff had completed the provider’smandatory training programme. Staff were aware oftheir responsibilities with regard to the protection ofpeople in vulnerable circumstances.

However


• Not all staff had attended major incident or businesscontinuity training, or attended any simulationexercises.

Medicalcare

Medical care

Good –––


Incidents

• No never events were reported in the period April 2015to March 2016. ‘Never events’ are serious, largelypreventable patient safety incidents, which should notoccur if the available, preventable measures have beenimplemented.

• The hospital reported they had no serious incidentsreported in the period April 2015 to March 2016.

• There were seven deaths reported in the period April2015 to March 2016 and one of these were reported asunexpected and was subject to a formal investigation.All deaths were reported to CQC and investigated fullyby the provider. Since March 2016 three deaths hadbeen reported to CQC.

• Eight of the 10 deaths were expected and wererecognised as end of life care patients. They were underthe care of the palliative care team.

• The hospital had an incident report writing policy andstaff used a paper based incident reporting system. Staffhad a good understanding of how to use the system. Weasked staff to give us examples of incidents they hadreported. Staff told us feedback from incidents wasdiscussed at ward meetings. We saw minutes ofmeetings which confirmed this. Lessons learnt wereprinted monthly and displayed on the notice board inthe office on St Clare ward. When all staff had signed toindicate they had read this, it was removed and filed,which we saw. Staff told us the hospital encouragedthem to report incidents to help the whole organisationlearn.

• The hospital told us since December 2015 theleadership of the hospital had made a significant effortto promote a culture of reporting and learning. This wasreflected in the increased reporting rates for clinical andnon-clinical incidents.

• A total of 233 reported clinical incidents occurred insurgery, inpatients or other services at the hospital fromApril 2015 to March 2016. Of these incidents 94%occurred in surgery and inpatients.

• Assessed rates of clinical incidents (per 100 bed days)increased and were higher than other independentacute providers for the period April 2015 to March 2016.The rate of clinical incidents April to June 2015 was 6.2and January to March 2016 10.9.

• Data provided by the hospital showed from December2015 to June 2016 there were 249 incidents reportedand 202 were clinical. Oncology accounted for 19incidents and inpatient wards 113 incidents during thisperiod. Clinical causes reported ranged fromadministration errors, natural circumstances,complications post-surgery, equipment malfunction,lack of clinical assessment and discharge planningfailure. No harm severity of the incidents accounted for57.6%, low severity 35.6% and 6.1% classed asmoderate. Five incidents related to end of life care. Fourwere patient deaths and one related to the wrongsyringe being used in a syringe driver. All incidentsoutlined any remedial or other action takenimmediately following the incident.

• There were 61 non-clinical incidents reported in theperiod April 2015 to March 2016 and occurred in surgery,inpatients or other services. Of this total 46% occurredin surgery or inpatients.

• Assessed rates of non-clinical incidents (per 100 beddays) increased and were higher than otherindependent acute providers for the period April 2015 toMarch 2016. The rate of non-clinical incidents April toJune 2015 was 1.72 and January to March 2016 3.42.

• Data provided by the hospital showed from December2015 to June 2016 37 (14.9%) were non-clinicalincidents. Causes of incidents included equipment (10),security (6), vehicle (2), personal accident (2), ill health(2), violence/abuse/harassment (3), water safety (1), fire(1) and other (3).

• We saw that all staff had signed to say they had read theduty of candour policy. Staff were able to describe thebasis and process of duty of candour, Regulation 20 ofthe Health and Social Care Act 2008. This relates toopenness and transparency and requires providers ofhealth and social care services to notify patients (orother relevant persons) of ‘certain notifiable safetyincidents’ and provide reasonable support to thatperson. Patients and their families were told when theywere affected by an event where something unexpectedor unintended had happened. The hospital apologisedand informed people of the actions they had taken.

Safety thermometer or equivalent (how does theservice monitor safety and use results)

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• The hospital used the NHS Safety Thermometer which isa national improvement tool for measuring, monitoringand analysing harm. It measures the proportion ofpatients that experience ‘harm free’ days from pressureulcers, falls, urinary tract infections in patients with acatheter and venous thromboembolism (VTE).

• Day case patients’ are excluded from the NHS SafetyThermometer. None of the patients undergoing anendoscopic procedure in the reporting period (April2015 to March 2016) stayed overnight.

• We saw the records of the 100% inpatient VTE screeningrates for April 2015 to March 2016. There were noincidents of hospital acquired VTE or pulmonaryembolism in this period.

Cleanliness, infection control and hygiene

• The hospital had a quality and risk manager, health andsafety advisor and infection control lead who workedclosely with staff in order to maintain standards ofservice and agree actions for improvement whendeficiencies were identified. The hospital had a full timeinfection prevention control (IPC) link nurse. The IPClead worked three days a week in that role, the othertwo days as an oncology nurse.

• All the areas we visited looked visibly clean and weretidy. The most recent patient led assessment of the careenvironment (PLACE) score, completed in 2016, was100% for cleanliness which was better than the nationalaverage of 98%.

• We observed staff following best practice in line with theRoyal College of Nursing essential practice for infectionprevention and control, guidance for nursing staff. Weobserved staff undertaking aseptic techniques such asinserting cannulas and administrating chemotherapy.

• In line with Department of Health (DH) guidance ‘SavingLives’ the hospital used a system of care bundles toguide and manage the use of indwelling devices such asintravenous cannula. The use of these bundles ensuredthat such devices were cared for using a best-practiceapproach and that the risk of serious infection wasminimised. The records we saw showed that therelevant care bundles were used and completed at thespecified times.

• Staff were bare below the elbow and demonstrated anappropriate hand washing technique in line with ‘fivemoments for hand hygiene’ from WHO guidelines onhand hygiene in health care.

• There were sufficient numbers of hand washing sinksavailable, supplied with soap and disposable handtowels. Sanitising hand gel was readily available.Information was displayed demonstrating ‘fivemoments for hand hygiene’ near hand washing sinks.

• We saw personal protective equipment was available forall staff and staff used it in an appropriate manner.

• The hospital had a policy for the management of apatient’s body following their death with a suspected orconfirmed infection. This had clear guidelines about thepotential risk from body fluids and specific advice forcaring for the deceased.

• The hospital audited hand hygiene of ten members ofstaff across the whole hospital on a monthly basis. Thiswas an observational audit and was adapted from theWHO ‘five moments for hand hygiene’. We saw theresults of the audits which showed from February toApril 2016, three members of staff were non-complaint.Two incidents related to not washing hands beforepatient contact and the third regarding a nurse wearingnail varnish. All three were successfully re audited andreflected on their practice.

• We saw the DH high impact intervention (care bundles)was completed monthly from February to May 2016. TheQuality Improvement Tool (QIT) was audited forendoscopy environment and decontamination(September 2015), standard precautions (September2015), hand hygiene environment (September 2015) andantimicrobial prescribing (February 2016).

• Some chemotherapy drugs are harmful to patients andstaff. We saw the oncology unit had kits readily availableto deal with chemotherapy spills. Staff had receivedtraining in how to use the kit and we saw records whichindicated staff checked the kits weekly to ensure theywere ready for use.

• We saw there were cleaning schedules in individualtreatment rooms and toilets, which were fullycompleted. Housekeeping staff showed us their

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cleaning schedules which clearly set out the tasks to beperformed and their frequency. They were required tosign when each task was completed and theirsupervisor checked their work.

• The endoscopy unit was cleaned daily in the evening,even when the unit was not open. Equipment in thetreatment room had green ‘I’m clean’ labels indicatingthat equipment was clean and ready for use.

• Waste in the clinic rooms was separated and in differentcoloured bags to identify the different categories ofwaste. This was in accordance with the DH HealthTechnical Memorandum (HTM) 07-01, control ofsubstance hazardous to health and Health and Safety atWork regulations.

• We saw sharps bins were available in treatment andclinical areas where sharps may be used. Thisdemonstrated compliance with health and safety sharpsregulations 2013, 5(1)d. This required staff to placesecure containers and instructions for safe disposal ofmedical sharps close to the work area. We saw labels onsharps bins had been fully completed which ensuredtraceability of each container.

• There were no incidences of E-Coli, MRSA and MSSAbloodstream infections or cases of C.difficile relateddiarrhoea reported in the period April 2015 to March2016 at the hospital.

• At the pre assessment stage, staff screened all patientsfor MRSA, a type of bacterial infection that is resistant toa number of widely used antibiotics. The test wasrepeated every three months. If a patient was positive,they received treatment for MRSA as per protocol and aprocedure not performed until the patient was clear ofinfection. We reviewed five sets of patient records; allfive indicated that screening was done at the preassessment stage. The result of the screening test wasavailable in all five records prior to the patientundergoing the procedure.

• The endoscopy suite had separate clean and dirty utilityareas for the preparation and cleaning of equipmentwhich minimised the risks of infection to patients. Stafftransported dirty endoscopes from the treatment areato the dirty area in a covered, solid walled, leak proofcontainer. This was in line with the Health and SafetyExecutive (HSE) Standards and Recommended Practicesfor Endoscope reprocessing Units, QPSD-D-005-2.2.

• In the endoscopy department, we saw there wereadequate systems to ensure that endoscopes weresafely decontaminated. We saw documentary evidenceshowing that the use of scopes was tracked and the useof a specific endoscope was linked to each procedure.Staff we spoke with could explain the correctdecontamination process. We saw the scopes werestored safely in a drying cabinet for up to three days,and there was a process for ensuring they werereprocessed at the appropriate time.

• We saw water sampling test results, which indicatedstaff tested the final rinse water from an automaticprocessor was tested for its microbiological quality atleast weekly. This was in line with HTM 01-06:decontamination of flexible endoscopes.

• We observed chemotherapy was prepared in an asepticpharmacy department to guard against the risk ofinfection being introduced when it was administered.We saw the chemotherapy prepared was compliant withrelevant guidance.

Environment and equipment

• The oncology unit was awarded the Macmillan QualityEnvironment Mark (MQEM) in 2014 which is valid forthree years. This stipulates units must be welcomingand accessible to all; they are respectful of people’sprivacy and dignity; they are supportive to user’scomfort and well-being and listen to the voice of theuser.

• The oncology unit had 16 accommodation rooms whichwere a mixture of individual curtained bays and singlebedrooms. This allowed patients to receive theirchemotherapy in single facilities or in a group settingdepending on patient need and choice. The area had itsown consulting rooms, counselling room, therapyrooms, and a separate waiting area. This metrecommendations of Health Building Note 02-01:Cancer treatment facilities.

• The store room on the oncology unit was visibly cleanand uncluttered. The health care assistant (HCA) wasresponsible for monitoring stock and ordering asrequired.

• The temperature of the clinical room was checked andrecorded daily when the unit was open in the oncologyunit.

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• We saw equipment service records which indicated100% of equipment had been serviced in the previous12 months. Individual pieces of equipment had stickersto indicate equipment was serviced regularly and readyfor use. We saw portable appliance testing (PAT) stickerson electrical equipment, which indicated electricalequipment was safe to use.

• The PLACE scores were 93%, which was the same orhigher than the England average for condition,appearance and maintenance of the hospital.

• Staff reported no problems with equipment and feltthey had enough equipment to run the service.

• We were told there were no issues around securing thenecessary equipment for end of life care patients, forexample pressure relieving mattresses. End of life carepatients requiring an air mattress received this promptlyto prevent the development of pressure ulcers.

• Syringe drivers were available across the hospital. Thesyringe driver is a portable battery operated device tohelp reduce symptoms by delivering a steady flow ofinjected medication continuously under the skin. It isuseful way of delivering medication for an end of lifecare patient when they are unable to take medicationorally. The hospital used an appropriate syringe driverwhich fulfilled the safety guidance by the NationalPatient Safety Agency Rapid Response Report (2010).

• Emergency equipment was located on all wards and inthe endoscopy unit. The resus trolleys were secure andwe saw the records of checks. All equipment neededwas available, as indicated by an equipment list. Allconsumables were in date. The trolley was checked onthe wards daily.The trolleys on the oncology unit andendoscopy units were checked on the days the unitswere open. The records stated clearly ‘not in use’ on thedays the unit was not open.

• All appropriate rooms and cupboards had numericalkey pads and self-closing doors. The numbers werechanged every four months as per BMI Healthcarepolicy.

• The hospital had a six bay ambulatory care unit.

• Inpatient accommodation was provided over threefloors in individual rooms with their own bathrooms.Three of these could be converted to twin occupancy.There were 12 beds each of the wards.

• The endoscopy unit had six individual bays. Each baywas curtained, contained a bed and locker. A lockablecupboard was available behind the nurse’s station forvaluables. Each bay had its own observation monitoringequipment and call bell.

• Endoscopy unit patients had access to separate maleand female toilets and a disabled toilet.

• Endoscopy patients had separate changing rooms andareas to store their belongings before and during theirprocedure. The recovery room did not have the facilitiesto separate male and female patients. Staff told us theytry to arrange appointments so genders were not mixed.

• The endoscopy lead told us the number and size ofendoscopes met the needs of the service. We saw avariety of scopes available to perform a variety ofexaminations.

• The room temperature and the temperature of thefridge in the endoscopy treatment room was monitoreddaily, when the department was open, to be withinrange and this was recorded.

• In the endoscopy unit we saw that equipment wasmaintained by an external contractor and we saw theequipment was labelled to show it had beenmaintained at the required frequencies.

Medicines

• The hospital had a pharmacy which provided bothinpatient and outpatient services. All wards and clinicaldepartments had a medicine stock top up service whichwas run weekly by the pharmacist technicians.

• The pharmacy department visited the ward areas dailyfrom Monday to Friday and Saturday mornings. Theychecked all drug charts to ensure safe and effective useof medicines. They organised the medicines given topatients on discharge from a hospital stay (TTO’s). Wewere told medication for end of life care patients waseasily accessible. A pharmacist was on call out of hoursto assist staff when required.

• Medicines were kept in locked cupboards. Access wasvia digital locks and we were advised that the numberwas changed every four months to minimise the risk ofunauthorised access. Only staff who were authorisedaccess were given the codes.

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• There were dedicated fridges for storing medicines,where required. We saw the fridge and roomtemperatures were monitored and recorded to ensuremedicines were kept in optimal conditions.

• The hospital had a named controlled drugs (CD’s)accountable officer. We found CD’s were kept securelyand stored in suitable cupboards with recordsmaintained. The CD cupboards were locked, withrestricted access and were bolted to the wall. We sawthat controlled drugs were checked by two members ofstaff each night.

• The clinical room in the oncology unit contained firstline antibiotics and pre-treatment medications in alocked cupboard. The clinical room had a digital lockand slow release door. We saw the door was proppedopen when a member of staff was in the room. Themember of staff removed the prop and the door closedwhen they left.

• Staff gave chemotherapy drugs directly into a patient’svein. A complication of this is a leakage of the drug fromthe vein in to the surrounding tissue and is calledextravasation. An emergency tray was kept in the clinicalroom in the event a patient had an anaphylacticreaction or a patient suffered extravasation. This traywas locked away when the clinic was not open. Staffchecked the emergency tray regularly and we sawrecords of these checks.

• Dose banding for chemotherapy was routine and was anexample of good cost-effective practice. Dose banding isa national system introduced by NHS England to reducevariation and wastage in chemotherapy. Patientsreceived optimised doses of drugs, rather than oneswhich are individually calculated.

• When chemotherapy was prepared we saw there was achecking system that ensured the accuracy of theprescription and dispensing of the treatment. There wasa system in place which meant only one prescriptionwas prepared at a time to minimise the risk of error.

• Chemotherapy drugs were delivered to the oncologyunit in a sealed bag. The drugs were checked by thenurses before being transferred to colour coded traysprior to administration, reflecting current best practice.These medicines were not stored away as they wereused almost immediately upon delivery.

• All registered nurses and medical staff were in theprocess of receiving training about the safe use ofmedication for an end of life care patient andprescribing anticipatory medication. The prescribing ofanticipatory medication is designed to enable promptsymptom relief at whatever time the patient developsdistressing symptoms.

• Medication guidance had been agreed andimplemented as per adult Palliative Care Guidance,2006 to support the management of dying patients. Theguidance was comprehensive and guided staff on theprescribing of medication covering the fiverecommended areas including pain, agitation,respiratory secretions, nausea and vomiting. Palliativeconsultants prescribed the medication which ensuredpatient safety was paramount and that specialised skillssupported the prescribing process.

• We observed nurses administering medication in allareas and found they met the Nursing and MidwiferyCouncil (NMC) standards for medicines management.We saw two registered nurses checking chemotherapyprior to administration.

• We saw in all departments across the hospital checksoccurred to ensure staff had the right drug, right route ofadministration and the drugs expiry date. Staff recordedthe batch numbers of the drug in the patient record andwe saw patient identification checks occurred.

• We looked at five medicine administration records andnoted that no prescribed doses of medicines had beenmissed or omitted. This meant patients received theirmedicines when they were prescribed.

• We saw the record of one end of life care patient duringour inspection. The patient had recently beenrecognised as end of life care and did not require asyringe driver or anticipatory medication at that point.

• Data provided by the hospital showed from December2015 to June 2016 there were 249 incidents reportedand 202 were clinical. Of these 21 related to medication.Eight regarding the administering of medication, sevendocumenting medication and six the dispensing orprescribing of medication. All incidents outlined anyremedial or other action taken immediately followingthe incident. Although the number of medical incidentswas less than other clinical incidents they werediscussed at clinical governance meetings.

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Records

• The hospital used a variety of information technologysystems that held patient data. All staff, clinical andnon-clinical were required to be compliant withinformation security and data protection with allservices around patients. We saw staff completedmandatory e-learning modules for informationgovernance. Some staff were provided with an NHSemail address for confidential transfer of patient datarelating to all NHS contracts.

• We saw five records of patients across the hospital. Allwere completed with appropriate assessments,signatures, allergies noted and all observations weredocumented and dated. The notes we saw hadevidence of pharmacy checking.

• We saw patient records were stored in locked cabinetsin locked rooms in the oncology unit.

• Oncology patients carried record books which indicatedthe chemotherapy type and frequency. It also includedtheir most recent blood test results.

• All patient records contained a laminated sheetexplaining the sepsis six (three diagnostic and threetherapeutic steps) action to be delivered within onehour of the initial diagnosis of sepsis.

• Patients receiving care from the palliative care team hadtheir documentation updated when reviewed. This gaveinformation around changes in patient care needs andmedicines management. Staff on the wards thenimplemented the changes required, such as applying asyringe driver or changing medication. We observedthat the palliative care team provided a holisticassessment on their first visit to a patient andsubsequent visits were documented in the patient’smedical notes.

• The hospital had a personalised end of life care plan forpatients who were recognised to have a life limitingcondition and were expected to die within seven days.The care was to be used in conjunction with other riskassessments. For example, pain management and painscale, ‘do not attempt cardio-pulmonary resuscitation’(DNACPR) form and National Early Warning System(NEWS) chart.

• We saw one record of a patient who was recognised asrequiring end of life care. The patient was not on the

specific end of life care plan as this was not appropriate.The notes were completed with appropriateassessments, signatures, allergies noted and allobservations were documented and dated. The noteswe saw had evidence of pharmacy checking theappropriate prescribing and administration ofmedication.

• We saw the log book for recording of the deceasedwhich was kept in the office on St Clare ward. This wascompleted by ward staff and the funeral directors. Thisenabled a record to be kept of identification of thedeceased, when they had been moved and thebelongings that had been taken with them.

• The hospital audited the medical records in April 2016 tomonitor clinical documentation and their compliancewith policies and national guidelines. Ten sets of recordswere audited in each month from January 2016 toMarch 2016 which resulted in a quarterly analysis ofresults. The quarterly results indicated there was acompletion of required elements between 88-92% ofthe records audited. The findings of the audit werepresented to the clinical governance committee andmedical advisory committee. The results weredisseminated in team meetings by the heads ofdepartment.

• The medical records audit showed there was evidenceof good practice and highlighted areas for improvement.These included no documented evidence of a 48 hourfollow up phone call following discharge in 13 cases,poor compliance with entry of consultant daily progressnotes in 11 cases, no evidence of consultant dischargesummary in eight cases and no copy of consultant clinicnotes within the main record in eight cases. The auditshowed recommendations with an action plan whichwere to be completed in a timely manner. At the time ofinspection there were no patients in the endoscopy unit.We were unable to see any patient records. However wesaw the systems in place to ensure the records weremonitored and stored safely. Records were kept in alocked trolley on the ward. Once the patient wasdischarged, the record was transferred to the medicalrecords department. Authorised personnel only couldaccess this department.

• Staff on the endoscopy unit kept full scope-tracking andtraceability records. These indicated each stage of thedecontamination process. We saw the audit scope log

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book was completed and up to date. The serviceaudited these records and we saw results of theseaudits, which indicated all stages of the process werecompleted. This followed guidance from the BritishSociety of Gastroenterology on decontamination ofequipment for gastrointestinal endoscopy (2014).

Safeguarding

• There had been no safeguarding concerns reported toCQC from April 2015 to March 2016.

• BMI Healthcare had policies for safeguarding adults andchildren and these were accessible to staff.Safeguarding training was mandatory for all staff andachieved via e-learning. Training for both adults andchildren was at induction and then at two yearlyintervals.

• Staff had a good understanding of what a safeguardingconcern might be. They told us they would escalate anyconcerns to their manager. They knew who thesafeguarding lead was.

• The training target for safeguarding was 90%. Thehospital told us 95% were trained to level 1 and 93% tolevel 2 for safeguarding vulnerable adults. Safeguardingchildren level 1 was 95%, and 93% level 2.

• One member of staff was trained to level 3 safeguardingvulnerable adults who was the director of nursing andthe safeguarding lead. Nobody at the hospital wastrained to level 3 safeguarding children.

• However, there was a service level agreement in placewith a neighbouring BMI Hospital facility. A leadregistered children's nurse, who held safeguarding forchildren level 3, was available to MountAlvernia Hospital for advice, action and support .

• The responsibility of a safeguarding lead is to ensureproviders have the right systems and process in place tomake sure children and adults are protected from risk oractual abuse and neglect. National statutory guidelines‘Working together to safeguard children – a guide tointeragency working to safeguard and promote thewelfare of children’ (2015) states safeguarding leads areto be trained to level 3 for vulnerable children as thelead takes the responsibility for the organisationssafeguarding arrangements. However, the hospital’ssafeguarding lead was trained to level 3 for vulnerableadults only. This is considered a risk as children could

accompany an adult who were visiting the clinic.Providers must have robust procedures and processesto prevent people using the service from being abusedby staff or other people they may have contact withwhen using the services, including visitors.

Mandatory training

• We saw the training records for staff (excluding medicalstaff) for mandatory training.

• The target for mandatory training set by BMI Healthcarewas 90%. Mount Alvernia hospital had a total of 93.1% inall departments of the hospital. Nursing staff 94.4%,pharmacy 100%, ward staff 90.3%, oncology 82.9% andendoscopy 100%.

• We saw there was an electronic monitoring systemwhich flagged when staff’s mandatory training was dueto expire. Managers described how they used the systemto ensure staff remained up to date.

• The mandatory training programme was tailored toeach staff job role. Most training was electronic basedand included a knowledge check and required updatingannually. Staff told us they had no problems completingon-line training. The training programme wascomprehensive and contained all the training subjectsthat would be expected. For example, safeguardingadults and children, dementia awareness, informedconsent, Mental Capacity Act and Deprivation of LibertySafeguards.

Assessing and responding to patient risk

• We looked at the records of medical inpatients and sawa range of risk assessments were used which usednationally recognised and validated tools. Theseincluded assessments for risk of pressure damage(Waterlow) and malnutrition (MUST, the MalnutritionUniversal Screening Tool). We saw these assessmentswere reviewed as required by the hospitals carebundles. Other risk assessments included thoseconcerned with falls, manual handling and the use ofbed rails.

• We saw the risks of VTE were assessed for each patientand appropriate prophylactic measures were in place asa result of this, for example the use of anti-coagulant

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medication when required. There had been no reportedincidents of VTE from April 2015 to March 2016. Thisshowed there were effective processes for managing therisk of VTE to patients.

• Guidance from NICE CG50 Acutely Ill Patients in Hospital,recommends the use of an early warning scoring systemto identify patients whose condition may bedeteriorating. The hospital used the National EarlyWarning System (NEWS) and we saw in the records thiswas routinely used for inpatients where appropriate.

• The hospital audited the use of NEWS in February 2016.The purpose of the audit was to identify whether theNEWS observations were completed accurately, andwhere concerns were identified, escalated to a moresenior member of the nursing or medical team. Theresults of the audit were compared with the auditresults from August 2015. The findings indicated anoverall improvement. The audit made furtherrecommendations to continue with areas ofimprovement. The action plan had intended outcomes,named responsibility and due dates.

• NEWS scoring was not used in the endoscopy unit as thepatient was not in unit long enough for this to be ofeffective use. The endoscopy care plan contained aseparate warning/assessment system. If it was clinicallyappropriate a separate risk assessment sheet could beused with the care plan.

• We saw there was adequate resuscitation equipmentand it was easily accessible. Staff knew where they werelocated.

• Medical cover was provided by the RMO 24 hours a dayseven days a week. The RMO was selected on theirexperience to enable them to manage and respond torisks relating to the wide mix of patients at the hospital.

• A senior nurse was available 24 hours a day seven days aweek as a contact point for both staff and patients. Thisincluded helping to resolve patient queries and toaccept out of hours admissions.

• In addition to clinical and consultant arrangements, thesenior management team operated a rota for on callsupport out of hours. There was an on call rota operatedby the pharmacy, radiology and physiotherapy teamsshould support be required. There was also an on callemergency theatre team.

• For end of life care patients, where the progression oftheir illness was evident the amount of intervention wasreduced to a minimum. Care was based on ensuring theperson remained as comfortable as possible at all times.

• The personalised end of life care plan used the ModifiedRichmond Agitation – Sedation Scale (m-RASS). Thisscoring system is a tool for measuring consciousnessand delirium. This would assist staff to administer theappropriate medication and support.

• The patients in the oncology unit were provided with atelephone number enabling them to have access tosupport and advice 24 hours a day. The phone was heldby a nominated qualified member of staff.

• Within 24 to 48 hours of a patient discharge the wardclerk would contact the patient by telephone to check ifall was ok. The hospital had introduced a pre-printedtelephone query sheet which provided staff withprompts and actions to be taken. This telephone recordwas kept in the patients records. This meant there wassystem to ensure that appropriate actions were takenwhen concerns were identified.

Nursing staffing

• The hospital used an electronic system for calculatingand recording nursing staff requirements and actualhours used. The system was used to plan the skill mix 24to 48 hours in advance. A spread sheet was completedand reviewed on a daily basis. The actual hours workedby members of staff were also entered to enable thehospital to understand variances from the plannedhours and the reasons for these. We looked at thereports on the oncology unit.

• The nursing manager for inpatient wards explained tous how they organised the off duty to ensure sufficientstaff were on duty and also accommodated individualstaff members preferences. Staff were allowed toallocate six days or shifts as a ‘wish list’. The majority oftime this was granted by the management and this gavethem some flexibility in allocation of the remainingshifts. Staff were given the choice if they preferred towork long or short days and these were accommodatedif work load permitted.

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• Nursing staff we spoke with told us they consideredthere was sufficient nursing staff to meet the needs ofpatients. Patients echoed this view and told us anyrequests for help or care were responded to promptly.

• Clinical staff were supported by unqualified staffmembers including health care assistants, porters andreception staff.

• As at 1 April 2016, 19.4 whole time equivalent (WTE)nursing and midwifery registered staff employed and11.1 WTE health care assistants for inpatients. Theinpatient departments had a ratio of nurse to healthcare assistant of 1:0.57.

• Staff turnover for inpatient departments was 9.1%nurses from April 2015 to March 2016. This was not highwhen compared to other independent acute hospitals.

• The hospital told us there was no staff turnover forinpatient health care assistants in the last year.

• The use of bank and agency for staff for nursing andhealthcare assistants in inpatients departments waslower than the yearly average of other independentacute hospitals. The bank to agency ratio for inpatientnurses at the hospital April to June 2016 was 1:3.Information was not provided by the hospital regardingbank to agency ratio for inpatient health care assistants.

• A full time nurse manager was responsible for allinpatient wards.

• St Clare ward was the main ward for inpatients. All staffreported to this ward at the start of their shift and wereallocated to their identified ward. This meant that eachward had sufficient numbers of qualified staff in eacharea to provide relevant patient care.

• St Clare ward reported they had limited sickness and sixvacancies at the time of inspection. The vacancies weredue to retirements and migration of staff to otherdepartments in the hospital.

• The oncology unit employed a manager, one seniorsister, two oncology nurses, two staff nurses (due to starttheir oncology training in September 2016), one HCAand a receptionist. The unit had one vacancy for a HCA.

• The oncology unit had two agency nurses who workedregularly for the ward. This provided continuity of carefor patients and ensured these staff could work safely asthey were familiar with the systems and processes of theunit.

• We saw the staff rotas for the oncology unit whichindicated two members of staff were in the departmenteach day the unit was open. If a member of staff was offsick, their shift would be covered by another member ofstaff working overtime. This was in line with safe staffingfor nursing in adult inpatient wards in acute hospitals,NICE guideline SG1.

• A palliative clinical nurse specialist visited the hospitaltwo days a week. Telephone support was provided 9amto 5pm seven days a week. This meant specialistknowledge was available at all times for patientsreceiving end of life care.

• The handover of shifts on inpatient wards took place at7am, 1pm and 8.30pm. This involved the team who werefinishing their shift handing over verbally to staff in thepatient’s room. This ensured an effective, accurate andpatient centred approach to care and gave theopportunity for patients to meet staff who would belooking after them on the next shift.

Medical staffing

• Consultants were supported by an on-site residentmedical officer (RMO) who provided a 24 hour medicalpresence.

• The RMO was on duty 24 hours a day and was based onsite a week at a time The RMO was provided to thehospital by an agency which was the preferred providerto BMI Healthcare. The hospital received assurancesthat all appropriate training had been undertaken. AllRMOs who worked at the hospital were registered withthe General Medical Council (GMC) and held a currentALS (advance life support) certificate and EPALS(European paediatric advance life support) certificate.

• Three palliative care consultants delivered consultantled care. The consultants provided medical advice andsupport when present at the hospital and by telephonevia the on-call rota when not. This meant specialistknowledge was available at all times for patientsreceiving end of life care.

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• The hospital told us they had 195 consultants workingwith agreed practice privileges. This related toconsultants in post at 1 April 2016 with more than 12months service.

• The hospital showed us their Practising Privileges Policyfor Consultant Medical and Dental Practitioners, 2015, acorporate policy by BMI Healthcare. The hospitalconfirmed that all medical staff had been fully trained toperform procedures which they regularly performedwithin their NHS practice.

• The granting of practising privileges is a well-establishedprocess within independent hospital healthcare sectorwhereby a medical practitioner is granted permission towork in a private hospital or clinic in independentprivate practice, or within the provision of communityservices. There should be evidence that the provider hascomplied with legal duty to ensure that the regulation19in respect of staffing and fit and proper personsemployed are complied with. Where practisingprivileges are being granted, there should be evidenceof a formal agreement in place. We saw that theseagreements were in place for all medical staff withpractising privileges.

• It was the responsibility of the consultant to becontactable at all times when they had patients in thehospital. They were required to be available to attendwithin an appropriate timescale according to the risk ofmedical emergency of the patients’ diagnoses orprocedures they had undergone. At times of annualleave cover was provided by a designated consultantcolleague. Staff told us that out of hours contact withconsultants was not a problem and they were amenableto being called.

Other Staffing

• Apart from medical and nursing staff, other staff whoworked in the hospital staff was equivalent 92.5 WTEstaff.

• From April 2015 to March 2016, there was 1.8% staffturnover for other staff in the hospital. This was not highwhen compared to other independent acute hospitals.

• The endoscopy unit was staffed by a lead endoscopypractitioner, two full time HCA’s and a bank endoscopypractitioner. Two registered nurses from the recoveryunit admitted and discharged all patients within theunit.

• The lead endoscopy practitioner told us they could flexstaff and the endoscopy list to ensure the appropriatenumber of suitably trained staff was available for eachprocedure.

• The pharmacy department employed seven contractedstaff. This was made up of two pharmacists, fourtechnicians and a manager. One bank staff wasemployed to support continuity of service duringholiday and busy periods.

Major incident awareness and training

• We asked the hospital for a copy of their localemergency preparedness resilience policy (EPRP). Wewere told this was not available as the hospital was notpart of the resilience forum.

• Not all staff had attended major incident or businesscontinuity training, or attended any simulationexercises. However, in our discussions with them staffcould articulate what they would do in the event of anevent that adversely affected business continuity.

• The hospital had a response team who would respondto an emergency situation. The team all held bleeps andwould respond immediately when required. The dailyward meeting in the morning on St Clare ward allocatedthe response bleeps and a fire marshal was designated.

Are medical care services effective?

Good –––

We rated medical services to be good for effective. This wasbecause:

• We found care and treatment reflected current nationalguidance. There were formal systems in place forcollecting comparative data regarding patientoutcomes.

Medicalcare

Medical care

Good –––


• Staff worked with other health professionals in and outof the hospital to provide services for patients. Patientswere cared for by staff who had undergone specialisttraining for the role and who had their competencyreviewed.

• Alternative end of life care guidance had beendeveloped in response to the national withdrawal of theLiverpool Care Pathway. The hospital used apersonalised end of life care plan to guide staff and putpeople and their families at the centre of decisionsabout their treatment and care. Guidelines includedprescribing anticipatory pain relief alongside guidancefor other common symptoms.

• Patients received adequate pain relief. Their nutritionalstatus was assessed and patients received food anddrink which met their needs in sufficient quantities.

• There were arrangements that enabled patients toaccess advice and support seven days a week, 24 hoursper day.

• Patients provided informed, written consent beforecommencing their treatment. Where patients lackedcapacity to make decisions, staff were able to explainwhat steps to take to ensure relevant legal requirementswere met.

• At the time of inspection there were no inpatients with a‘do not attempt cardio-pulmonary resuscitation’(DNACPR). However medical and clinical staff we spokewith understood the decision making process anddescribed decisions with patients and families.

• The hospital did not have Joint Advisory Group (JAG)accreditation for the endoscopy unit at the time ofinspection. The service had registered with JAG who hadyet not formally reviewed the hospital and the hospitaldid not have a date for this.

Evidence-based care and treatment

• We saw relevant and current evidence based guidance,standards, best practice and legislation were identifiedand used to develop how services, care and treatmentwere delivered. For example National Institute forHealth and Care Excellence (NICE) guidance CG161: fallsin older people assessing risk and prevention, QS24:nutrition support in adults, QS3: VTE in adults reducingthe risk in hospital, QS66: intravenous (IV) in adults in

hospital therapy and QS90: urinary tract infections (UTI)in adults. NICE guidance was reviewed at clinicalgovernance meetings and if relevant discussed withclinicians to ensure best practice.

• There were policies in place describing themanagement of neutropenic sepsis which werecompliant with NICE guideline CG151 (neutropenicsepsis: prevention and management in people withcancer). Staff we spoke with were aware of the need toget patients to a facility that would enable thecommencement of antibiotics within the hour.

• We reviewed a range of clinical policies and found thatall expected topics were covered by a policy framework,either locally or at corporate level. The palliative careteam consisted of palliative care consultants and apalliative nurse that demonstrated a high level ofspecialist knowledge. They provided the wards withup-to-date holistic symptom control advice for patientsin the last year of life.

• The hospital was working towards achieving theAmbitions for Palliative and End of Life Care: a nationalframework for local action 2015-2020 and NICE End ofLife Care Quality Standard for Adults (QS13). Thehospital had an action plan to support palliative andend of life care, May 2016. The plan had support for andevidence of actions and was updated when completed.Actions included the nomination of a palliative care linknurse, all nursing staff to attend and complete end of lifecare training and set up an end of life care steeringgroup. At the time of inspection a link nurse had beennominated and the other actions were on going.

• The hospital had responded to the withdrawal of theLiverpool Care Pathway (LCP) and the publication of‘One Chance to Get it Right’. The hospital had apersonalised end of life care plan for patients who wererecognised to have a life limiting condition and wereexpected to die within seven days. At the time ofinspection, no patients were on this care plan.

• Patient records we reviewed showed the care patientsreceived was consistent with NICE guidelines andprotocols in use at the hospital.

• We saw an alert system could be quickly cascadedthrough the hospital to ensure they were working within

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the national framework for the Medicines andHealthcare Products regulatory Agency (MHRA). This isresponsible for ensuring that medicines and medicaldevices work and are acceptably safe.

• The endoscopy unit did not have Joint Advisory Group(JAG) accreditation at the time of inspection. The servicehad registered with JAG and had completed anendoscopy global rating scale (GRS) self-assessment.GRS is a quality improvement system designed toprovide a framework for continuous improvement forendoscopy services to achieve and maintainaccreditation. JAG had yet not formally reviewed thehospital and the hospital did not have a date for this.

• The hospital had a robust audit programme throughoutall clinical departments. Audits were completed andreported to the departments and through to the clinicalgovernance committee and clinical effectivenessmeetings. Trends were identified and action planscreated to improve the service to patients which wascommunicated back to the clinical departments fortheir action.

• The hospital partook in national audits: safetythermometer, VTE, NCEPOD (The National ConfidentialEnquiry into Patient Outcome and Death reviews clinicalpractice and identifies potentially remedial factors).

Pain relief

• We saw effective pain control was an integral part of thedelivery of care. Pain scores were documented on theNEWS charts in patient’s records and managedaccordingly. Patients had regular assessments for painand appropriate medication was given frequently andas required.

• Patients we spoke with told us they received adequatepain relief.

• The hospital had implemented the Faculty of PainMedicine’s Core Standards for Pain Management (2015).There were guidelines for prescribing using NICEguidance on opioids (a strong pain killer) for palliativecare.

• The pharmacy team supported pain management atward level providing advice and support to patients andclinical teams. All medications given to patients ondischarge were communicated to the patients GP in thedischarge letter.

• The hospital said they gained feedback on painmanagement from all patients and took steps torespond positively to feedback.

• The palliative care team managed pain control forpatients on the oncology ward. Ad hoc issues weremanaged by the patient’s consultant or RMO who werecalled to reassess patients and amend medicationprescriptions.

Nutrition and hydration

• We saw risk assessments were completed by a qualifiednurse when patients were admitted to hospital. Thisincluded a nutritional screen assessment tool MUST(Malnutrition Universal Screening Tool) which identifiedpatients who were at risk of poor nutrition ordehydration. It included actions to be taken followingthe nutrition assessment scoring and weight recording.If a patient scored two due to a low BMI, 10% weight lossin six months or had little or no food in the previous fivedays or more, they were referred to the dietician.

• We were told that discussions around the nutritionalsupport that end of life care patients needed includeddiscussions with the patient and the family. Their viewsand preferences around nutrition and hydration at theend of life were explored and addressed along with therisks and benefits. We were told separate menus wereavailable which included soft and pureed food and foodto meet cultural requirements.

• Staff told us mouth care management was carried outon all end of life care patients. The personalised end oflife care plan had prompts for this. Mouth care packswere available on the wards.

• End of life care patients were supported to eat bynursing staff, if required. Relatives were also encouragedto support family members at meal times.

• The dietetic service was provided on a sessional basisby the local acute NHS hospital. The dieticians formedpart of the multidisciplinary team. They reviewedpatients and appropriate advice was given andactioned.

• We saw food and fluid intake was monitored using foodcharts and fluid balance charts. We were told patients

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who were unable to feed themselves were assisted bythe nurses and health care assistants. At the time ofinspection all inpatients were independent and did notrequire assistance with feeding.

Patient outcomes

• The hospital told us they audited patient outcomes byparticipating in national and local audit programmes.Locally, a quality dashboard was produced in additionto making local data available to the hospital on amonthly basis. This demonstrated various indicatorsincluding transfers out, returns to theatre, surgical siteinfection rates, average length of patient stay, day caseconversion rates and readmission rates.

• Any downwards trends or unexpected deviations wouldbe reviewed by the governance committee and medicaladvisory committee (MAC). Further advice could besought from BMI Healthcare’s group medical directorand national director of clinical services.

• The hospital reviewed morbidity and mortality rates,patient satisfaction feedback, incidents and complaints,activity data and staff surveys.

• The palliative clinical nurse specialist and consultanttold us that the majority of patients they see forpalliative and end of life care were patients with aprimary diagnosis of cancer.

• We did not see any evidence that end of life care datawas collected and used to develop the service. We weretold end of life data on referral patterns, patientdemographics and patient activity was not collectedand not sent to the National Council of Palliative CareMinimum Data Set.

• Results on patient outcomes were compared with otherlocations within the region and across BMI Healthcarethrough the corporate clinical dashboard. This useddata from the incident and risk reporting database. Thisallowed the hospital to review both their own data andcompare this with hospitals of a similar size within BMIHealthcare to enable them to plan patient care.

Competent staff

• The hospital had over 300 contracted and bank staffincluding nurses, physiotherapists and dieticians, all ofwhom had the relevant qualifications and memberships

appropriate to their position. There were systems whichalerted managers when staff professional registrationswere due and to ensure they were renewed. These weredemonstrated to us.

• The Medical Advisory Committee (MAC) was responsiblefor granting and reviewing practising privileges formedical staff. The hospital undertook robust procedureswhich ensured surgeons who worked under practisingprivileges had the necessary skills and competencies.The surgeons received supervision and appraisals.Senior managers ensured the relevant checks againstprofessional registers and information from theDisclosure and Barring Service (DBS) were completed.The status of medical staff consultants practisingprivileges was recorded in the minutes of the MAC notes.

• The hospital had an appraisal policy to ensure that allstaff understood their objectives and how they fit withthe departmental and hospital objectives and vision. In2015, 90% of registered staff and 86% of HCA’s hadcompleted an appraisal. In 2016, at the time ofinspection, 89% of registered nurses and 92% of HCA’shad completed an appraisal. All the staff we spoke withhad received an annual appraisal. They told us thisprocess was effective in developing their skills andknowledge further. It also contributed to maintainingregistration with the NMC.

• The hospital encouraged staff to experience other areasof the hospital when patient occupancy allowed. Thisenabled staff to experience other areas of expertise, forexample oncology.

• Staff had customer care modules specific to staff groupsfor example nursing, administration and physiotherapy.Training was provided on respecting equality anddiversity.

• Agency staff had access to up to date printed policiesand guidelines in the ward areas. Agency staff whoworked on the oncology unit completed acomprehensive induction and competency assessmentand we saw checklists that demonstrated this hadoccurred. The manager told us competencies werechecked to ensure they had completed specialisedtraining in chemotherapy.

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• Staff underwent an annual competency assessment inrelation to chemotherapy and we saw from staff filesand training records these were completed and in date.This meant staff had the specialist skill they required toeffectively treat and care for patients.

• We saw competency certificates in endoscopy whichindicated staff were competent in a variety ofprocedures and in the decontamination of equipment.

• End of life care training was not mandatory across BMIMount Alvernia. However, the palliative clinical nursespecialist had provided training on palliative and end oflife care training for nursing staff. This enabled staff tofeel confident to care for dying patients. We saw therecords that 19 staff had attended. The majority of staffhad completed an e-learning module and gained acertificate. The hospital told us they planned to provideend of life care training for all staff includingnon-clinical.

• The hospital had an allocated end of life care link nursewho had attended specific training at the local acutetrust. The link nurse had an increased awareness ofpalliative and end of life care issues. They disseminatedtheir knowledge to all nursing teams across the hospital.

• The wards had a resource folder with end of life careinformation as a reference for staff. This contained theout of hours contact details, care plan, training andlearning opportunities and syringe driver information. Italso contained information leaflets on pastoral care,travel insurance and organ donation.

• The hospital was working with the palliative care teamto provide training for the use of syringe drivers. Themanufacturer had been contacted to provide training onthe actual device. The palliative care team wasorganising a training session for staff for the appropriateuse of syringe drivers. This included the indications foruse, reasonable starting dose for medication, basicconversion from oral to injectable medication andemphasis on the hospital to always contact thepalliative care team for help and advice. We saw thistraining had been booked for the end of July 2016.

Multidisciplinary working ( in relation to this coreservice)

• Patients could be referred to a full range of allied healthprofessionals including speech and language therapist

and dietician. This was arranged via a service levelagreement with the local NHS trust. The staff wereskilled and experienced in assessing and treatingpatients using medical care services at the hospital. Thisarrangement ensured there were good links betweenthe services and specialist input and continuity of care.

• Staff could refer patients to allied health professionalsand counselling services if they were required.

• Inpatient wards had a multi-disciplinary communicationsheet. This was completed on a daily basis forinformation to be passed to members of staff onsubsequent shifts. For example a reminder of meetingsor specific information relating to a patient. Staff had tosign the forms to show they had read the informationand action had been taken.

• The hospital had a service level agreement with thelocal acute trust for palliative care services. Thepalliative team worked closely with the oncology unitand inpatient wards to provide effective joint workingfor palliative and end of life care patients.

• We were told the medical staff liaised with colleagues inthe NHS if the findings following procedures indicatedfurther medical support might be required.

• The hospital had a service level agreement with thelocal acute trust for palliative care services. Thepalliative team worked closely with the oncology unitand inpatient wards to provide effective joint workingfor palliative and end of life care patients.

• The staff on St Clare ward told us the palliative clinicalnurse specialist was very good and supportive.

• We attended a multidisciplinary meeting for thedischarge planning of a patient who had been assessedas end of life care. This was attended by the director ofnursing, ward sister, physiotherapy, occupationaltherapy and palliative care clinical nurse specialist. Thepatient was aware of the meeting but declined toattend. An action plan was agreed to enable the patientto return home in the following five days if appropriate.

Seven-day services

• The hospital had medical cover from a resident medicalofficer (RMO) and a senior nurse 24 hours a day sevendays a week as a contact point for both staff andpatients.

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• Patients had access to telephone advice 24 hours a day,seven days a week.

• The pharmacy was accessible 24 hours a day, sevendays a week. Out of normal working hours a seniornurse and RMO had access to the department. Thepharmacy provided an on call 24 hour service for adviceand medical information. The on call pharmacist wouldattend the hospital if required in an emergency.

• A palliative clinical nurse specialist visited the hospitaltwo days a week. Telephone support was provided 9amto 5pm seven days a week.

• An on call system managed by the palliative careconsultants ensured that access to advice at all timeswas available for patients who were end of life care.

• The chapel was open 24 hours a day for those of anyfaith who wished to pray or spend time in quietreflection. The pastoral care worker could be contactedby the ward staff or main reception when required.

Access to information

• Endoscopy patients received a letter on discharge. Thisincluded the reason for the procedure, findings,medication and any changes, potential concerns andwhat to do and details of any follow up. A copy of thisletter was send to the patients GP and a copy was keptat the hospital in the patients’ medical records. Thismeant there was a continuity of service and all medicalteams were kept informed.

• Patients receiving chemotherapy treatment carried theirown record which enabled other clinicians to see thetreatment they had received. Details of recent bloodtests were also kept in this record.

• The hospital used electronic prescribing forchemotherapy. This meant the ward and pharmacy hadaccess to the patients information without removing theprescription charts from the wards.

• We saw the two BMI Healthcare policies: themanagement of the deceased and end of life care andpalliative policy and these were in the process of beingratified centrally.

Consent, Mental Capacity Act and Deprivation ofLiberty Safeguards

• The hospital had a Safeguarding Adults Policy whichincorporated the Mental Capacity Act and Deprivation ofLiberty Safeguards (DoLS). The policy had clearguidance that included the Mental Capacity Act (MCA)2005 legislation and set out procedures that staff shouldfollow if a person lacked capacity. The policy includedthe process for consent, documentation, responsibilitiesfor the consent process and use of information leafletsto describe the risks and benefits. MCA and DoLStraining was part of the safeguarding mandatorytraining.

• Patients signed consent for chemotherapy agreementsand we saw these in patients’ records. We saw theyoutlined the expected benefits and risks of treatment sopatients could make an informed decision.

• We spoke with a range of clinical staff who could allclearly describe their responsibilities in ensuringpatients consented when they had capacity to do so orthat decisions were to be taken in their best interests.

• The most recent PLACE score for dementia care in thehospital completed in 2016, was 85%. This was the sameor higher than the England average.

• Medical and clinical staff we spoke with understood the‘do not attempt cardio-pulmonary resuscitation’(DNACPR) decision making process and describeddecisions with patients and families. They told us theyprovided clear explanations to ensure that the decisionmaking was understood. At the time of inspection therewere no patients who had a DNACPR in place.

Are medical care services caring?

Good –––

We rated caring for medical services as good. This wasbecause:

• Staff provided sensitive, caring and individualisedpersonal care to patients. Staff supported patients tocope emotionally with their care and treatment asneeded.

• Patients commented positively about the care providedfrom all staff they interacted with. Staff treated patientscourteously and with respect.

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• Patients felt well informed and involved in theirprocedures and care, including their care afterdischarge.

• Patients and their relatives were involved in their careand were given adequate information about theirdiagnosis and treatment. Families were encouraged toparticipate in the personal care of their relatives withsupport from staff.

• Emotional support was provided by staff in all areas.Staff knew who to signpost relatives to for bereavementsupport.

• Patient’s surveys and assessments reflected the friendly,kind and caring patient centred ethos. Our observationsof care confirmed this.

Compassionate care

• The PLACE scores for privacy, dignity and wellbeingwere 84% which were below the England average.However, we saw staff treating patients in a kind andconsiderate manner. We saw staff knock and wait beforeentering patient’s rooms in all areas of the hospital.Patients and their relatives told us staff always treatedthem with dignity and respect.

• All patients were asked to complete a patientsatisfaction questionnaire that incorporated questionsof all aspects of their care and experience. The hospitalmeasured national survey information, for example theFriends and Family test (FTT), and used all patientfeedback to guide investment plans, treatments offeredand the overall patient experience.

• The hospital had a patient satisfaction group that metmonthly to review trends and particular comments.Lessons could be learnt and improvements made toensure compassionate care was provided across thehospital.

• The FFT scores for NHS patients from October 2015 toMarch 2016 was 100%, except in December 2015, whenit was 90%. There was a high response rate in the samereporting period with the exception of October 2015when the response rate for NHS patients was lower thanthe England average.

• The hospital provided reports with their FFT results forall patients, NHS and private funded for January to

March 2016. In January 2016 there were 305 responses:98.02% were satisfied and 1.8% dissatisfied; February2016 98% satisfied and 2% dissatisfied; and March 201698.6% satisfied and 1.4% dissatisfied.

• We saw approximately 80 thank you cards displayed onSt Clare ward. Comments included: “You are the Ateam”, “You were all working so hard to make my staycomfortable”, “I appreciated your kindness, support andcompany” and “You made me feel very relaxed”.

• St Martha ward, the oncology unit, had thank you cardsdisplayed and a book in the private room whichcontained a further collection of cards. Commentsincluded: “Thank you for all your care, support and hugsand laughter over the last six months”, “You made anunpleasant experience bearable”, “Thank you for yourcare, support and friendships throughout dad’streatment. It was such a difficult time for him” and “Itwas helpful just knowing you were a phone call away”.

• We observed staff introducing themselves to patientsand their relatives.

• Staff we spoke with demonstrated a strong commitmentto empathy and enhancing the environment for dyingpatients.

• On St Clare ward we saw the quick response by staff to apatient’s emergency bell which had been activated.

Understanding and involvement of patients and thoseclose to

• Staff discussed side effects of treatment with patients ina kind and considerate manner.

• Oncology patients could ring a dedicated number if theyfelt unwell at home. They carried a record book withdetails of what to do if they experienced feeling unwell.This was in line with the Manual for Cancer Services:Department of Health; 2004.

• Patients received full explanations and details about theprocedures they were to have. We saw leaflets with thisinformation on.

• We spoke with three patients and one of their relativesin the hospital. One patient had recently beendiagnosed as end of life care. They told us staff werecaring and professional. They felt involved in their care

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and were given adequate information about theirdiagnosis and treatment. They felt they had time to askquestions and that their questions were answered in away they could understand.

• Relatives were encouraged to participate in the care ofpatients when this was appropriate. For example, weobserved relatives assisting with mouth care andpersonal care.

• Patients undergoing an endoscopic procedure wouldattend the pre assessment clinic to receive a fullexplanation and medicines necessary for them to havetheir procedure at this appointment.

• The hospital did not have a formal bereavement surveyHowever, the hospital had recently produced a patientinformation leaflet: Coping with bereavement. This wasspecific to Mount Alvernia Hospital and was a guide tohelp with practical issues when someone dies. Itincluded information on registering the death andcontact details of the local registry office.

Emotional support

• The palliative clinical nurse specialist from the local NHStrust provided specialist palliative support to patients,their relatives and staff. The palliative care team werecontactable seven days a week.

• Bereavement support was provided directly to relativesby the nursing, consultant and palliative care teamwhilst the patient remained in the hospital. Relativeswere signposted to the relevant agencies that couldsupport them. A relative told us they had been providedwith information on who to contact if they requiredemotional support.

• The pastoral care worker was able to provide practical,emotional and spiritual support. Patients were offeredchaplaincy support on request or put in touch with aminister of their faith.

• Staff told us debriefing sessions were encouraged forstaff. Staff involved in a difficult case were encouragedto talk about their experiences and support each other.

• We saw staff interacting with patients in a supportivemanner and provide sympathy and reassurance.

• An oncology patient told us they could relax when theywere having treatment.

The oncology unit had a private room where patients,their relatives and staff could have a privateconversation.

Are medical care services responsive?

Good –––

We rated medical services good for responsive. This wasbecause:

• The hospital provided a service that reflected the needsof the local population and ensured flexibility, choiceand continuity of care.

• The palliative care team was embedded in all clinicalareas of the hospital. They were professional, responsiveand supportive to patients, relatives and other membersof the multidisciplinary team. The team respondedpromptly to referrals to assess the patient and plan care.

• There were a variety of mechanisms to providepsychological support to patients and their supporters.This range of service meant that each patient couldaccess a service that was relevant to their particularneeds. For example those with spiritual needs, bariatricequipment, patients whose first language was notEnglish, or support for people living with dementia orlearning disabilities.

• There were systems to ensure that patient complaintsand other feedback was investigated, reviewed andappropriate changes made to improve treatment careand the experience of patients and their supporters.

Service planning and delivery to meet the needs oflocal people

• All patients requiring end of life care received holisticcare. This included being nursed in a single room withen-suite shower facilities that had space for relativesstaying overnight.

• Visiting times for end of life care patients was unlimitedand there was access to an outside area where patientsand relatives could reflect and enjoy time together.

• Complimentary therapies were available for patientsand they also had access to physiotherapists,occupational therapists, dieticians and speech andlanguage therapists. This meant patients wider needswere met.

Medicalcare

Medical care

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• The endoscopy unit was open daily Monday to Fridaywhen sufficient patient numbers permitted. We weretold that occasionally the unit was open until 6pm toaccommodate for late sessions.

• The oncology unit was open Monday to Friday 8am to6pm. Patients had access to telephone advice 24 hoursa day, seven days a week.

• The pharmacy was open 8.30am to 5.30pm Monday toFriday and 9am to 12am on Saturdays.

• Inpatient wards offered en-suite accommodation. Therewere televisions available and internet connections forpatients to use.

• The oncology unit was open in the evening on somedays which gave patients a choice in the time or day ofthe week they had their treatment.

• Visitors of inpatients were welcome at almost all timesbetween 9am and 9.30pm. Outside of these hoursvisiting was by agreement with the nursing staff.

• A café was located in the main reception of the hospitalfor patients and their families to purchase snacks anddrinks. The restaurant was accessible to all. We saw coldand hot drinks were available in all waiting areas wevisited.

• We found patients and those supporting them hadaccess to hot and cold drinks at all times. We saw drinksmachines were available in waiting areas and we notedinpatients always had a drink within reach.

• Hotel service assistants on the wards discussed themenu with patients and collected their choices. Patientshad the opportunity to order meals that were not on themenu. The ward had a book for special meals requestswhich was passed to the chef. Cultural and therapeuticdiets were available. For example, gluten-free, Kosher orHal-al.

• The most recent PLACE score, completed in 2016, werebelow the England average for food (74%),organisational food (70%), and ward food (77%).

• Catering at the hospital was provided by an outsourcedservice. The hospital was aware this had causeddisturbance in the provision of service. The bottom fivedeteriorating patient satisfaction results all related tothis function. The hospital was working with the cateringcompany to ensure patient satisfaction results returnedto the previous level that was achieved before theintroduction of the present catering service.

• The hospital had lounges and gardens for patients andvisitors use. The oncology unit had a separate roomwhich patients, relatives and staff could use for privateconversations.

• For patients who were having specialist cancertreatment, the hospital ensured they had the relevanttrained staff available at pre assessment and in the unitto ensure that safe and effective care was given topatients. Cancer patients were supported with a varietyof specialist nurse roles and a holistic therapy servicewas provided.

• The oncology unit provided a therapist service. This wasprovided by a local cancer charity who also providedcounsellors. A therapist was at the hospital Monday toFriday between 9am and 2pm. They offered oncologypatients one free hour session and any furtherinvolvement was billed by the hospital. The therapistshad consent forms for each type of treatment and keptin the patients’ medical notes.

• Oncology patients had a choice of receiving theirtreatment in an area with other patients or an individualroom if they wished. Patient’s relatives and loved oneswere encouraged to stay and were provided with foodand drinks.

• The hospital provided endoscopy services to both NHSand private funded patients.

Access and flow

• The majority of inpatients were seen initially inoutpatients and from there if required would beadmitted. All patients who were admitted were eitherpre-assessed face to face or by telephone. Patients forsmall procedures, young persons and otherwise fitadults, the hospital conducted an interview bytelephone. This meant the hospital was responsive tosharing the patient pathways and ensured that allrelevant information was given to the patients.

• The oncology unit provided about 123 episodes ofchemotherapy per month, and this capacity met thecurrent demand.

• Oncology patients accessed treatment through theirinsurance companies or privately. Patients received apre assessment clinic appointment where the doctordecided on the treatment regime, with a nurse inattendance. This would decide how many days a weekthe patient would attend for treatment.

• The hospital accepted patients for end of life care bothinside and outside normal working hours. The palliative

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care consultants were available, on call, to receivereferrals at all times. We were told referrals werereceived with or without a cancer diagnosis. Data on thepercentage of patients who were referred with a cancerand non-cancer diagnosis were not collected. Thereforewe were unable to establish the mix of patientsrequiring end of life care.

• The hospital did not have an end of life care alert systemto alert staff to a new admission. However, very fewpatients were admitted to the hospital for end of lifecare. Patients admitted were usually known to theoncology team and the admission was often expected.

• No systems were in place to support those patients whodid not have a cancer diagnosis. However as very fewpatients were admitted for end of life care newadmissions were flagged up daily and referrals made tothe palliative care team.

• Systems were in place to facilitate the rapid discharge ofpatients to their preferred place of care. An occupationaltherapist was responsible for complex discharges ofpatients who required funding from NHS continuinghealthcare. They would also assess and arrange for theappropriate equipment and ensure it was in place whendischarged.

• We were told the number of patients achieving theirpreferred place of care was high and patients weredischarged within 48 hours if equipment was required.However no data was available to confirm thepercentage of patients that received their preferredplace of care and how rapid the discharge was.

• We saw the care pathways in use directed staff toconsider all aspects of discharge planning for inpatients.We saw sections had been completed which meantpatients were protected from the risks associated withpoorly planned discharge from the hospital.

• Nurses on the wards would refer to the communityteams if a patient required additional assistance whenthey returned home. For example, medication, palliativecare and wound care.

• The GP’s of endoscopy patients were sent a copy of thedischarge letter on the same day as the procedure.

• The hospital reported there had been 23 incidents ofpatients admitted as a day case and required anovernight stay October 2014 to October 2015. Thehospital audited the incidents in November 2015. Thepurpose of the audit was to confirm that the cases weremanaged appropriately and to identify any contributingfactors. The medical records of 22 of the reported

incidents were reviewed. The conclusion of the auditshowed the decision to keep the patient overnight wasmade in the best interests of the patient and withconsideration of the minimum discharge criteria.

• Eleven incidents had been reported by the hospital ofpatients who had been transferred out to anotherfacility July 2015 to March 2016. Seven incidents relatedto patients who had complications post-surgery, twomedical patients who had bowel obstruction, oneoutpatient who was unwell and the suitable equipmentto test this was not working and an end of life carepatient who had deteriorated and required furthertreatment in critical care. All eleven incidents wereinvestigated and showed findings, root cause andlessons learned.

Meeting people’s individual needs

• Oncology patients had access to a range of leafletsexplaining their condition and treatment. Most of thesewere produced by national charities. No leaflets weredisplayed in other languages. However the managertold us these could be obtained from the charity ifrequired.

• Patients attending the oncology unit could experience arange of complimentary therapies. These includedIndian head massage, reflexology and acupuncture. Wesaw these therapies being provided and staff andpatients we spoke with valued them and felt they wereof great therapeutic benefit. These services wereprovided in partnership with a local cancer charity.

• We saw a range of information was available forpatients. These included post-operative pain advicebooklets, information published by Macmillan regardingcancer and the endoscopy service.

• Patients admitted to the wards were provided with aletter from the senior sister. This welcome letterexplained the process of admission, facilities on theward and hospital and provision of meals. It alsoexplained the staff handover arrangements on thewards and medication rounds.

• The hospital provided a pastoral care worker who wouldprovide spiritual support to patients regardless of theirreligious denomination. Staff were aware how tocontact the service.

• The hospital had a multi faith chapel. A visitors andprayer request book was at entrance. The chapel wasavailable for quiet reflection.

Medicalcare

Medical care

Good –––


• In the event of death of a patient the hospital had aservice level agreement with a local undertaker. Theycould be contacted at any time and would collect thepatient from the ward. If a relative wanted the patient tobe moved to a different location this could be arrangedwith the funeral directors.

• Staff explained to us how deceased patients were caredfor after death. We were told the family could stay aslong as possible after death has occurred. Relativeswere given the choice of whether they helped in theafter death care or whether they left this to nursing staff.The RMO verified death in front of the relatives and themedical certificate of cause of death was available tothe family before leaving the hospital.

• St Clare ward had a resource box regarding the death ofthe patient and this was accessible to all staff in thehospital. This contained the blank medical certificates,cremation forms and guidance, local funeral directorcontact details, register office information, BMI policy forthe management of the deceased, after death patientcheck list, pastoral care information and log book forrecording of the deceased.

• Advance care planning (ACP) was based on the cancernetwork guidelines. The information was available forstaff and was available on the wards for completion. Thepalliative care nurse told us support was given topatients who wished to complete an ACP. No formaltraining had been given to staff to support thedevelopment of the ACP and this task was left to thepalliative care nurse to complete with the patient.

• Staff could tell us how they would access professionaltranslation services for people who needed them.However we were told these were rarely needed.

• Staff told us they could access leaflets containinginformation about endoscopic procedures in otherlanguages if required.

• Staff received training on respecting equality anddiversity in their mandatory training.

• We asked staff about any arrangements to supportpeople living with a learning disability or dementia. Staffidentified the needs of these patients at the preassessment appointment.

• We saw there was an individual room opposite thenurse’s station on all three inpatient wards. This roomwas a larger room and had space for an additional bed.Staff told us this was appropriate for relatives whowished to stay with a patient who was living withdementia or learning disabilities.

• The hospital had equipment that could cater for abariatric patient up to a certain weight. Themanagement of bariatric patients was risk assessed andequipment was suitable for patients with a BMI of lessthan 50. They had wider chairs, appropriate beds,theatre tables and a wheelchair. Patients would beassessed before admission if more appropriateequipment was required.

Learning from complaints and concerns

• The hospital recognised there may be occasions whenthe service provided fell short of the standards to whichthey aspired and the expectations of the patient werenot met. Patients who had concerns about any aspect ofthe service received were encouraged to contact thehospital in order that these could be addressed. Theseissues were managed through the complaintsprocedure.

• We saw all patient rooms had a patient guide whichincluded a section which covered the formal complaintsprocedure. Copies of the BMI leaflet ‘Please tell us’ werelocated throughout the hospital to make patients andtheir relatives aware of how they can highlight anyconcerns.

• There were three items of rated feedback on the NHSChoices website for the hospital in the period April 2015to March 2016. CQC directly received four complaints inperiod April 2015 to April 2016.

• The number of complaints received by the hospital April2015 to March 2016 was 25 which was a decrease from2014/15 (43). One complaint had been referred to theOmbudsman which related to a patient using theservice in 2013.

• The assessed rate of complaints (per 100 day case andinpatient attendances) was significantly lower than theother independent acute hospitals CQC hold data for.

• The hospital told us that due to the size of the hospital itwas normal practice for complaints to be discussed asthey were received and reviewed in the daily morningmeeting. This was attended by the executive director,director of nursing and hospital heads of departments.They told us this ensured a transparent approach whichallowed early identification of issues for onwardcascade.

• Complaints and compliments were formally discussedat the monthly senior management team meetings,clinical governance meetings, and department meetingsas appropriate. The hospital held a monthly patient

Medicalcare

Medical care

Good –––


satisfaction meeting, which comprised of variousmembers of staff at all levels from the organisation,where results and improvement actions were discussed.This reviewed patient satisfaction data and where thehospital sat in comparison to it’s BMI Healthcare peers,complaint trends, onwards action as appropriate andareas for continuous improvements for the patientexperience.

• All staff were encouraged and empowered to identifyand address any concerns or issues while the patientwas still on site. If needed, complaints were escalated toheads of department, director of nursing or theexecutive director while the patient or their relative wasstill at the hospital to prevent issues developing into aformal complaint.

• The responsibility for all complaints rested with theexecutive director who would decide which head ofdepartment and/or consultants needed to be involvedin the investigation. Based on the nature of thecomplaint the investigation may be led by either theexecutive director, director of nursing or the quality andrisk manager. An acknowledgement would be sentimmediately upon receipt of the complaint explainingthe investigation process and timescales.

• The BMI Healthcare complaints policy set out therelevant timeframes associated with the various parts ofthe complaint response process. An initialacknowledgement was required within two workingdays and a full response within 20 working days. If acomplaint was escalated to a further stage thecomplainant would be given the information of who totake the complaint to if they remained unhappy with theoutcome. For private patients they would be signpostedto an independent adjudicator and NHS patientstreated at the hospital, to the NHS Ombudsman.

• During the complaint investigation the process wasmonitored to ensure timescales were adhered to andresponses provided within 20 working days. If aresponse was not able to be provided within thistimeframe a holding letter was sent so they were keptfully informed of the progress of their complaint. We sawthe records of complaints investigations. All complaintsinformation was retained within a paper file, with copiesretained electronically and also stored in the hospitalinformation management system.

Are medical care services well-led?

Good –––

We rated medical services for well-led as good. This wasbecause:

• The management structure for medical services at thehospital meant the executive director and the director ofnursing were responsible for the managers of theoncology and endoscopy services and the wards. Thesenior management team were highly visible andaccessible across the hospital. Staff described an openculture and said managers were approachable at alltimes.

• The lead for end of life care services at the hospital wasthe director of nursing. The palliative team and wardstaff had a vision to ensure that end of life care wasconsistent. This was to be delivered in a timely,sensitively, spiritually and culturally aware manner, withappropriate patient and relatives focused care of thedying and deceased patients.

• Staff spoke highly about their departmental managersand the support they provided to them and patients. Allstaff said managers supported them to report concernsand their managers would act on them. They told ustheir managers regularly updated them on issues thataffected the separate departments and the wholehospital.

• Governance processes were evident at departmental,hospital and corporate level. This allowed formonitoring of the service and learning from incidents,complaints and results of audits.

• The hospital had a policy in place for end of life care andmanagement of the deceased.

• Staff from all departments had a clear ambition for theirservices and were aware of the vision of theirdepartments.

• Staff asked patients to complete satisfaction surveys onthe quality of care and service provided. Departmentsused the results of the survey to improve services.

• The hospital had a risk register and was reviewed at thegovernance committee meetings.

However

• The risk register was not divided into separatedepartments.

Vision and strategy for this this core service

Medicalcare

Medical care

Good –––


• BMI Healthcare had a corporate strategy in place. Thehospital had a clinical strategy which was made up of sixkey themes. These were: putting patients at the heart ofwhat they do; staff were the most important attribute;quality should underpin everything they do; workingtogether; engaging with consultants; and being as costeffective and efficient as possible.

• Staff from the oncology, endoscopy and inpatient wardshad clear ambitions for the services they provided andwere aware of the visions of the departments. The visionwas to provide the highest standard of care, ensuring apatients experience was as comfortable as possible.

• The endoscopy team were working towards JointAdvisory Group (JAG) accreditation. On completion ofdata collection they could proceed to the next part ofthe process.

• An action plan was in place with education in end of lifecare as a focus. An end of life care steering group wasplanned to discuss relevant issues and considerimprovements of the service.

• Policies for palliative and end of life care andmanagement of the deceased had been developed andwere in the process of being ratified.

• The director of nursing told us they had identified theneed for a director of nursing network with other localhospitals and acute trusts. This had been organised bythe CCG and was due to start in September 2016.

• St Francis ward was not in use at the time of inspection.An action plan was in place to open the ward as amedical admissions unit. This was planned for thebeginning of August 2016 and would only happen if allactions were completed. For example ensuring therewas a clear understanding of the admission process byall staff and to ensure sufficient competent staff wereemployed. At the time of inspection a sister was in postfor managing the ward and was in the process ofreceiving their training.

Governance, risk management and qualitymeasurement for this core service

• The governance framework ensured an effectiveorganisational structure that supported the delivery ofservices and minimised the risks across all areas ofbusiness.

• There was a robust system of governance. Heads ofdepartments met monthly and discussed incidents,complaints and the risk register. They reported to thehospital leadership team. The monthly senior

management team and heads of department meetingcovered a variety of key areas and these were thenbacked up by departmental meetings and staff forumswhich ensured good communication across thehospital.

• The hospital had a clinical effectiveness committeewhich met every other month and fed into the clinicalgovernance committee which also met bi-monthly.

• Clinical quality and governance issues were reviewed atthe quarterly MAC meetings. This involved a high level ofengagement from the consultants. The MAC wasresponsible for ensuring there were robust systems andprocesses in place in relation to governance andassurance.

• The minutes and actions from the clinical governance,MAC, health and safety, infection prevention meetingswere reported to the management team through theservice leads meeting. The information was cascaded tothe wider team through departmental meetings andstaff briefings. These were conducted by the executivedirector and other members of the executive team. Theywere designed to be informal to encourage a high levelof engagement with the staff.

• The hospital utilised a daily informal communicationmeeting as an effective way to share information anddrive continuous improvement. Representatives from alldepartments met on a daily basis at 9am to discuss theprevious day and plan daily hospital activity. Thismeeting presented the opportunity to discuss daily keyperformance indicators, incidents, raise concerns andshare successes.

• The hospital did not have a formal steering group forend of life care. The director of oncology for BMIHealthcare, director of nursing, oncology manager,palliative care nurse and consultant met in March 2016to set up the service level agreement and agree thefuture of the service. We were told the group wouldmeet in September 2016 to review.

• A structured audit programme supported the hospital toensure patient safety was at the forefront of serviceprovision. Actions were monitored locally and withinsub-committees and clinical governance meetings.These ensured lessons could be learnt and actions hadbeen completed.

• The management of the inpatient wards were proactivein their understanding of the risks that could affect theinpatient wards. We saw a separate action plan for the

Medicalcare

Medical care

Good –––


inpatient areas which was separate to the hospitals riskregister. This included a list of the issues, plan of action;date of completion and by who. Topics on the actionplan included recruitment, training, and rotation of staffand development of new services.

• We saw the hospital risk register for April 2016. The riskswere divided into categories: patient safety, informationmanagement, financial, reputation, governance,operational, leadership and workforce, workforce healthand safety, and facilities and infrastructure. The registerdescribed the risks involved with their impact, likelihoodand risk ratings. Existing risk controls and further actionswere listed responsible committee and key lead.

• We were told the hospital risk register was reviewed atthe governance committee meetings and ensured if anyrisks have been identified they were on the register andif any risks had changed they were re scored andidentified.

• However, the hospital risk register was for the wholehospital and was not divided into separate areas.

Leadership and culture of service

• There was a clear management structure which staffwere aware of. This meant leadership and managementresponsibilities and accountabilities were explicit andclearly understood.

• The management structure for medical services at thehospital was the executive director and the director ofnursing who were responsible for the managers of theoncology and endoscopy services and the wards.

• The lead for end of life care services was the director ofnursing. Ward staff told us the palliative care team werevisible and provided good levels of education andsupport.

• Heads of departments oversaw the running of theirrespective areas and reported to the executive directorand director of nursing.

• All staff we spoke with thought their line managers andsenior managers were approachable and supportive.Staff told us they could approach immediate managersand senior managers with any concerns or queries.

Public and staff engagement

• The hospital monitored patient satisfaction in all areasof its service delivery. This was achieved through

obtaining patient feedback and views through the formsthey placed in each patients room and outpatient areas.The analysis of this information was provided by anexternal provider and this was arranged through thecorporate teams. The hospital received a corporatemonthly report which showed response rates, ratingwithin categories and ranking against all BMI hospitals.It also included all the freehand patient comments.

• The hospital had a patient satisfaction group was madeup of a number of employees around the hospital. Thisgroup continually reviewed the patient satisfactionscores and dealt with areas for improvement.

• We saw the meetings of monthly staff meetings for wardstaff. New starters were welcomed, audits, patientsurvey results and management structure werediscussed. We saw these meetings were well attendedby staff.

• The hospital encouraged social interaction for staffthrough a range of events organised specific to thehospital. For example, the Pin Awards, Above andBeyond Awards and charitable initiatives to encouragestaff engagement in a social context.

Innovation, improvement and sustainability

• The oncology service benchmarked against otherservices and reciprocated in peer review with otherservices. We saw copies of the most recent peer reviewcompleted with staff from another hospital. It identifiedareas of good practise and areas for development. Thisprocess identified and encouraged improvement withinthe service.

• The oncology service received the Macmillan QualityEnvironment Mark in October 2014 (a detailed qualityframework used for assessing whether cancer careenvironments meet the standards required by peopleliving with cancer).

• The hospital had BUPA Breast Care, MacMillan andbowel accreditation.

• A clinical governance bulletin was produced across theBMI Healthcare organisation which supported thehospital monthly to manage risk. The bulletin identifiedchanges in legislation relating to NICE publications andalerts regarding drugs and equipment. It also provideddetails of issues of best practice at other hospitals sothat shared learning could be applied locally.

Medicalcare

Medical care

Good –––


Safe Requires improvement –––





Information about the serviceMount Alvernia Hospital, part of BMI Healthcare, is an acuteindependent hospital. It provides a range of clinicalservices for outpatients, day-care and inpatients. Servicesare available to people with private or corporate healthinsurance or to those paying for a one off treatment. Thehospital also offers services to NHS patients on behalf ofthe NHS through local contractual agreements.

The hospital clinical team is made up of medical staff,nurses and a resident medical officer (RMO) who is on duty24 hours a day. A senior nurse is available at all times toassist patients following discharge and arrange admissionsfor patients who require hospitalisation for unplannedsurgical treatments.

Surgical services provided included orthopaedics, breast,gynaecology, urology and cranial. All services are for in andoutpatients. Only patients aged 18 years and older areadmitted for surgery. Young people between the ages of 16and 18 are seen in outpatients. In the period April 2015 toMarch 2016 there were 4,126 inpatient and day caseadmissions.

Inpatient accommodation is provided over three floors inindividual rooms with their own bathrooms, three of whichcan convert to twin occupancy. There are 12 beds each inSt Clare ward (mixed medical and surgical), St Elthelbert(surgical) and St Francis ward. At the time of inspection StFrancis was not in use.

There are three main theatres, two with laminar flow andone used mainly for laparoscopic procedures.

During our inspection we visited St Clare’s and StEthelbert’s wards, the theatre suite and the pre-assessmentunit. We spoke with 35 members of staff that included

consultant surgeons and anaesthetists, theatre staff, wardstaff, administrative staff, managers and support services.We observed the care provided by medical, nursing andsupport staff in the departments visited. We carried out anunannounced inspection the week after our announcedinspection.

We spoke with six patients and one relative. We reviewedinformation received from members of the public whocontacted us separately to tell us about their experiences.We evaluated results of patient surveys and otherperformance information about the hospital.

Surgery

Surgery

Good –––


Summary of findingsWe rated the surgical services at Mount AlverniaHospital as good because:

• The hospital had good systems and processes inplace to keep patients free from harm. There was agood track record on safety.

• Staff understood the incident reporting process andtheir responsibilities to report, investigate and learn.

• There were processes for assessing and respondingto patient risk and safe protocols for patient transfer.There was a comprehensive assessment of patientneeds. There were sufficient skilled and experiencedstaff to care for patients.

• The hospital worked to current national guidance.The hospital participated in national audits and hada proactive programme of hospital and departmentalaudits. Results and recommendations were sharedthroughout the hospital with change and learningevidenced.

• Patients were treated with compassion, care anddignity. They were well supported and provided withgood information.

• Services were provided to meet the needs of thelocal population and allow access to care andtreatment. There were minimal delays orcancellations for treatment and these were wellmanaged.

• Complaints were investigated and discussed openlywith staff.

• The organisational and committee structuressupported good governance systems and processes.Staff described an open culture within the hospitaland were clear on roles and responsibilities.

• The hospital collected patient feedback anddemonstrated ongoing work by all staff towardscontinuous improvement in the patient experience.

However:


• The side of the patient due to be operated on wasnot always clearly or accurately documented on dailyoperating lists.

• Not all staff had attended major incident or businesscontinuity training.

• The risk register was not compiled so thatdepartment risks could be identified

Surgery

Surgery

Good –––


Are surgery services safe?


We rated safe as requires improvement because:

• The side of the patient due to be operated on was notalways clearly or accurately documented on dailyoperating lists.

• Staff did not consistently adhere to the World HealthOrganisation Safe Surgery checklist.

• Not all staff had attended major incident or businesscontinuity training.


However:

• Incidents and near misses were reported andinvestigated. Reports were communicated to all staff.

• The hospital was visibly clean with cleaning systems,checks and audits. There were arrangements to preventthe spread of infection that were regularly monitored.

• There was sufficient equipment that was wellmaintained. Medicines were managed safely. Mandatorytraining rates were good.

• There were processes for assessing and responding topatient risk. The service had enough staff with the skillsand experience to care for the number of patients andtheir level of need.

Incidents

• There were no never events during the last 12 months.Never events are serious incidents that are whollypreventable as guidance or safety recommendationsthat provide strong systemic protective barriers areavailable at a national level and should have beenimplemented by all healthcare providers.

• BMI Healthcare Limited, the provider company, sentexamples of any never events that occurred at any oftheir hospitals to all hospitals for discussion and actionwhere relevant. We saw that the national patient safetyinitiative “Stop before you block” posters were in eachanaesthetic room as part of organisation wide learning.

• The hospital reported seven deaths for the period April2015 to March 2016 of which six were expected but onewas unexpected. Although two of these patients had asurgical procedure within 30 days of their death, no

deaths were directly linked to these procedures. Welooked at the patient record and the subsequentinternal investigation which was thorough. We saw thatwhilst there was no confirmed cause of death followingtwo post mortems all processes had been followedcorrectly, including correct procedures and antibioticprescribing. We saw that this was discussed at theclinical governance committee.

• No incidents were reported as “severe” in the periodApril 2015 to March 2016.

• The majority of reported clinical incidents related tosurgery with 219 of 233 incidents over the period (94%).The hospital quarterly reports showed that the numberof incidents rose from 46 in the quarter April to June2015, to 68 for quarter January to March 2016.

• All staff we spoke with were aware of the incidentreporting process and stated they felt able to raiseconcerns through the process, including reporting onthemselves. We were aware of considerable workundertaken to raise awareness of the importance ofincident reporting and learning. There was a healthyreporting culture which indicated (but cannot beproved) high reporting rather than a higher number ofincidents than other independent hospitals. There wasclear evidence in the clinical governance committeeminutes we looked at that this was on going work withchanges implemented to enable benchmarking withother BMI hospitals and shared learning.

• The number of non-clinical incidents reported over thesame 12 month period were also slightly higher thanother independent providers which reflected the workundertaken to promote a culture of reporting andlearning. Of the 61 incidents, 28 (46%) related to surgicaldepartments.

• Currently the hospital used a paper based document forreporting incidents with proposals to move to anelectronic system. Staff we spoke with in the variousareas we visited on the inspection were all able todescribe the reporting process and the feedback at wardmeetings. One example of an incident reported waswhere a patient for a joint injection arrived with nobooking form.

• In theatres, the paper incident forms were sent to thetheatre manager who input them onto an electronicdatabase and investigated as required. These were thendiscussed at theatre meetings, together with learning.We saw examples in minutes we were shown. Feedbackwas provided to individuals. Incidents for corporate

Surgery

Surgery

Good –––


learning were fed up accordingly. We were provided withan example where practice had changed as a result ofcorporate learning where implants were checked withthe surgeon before opening.

• The theatre manager also kept a paper record of allincidents which we saw. Examples included near missessuch as the wrong side recorded on the booking formand where the operating list was incorrect. We were toldthat wrong site near misses had occurred where therewas a discrepancy between the patient record and thebooking form. We were told that the rigorous use of theWorld Health Organisation (WHO) checklist meant thaterrors were identified and corrected prior to surgery.However, whilst we observed four examples of goodpractice we also saw two examples of poor practice inthe urology theatre where not all staff were engaged inthe WHO checklist process. This meant there was risk ofan error occurring.

• Another example staff told us about was where aconsultant felt that a consent form was not required fora procedure. Action was taken, the consultant was senta letter reminding them of the policy and the issue wasdiscussed.

• Incidents reported in the pre-assessment departmentwere sent directly to the quality and risk manager, forexample if the full previous medical history was notavailable for a patient.

• Staff told us that they received feedback regardingreported incidents and this included regular emailshighlighting actions and lessons learned as well asdiscussions at their ward and theatre meetings.

• We were told of an incident where a patient requiredblood but one piece of equipment had failed. Stafftelephoned the support number, took advice and thepatient received blood and was well post operatively.Staff discussed informing the patient and spoke to thehaematologist. The surgeon saw the patient and fullyexplained what had happened. The equipment issuewas also resolved. We saw evidence that the incidentwas discussed at the clinical governance committee andthe Medical Advisory Committee. Staff we spoke withunderstood duty of candour.

• Patient morbidity and mortality data was collected andreviewed with those within the criteria presented atclinical governance meetings.

Safety thermometer or equivalent (how does theservice monitor safety and use results)

• The hospital used the NHS Safety Thermometer, anational improvement tool for measuring, monitoringand analysing harm. It measured the proportion ofpatients that experienced ‘harm free’ days frompressure ulcers, falls, urinary tract infections in patientswith a catheter and venous thromboembolism.

• Day case patients were excluded from the safetythermometer.


• No episodes of hospital infections such as MRSA andClostridium Difficile (C. difficile) were reported in the last12 months. Inpatients were screened for MRSA. If foundpositive they were treated before surgery. We saw theprotocol and evidence of screening in the patientrecords we looked at.

• For the period April 2015 to March 2016 the hospitalreported five surgical site infections, four orthopaedicand one breast procedure. Orthopaedic surgeryaccounted for 44% of surgical procedures for the samereporting period.

• The support services manager had overall responsibilityfor cleaning clinical areas. Housekeeping staff cleanedat nights and worked to housekeeping checklists foreach area. We saw that the theatre cleaning checklistwas visible and completed. We saw the completed dailycleaning check list in the pre-assessment unit.

• All areas visited were visibly clean.• The patient led assessment of the care environment

(PLACE) for the period February to March 2015 scored100% for cleanliness, which was better than the nationalaverage of 98%.

• Decontamination for theatre instruments wasoutsourced to a BMI sister company. We were told of areported issue with the logging and numbers betweenthe hospital and the decontamination unit which raisedconcern regarding the traceability of items. The processwas under discussion for resolution at the time of thevisit.

• We saw green ‘I am clean’ stickers in use on equipmentwe checked in all clinical areas we visited.

• Water was flushed every Tuesday and Friday to ensurecleanliness and water free of Legionella bacteria.

• We saw that the World Health Organisation Guidelineson Hand Hygiene in Healthcare Five moments for handhygiene posters were at all hand washing facilities.

• We saw good infection prevention and control practicesin theatres and associated areas.

Surgery

Surgery

Good –––


• The infection prevention and control (IPC) lead for thehospital chaired meetings every two months for the linknurses from each department. We saw minutes thatdemonstrated good attendance. The link nurse wespoke with told us that they attended the meetings andfound them valuable and useful.

• The IPC lead attended quarterly Surrey IPC meetingsthat included representatives from the clinicalcommissioning groups and other independent healthproviders with the aim of sharing best practice.

• The IPC lead worked three days a week in that role, theother two days as an oncology nurse.

• There were monthly hand hygiene audits. We looked attheatre audits from January 2016 to date and saw theyall scored 100%. This was an improvement on 2015where a few scored less. The audits were co-ordinatedby the infection prevention and control link nurse fortheatres. Monthly hand hygiene audits across thehospital demonstrated 100% compliance in thequarterly audit reports we were provided with.

• The IPC lead said that they followed up any repeatednon-compliance by individual staff identified by thehand hygiene audits by sending a letter reminding themof their infection prevention and control responsibilities.

• We observed anaesthetic staff washed their handsbefore commencing anaesthesia.

• Theatres and associated areas were visibly clean,floorings and wall covering intact. There was sufficientspace and secure storage.

• All staff we observed followed the bare below the elbowpolicy.

• We observed the scrubbing procedure with trolleypreparation, swab and instrument checking. We sawgood aseptic technique for patient preparation anddraping. Sharps handled safely. There was good practiceusing only safety needles for cannulation andinfiltration.

• Single use items were checked appropriately. Allanaesthetic items were single wrapped and disposable.We saw good recording and documentation practices.

• Blood pressure cuffs were single patient use on thewards.

• Specimen pots were prefilled with the preservingsolution so that staff were not exposed to it. Two spillkits (equipment for effective cleaning and safe disposal

of clinical waste, helping to reduce the risk of crossinfection) were in the theatre department with guidanceand the contents were in date. Spill kits were alsoavailable on the wards.

• There were colour coded infection control procedures inplace in respect of, for example, waste bags and linens.

• We saw that there was a plentiful supply of personalprotective equipment available for staff in all areas wevisited. These included gloves and aprons. Cleaningwipes were readily available in appropriate areas.

• Curtains were disposable and last changed May 2016.They were changed every six months unless requiredearlier due to damage or contamination. The medicalequipment list flagged this up one month in advance ofthe change required.

• Sharps bins we looked at in the three main theatreswere clearly marked and dated with the containersplaced close to areas where medical sharps were used.They were used in accordance with the Health andSafety (Sharp Instruments in Healthcare) Regulations2013.

• However, having found evidence of poor performanceon the annual sharps audit, we saw this was to berepeated early. The link IPC nurses had been retrainedas a result of the audit.


• The hospital had three main theatres, two with laminarflow (a system for ensuring clean air flow in theatres).

• The theatre department was controlled through a swipecard system. There was a visitors’ book in use. When, forexample, surgical equipment representatives wereinvited to theatre by surgeons they were required toobtain a visitor’s pass before entering the area. Weasked to see the hospital’s visitors’ policy but staff wereunable to provide this during the inspection.

• We observed one occasion where a representative cameto theatre but as the surgeon had not arranged the visitthey did not remain.

• We checked the theatre resuscitation equipment whichwas visibly clean with all medicines and equipment indate. The anaphylaxis kit was seen and in date. Wechecked the difficult airway trolley which was visiblyclean and all devices in date with the appropriateguidelines from the Difficult Airway Society. We checkedthe malignant hyperthermia kit which was clean, in dateand staff could locate the guideline and the medicines

Surgery

Surgery

Good –––


for treatment, specifically dantrolene. We saw evidencethat staff had completed all required checklists toensure that all the equipment was ready and availableat all times.

• An operating department practitioner (ODP) wasresponsible across the hospital for monitoring andauditing resuscitation incidents and trolleys.

• We saw evidence that theatre equipment service checkswere carried out on the equipment we looked at. Therewas a completed asset register in theatres with theappropriate sign seen on the equipment. Theanaesthetic machine checks complied with theAssociation for Perioperative Practice guidelines.

• Portable appliance testing (PAT) checks were completedannually and we saw certificates and the record on allindividual pieces of equipment we checked during thevisit.

• However, the electronic database that contained the fulllist of PAT compliance for the hospital was lost due to asoftware failure. An external company had been bookedto repeat testing and ensure a full list of compliance.Medical equipment under contract did not require PATtesting as this was carried out under the maintenancecontracts.

• We saw evidence that equipment was calibrated toensure accuracy, for example a blood pressure device.

• Patient trolleys had oxygen and suction available fortransfer.

• There was a wide range of pressure relieving devicesavailable and in use.

• We saw patslides and transfer sheets in use as per thehospital’s moving and handling protocols. There wasalso air-assisted safe patient transfer equipmentavailable for patients with high body mass index as thehospital provided bariatric surgery.

• There was a CO2 laser that we were told was rarely used.We saw evidence that there was an up-to-date policyand laser protection advisor training. We saw evidenceof robust systems for the ordering and management ofloan instruments.

• There was work underway to complete a full medicalequipment list, and at the time of inspection it wasabout 50% completed. We saw evidence that the systemprovided a flag when equipment was due formaintenance. There was a process for any equipmentout of service and we saw three examples.

• There were call bells in all the patient rooms and weobserved the weekly test during the inspection.

• There was a programme underway to replace all patientchairs on the wards to wipe clean surfaces for improvedinfection prevention and control.

• We saw that the hospital undertook the annualHealthcare Waste Pre-acceptance audit in February2016 for the whole site. Conclusions andrecommendations were included and the report sent toappropriate bodies.

Medicines

• Medicines were stored securely. All medicines were inlocked cupboards in theatres. Intravenous (IV) fluidswere kept in lockable cupboards. We saw that the IVcupboards were left open during use for easy access butwere told would be locked at night. Once opened, thetheatre was secured with key card access.

• We saw controlled drugs were kept in a lockedcupboard in theatres. The order book and controlleddrug record book were seen and correctly completed.

• For patients undergoing surgery, antibiotics werediscussed at the appropriate stage of the WHO SurgicalSafety Checklist prior to the procedure.

• We checked medicines management on one of the twowards that were in use at the inspection.

• All medicines were stored securely in locked cupboards.The medicines trolley was locked and secured to a wallwhen not in use.

• We looked at a sample of medicines and found theywere all in date. One opened pack highlighted in red theexpiry date later in the month.

• We saw daily checks done for the drugs fridge. Therewas an alarm should the temperature fall outside thecorrect range which was clearly stated.

• We saw current editions of the British NationalFormulary in clinical areas.

• We looked at the controlled drugs register which waswell completed. We saw the Home Office ControlledDrug Licence with expiry date 22 November 2016.

• On the wards we saw that patients’ own medicines werelocked in a cabinet in their room. Patients did notself-medicate whilst in hospital.

Records

• The medical records for all inpatients were securelystored in the hospital in all areas visited. A copy of thesurgical procedure and inpatient episode for NHSpatients was sent to the relevant NHS hospital.

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• We checked the operating lists on the two days of theinspection. The planned side that the procedure wouldbe carried out on was not recorded in every case. Wewere told that this information was not alwaystransposed from the patient record. This could pose arisk if other checks were not always completed.However, we were not aware of any such incidents.

• We saw the paper diary for theatre planning. This didcontain some personal identifying information and,whilst it was not locked away at night, there wasenhanced access to theatres which meant only staffmembers with an access card could enter.

• We looked at four sets of pre-operative patient recordsand three sets of post-operative records. We found thatrecord keeping was good.

• We saw the appropriate patient pathways used. Thesewere single, comprehensive paper based documentsthat incorporated the perioperative care plans. Alltheatre items including swabs were tracked in thisrecord which we saw fully completed. We also looked attwo sets of records for patients discharged the previousday and saw the pathway fully completed withdischarge information and letter.

• The patient records demonstrated completeness with,for example, referral, GP information including pastmedical history, risk assessments, pain score andmanagement, medicines chart, discharge letter andmedicines to take home.

• We saw that specimens were double checked for correctpatient details. The scrub nurse (registered nurses whoassist in surgical procedures) entered the details in thepatient record.

• We saw that some signatures were illegible on acontrolled drugs patient register we looked at on StClare’s Ward. When we looked at the clinical staffsignature sheet this was incomplete and staff wereunable to identify one signature we tracked. This meantthat it would not be possible to find the relevant personif there was a query.

Safeguarding

• We were informed that there were no safeguardingconcerns reported in the period April 2015 to March2016.

• The director of nursing was the safeguarding lead andwe were informed that they were trained to level threefor vulnerable adults and level two for children. This isconsidered a risk as children could accompany adults to

the hospital. The hospital told us that there was aservice level agreement in place with a neighbouringBMI Hospital facility for a Lead Nurse for ChildProtection, who held safeguarding level three. Thismeant that the hospital could access advice onsafeguarding children issues but did still not meetnational guidelines which recommended that all staffworking with children should be trained to level three.

• We spoke with two registered nurses in theatres whodemonstrated a good understanding of safeguardingand the triggers. They had access to training andsupport and said they felt able to raise concerns withtheir manager if necessary.

• Nurses on the wards told us they had undertakene-learning for both children and vulnerable adultsafeguarding and knew how to report concerns.

• The training target for safeguarding was 90%. Thehospital told us 95% were trained to level 1 and 93% tolevel 2 for safeguarding vulnerable adults and forsafeguarding children.

• Equipment sales representatives were invited intotheatres by consultants and, we were told, known tothem. However we could not clarify how the hospitalwas assured that all representatives had been checkedby the disclosure and baring service. This, whilstunlikely, meant that there was the possibility ofinappropriate people present with adults renderedvulnerable by anaesthesia.

Mandatory training

• The target for mandatory training set by BMI Healthcarewas 90%. Mount Alvernia hospital had a total of 93% inall departments of the hospital with nursing staff at 94%,pharmacy 100% and ward staff 90%.

• The majority of training was e-learning based on anelectronic system with a knowledge check. Topicsincluded informed consent, safeguarding vulnerableadults and children and dementia awareness. Othertraining with an additional face-to-face elementincluded fire training, moving and handling and basiclife support.

• Fire safety training was provided in house and wasmandatory for all staff. Hospital wide we were shownthat 91% of the 300 staff members had completed thetheory part of the training. There was a fire warden foreach department.

• Staff we spoke with showed us examples of completedmandatory training. One showed us that they were

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100% compliant. Another showed us that their firetraining was booked and they were otherwise in datewith training such as infection control, basic life supportand equality and diversity.

• Staff received emails via their managers if any trainingwas overdue. We were shown e-learning alerts andreminders. Managers were responsible to ensuring staffremained up to date.

• The RMO was supplied by an agency. We were told thatit was the agency’s responsibility to ensure that all RMOshad completed their mandatory training and this wouldbe evident on their CV. The hospital checked the agencydocumentation to ensure that they were fully up to datebefore starting work. The RMO we spoke with confirmedthat they had completed their mandatory training andwere up to date.


• Pre-assessment of patients for surgery included athorough assessment of risk. If there were any concernsthe RMO was contacted to see the patient. The RMOreviewed all test results the following day and, ifrequired, would refer the patient to the relevantconsultant.

• We saw evidence in the seven medical records welooked at of risk assessments such as skin viability,nutrition and falls. There were risk scores recordedwhich meant that any high risks were identified prior toadmission so that prevention measures could be put inplace. Risk assessments were reviewed on admission.

• The hospital used the national early warning score(NEWS) for tracking patients’ clinical condition andalerting the clinical team to any deterioration thatwould trigger timely clinical response. We saw that thepre-operative entries had been completed correctly.

• The RMO provided medical cover 24 hours a day, sevendays a week. This meant concerns regarding a patientcould be escalated at any time of the day. The RMOcould contact the relevant consultant as they wererequired to be available at any time of day when theyhad patients admitted to the hospital.

• We were informed that 100% of patients were screenedfor venous thromboembolism (VTE) for the period April2015 to March 2016. We looked at seven sets of medicalrecords and saw that patients had been screened forVTE in all cases. The audit results confirmed this for theperiod January to June 2016.

• There were no incidents of hospital acquired VTE orpulmonary embolism in the last 12 months.

• We observed theatre staff carrying out the WHO SurgicalSafety Checklist for six procedures. The WHO checklist isa national core set of safety checks for use in anyoperating theatre environment. The checklist consists offive steps to safer surgery. These are: team briefing; signin (before anaesthesia); time out (before surgery starts);sign out (before any member of staff leaves the theatre);debrief. It was developed to decrease errors and adverseevents, and increase teamwork and communication insurgery.

• On four occasions we saw that this was done well withthe whole team involved. Introductions were observedand the sign out was completed with everyone’sattention. We saw that the checklist could be initiatedby any member of the team. For some procedures thechecklist was initiated by the surgeon, and for another itwas initiated by the registered nurse.

• However, on two occasions in the urology theatre, wesaw examples of poor practice. One example was in theanaesthetic room where the ‘sign in’ was done by anoperating department practitioner (ODP) alone whilstthe anaesthetist was making up the drugs and thesurgeon came and went. Another example was at theend of a procedure, no ‘sign out’ was done, theprocedure done was not confirmed and the anaesthetistwas on the telephone. This meant there was anincreased chance of error with decreased teamwork andcommunication evidenced.

• We were provided with the first two quarterly auditreports for 2016 which demonstrated the monthlyaudits of the WHO checklist with issues highlighted anddiscussed at the Medical Advisory Committee and otherstaff groups as required. The April to June 2016 reportshowed some improvement.

• We were provided with an example where it wasidentified that a patient did not have the optimumtemperature for surgery. The order of the theatre list waschanged to allow appropriate care that ensured surgerycould safely go ahead that day.

• One patient described a ‘seizure’ they hadpost-operatively and told us staff attended immediatelyand the consultant came in to see them.

• In case of cardiac arrest or stroke staff called thehospital crash team and an ambulance to take the

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patient to the appropriate NHS hospital. The hospitalhad a service level agreement with the local NHS trust.This enabled them to transfer any patients who becameunwell after surgery and needed critical care support.

• Resuscitation simulations were carried out with themost recent one in June 2016. Simulations areunannounced crash calls (emergency call outs forcardiac or respiratory arrest) with staff attending as ifthey were real life incidents. Feedback was provided byan external company which staff described as “veryuseful”.

• We reviewed the medical records for three patients whohad returned to theatre following their operation. Twowere for known complications that were recognised andtreated promptly. The third was investigated andlearning identified regarding timely documentation. Theoutcome for the patient was unchanged.

Nursing, theatre and other staff

• We were told that the BMI Healthcare nursingdependency and skill mix tool is a guide to ensure theright members of staff are on duty at the right time andwith the right skills, to ensure high quality patient care.

• The tool was used to plan the skill mix at least 24 to 48hours in advance. The spreadsheet was completed on adaily basis reviewing the time period midnight tomidnight as a rolling 24 hour period. The actual hoursworked were also entered retrospectively to understandvariances from the planned hours and the reasons forthese.

• We saw evidence of the May daily rota for the wards thatincluded average staff utilisation through the day. Thisdata demonstrated actual staff against that requiredand that there were no agency payments during thatmonth.

• St Clare’s Ward showed actual staffing in line withexpected for late and night shifts with an additionalregistered nurse on the early shift. We were told thatstaffing was changed dependent on need. On StEthelbert’s Ward there were two registered and onenon-registered nurse on both early and late shifts. Fiveinpatients were admitted on the early shift with four daycases admitted in the afternoon, a maximum of ninepatients.

• Sickness rates for nurses working in theatredepartments for the same reporting period were nothigh when compared to the yearly average of otherindependent acute hospitals CQC holds this type of data

for. However, rates for ODPs and health care assistantswere more variable and higher than the yearly averagefor six out of the 12 months. Sickness rates for nursesand health care assistants working in inpatientdepartments were not high.

• There were no vacancies for ODPs or health careassistants as at April 2016. There was one full timevacancy for theatre nurses which was low whencompared to other independent acute hospitals. Therewas one full time registered nurse vacancy on the wardsbut no vacancies in respect of health care assistants.

• Staff turnover figures for theatre and ward staff was nothigh when compared to other independent acutehospitals CQC holds this type of data for.

• All shifts were filled on the wards and in theatresbetween January and March 2016.

• The rates of use of bank and agency staff for inpatientnurses, both registered and non-registered, were mainlylower than the yearly average of other independentacute hospitals we hold that type of data for.

• Theatre staff numbers were in line with the Associationfor Perioperative Practice guidelines. We saw four staff intheatre for the procedures we observed. A porter wasavailable to collect patients as required. The majority oftheatre staff were either registered nurses or operationdepartment practitioners.

• The rates for use of bank staff in theatres were low whencompared to the yearly average of other independentacute hospitals we hold this type of data for.

• Ongoing recruitment resulted in some new teammembers. Staff told us that this enabled them to upskillstaff more easily which in turn made for more flexibility.Staff felt that there were sufficient staff and no agencystaff had been used for over 18 months. There wasoccasional use of bank staff.

• Staff were supported in achieving competence basedtraining to ensure flexibility in the workforce.

• We observed that the recovery bay was well staffed andwell run.

• The pre-assessment unit was staffed by one sister, tworegistered nurses and one pre-assessment coordinator.Cover was provided for absence such as annual leave bybank staff. Staff could bleep the RMO if they hadconcerns about a patient.

• In addition, there was always a duty matron (a seniornurse) available at the hospital as a contact point forboth staff and patients, including to help resolve patientqueries and to accept out of hours admissions.

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• In addition to clinical and consultant arrangements, thesenior management team operated a rota for on callsupport out of hours. There was also an on call rotaoperated by the pharmacy, radiology and physiotherapyteams should support be required out of hours, as wellas an on call emergency theatre team.

Surgical staffing

• Consultants were required under their practicingprivileges to be available both by telephone and, ifrequired, in person whenever they had patientsadmitted to the hospital. Consultants were required toarranged appropriate alternative named cover if theywould not be available.

• Consultants visited their patients daily until they weredischarged from the hospital.

• Anaesthetists were available for the first 24 hoursfollowing surgery to ensure availability should a patientneed to return to theatre.

• A RMO, supplied by an external agency, provided a 24hour seven day a week service on a rotational basis. TheRMO worked closely with the consultants in the care ofthe patients. Should the RMO become unwell theagency was called to provide cover.

• The director of nursing regularly met with the RMOs anddiscussed their welfare and any concerns. If there wereany concerns regarding the RMOs the agency would becontacted. The hospital received assurance from theagency regarding registration and up-to-date training forthe RMOs.

• The RMOs were supported by senior nursing staff. Wesaw the RMO book on the wards into which staff enteredtasks and patient requirements.

• Protocols were in place to ensure rest periods. A teambrief took place prior to the RMO settling for the night toensure all patient requirements had been attended toand any other measures taken to reduce the possibilityof calling the RMO at night.

• We saw the corporate BMI Healthcare PracticingPrivileges Policy for Consultant Medical and DentalPractitioners, 2015. Adherence to the policy wasmonitored and any concerns discussed at the MedicalAdvisory Committee.


• We asked the hospital for a copy of their localemergency preparedness resilience policy (EPRP). Wewere told this was not available as the hospital was notpart of the resilience forum.

• We found all staff we spoke with demonstrated a verygood awareness in the case of fire and describedscenario training. We were told there were slide sheetsunder the mattresses for evacuating patients.

• Not all staff had not attended major incident orbusiness continuity training. However, in ourdiscussions with them staff could articulate what theywould do should there occur an event that adverselyaffected business continuity.

• The hospital had a response team who would respondto an emergency situation. The team all held bleeps andwould respond immediately when required. The dailyward meeting in the morning on St Clare ward allocatedthe response bleeps and a fire marshal was designated.

• There were back-up generators for electricity failure.

Are surgery services effective?

Good –––

We rated effective as good because:

• We found care and treatment reflected current nationalguidance.

• There was comprehensive assessment of patient needs.This included clinical needs, physical health, nutritionand hydration needs. Patients received adequate painrelief.

• The hospital routinely collected and monitoredinformation about patient care and treatment as well astheir outcomes. There were protocols in place forpatient transfers.

• There was a proactive audit programme that includednational, corporate, hospital and departmental audits.Results were shared throughout the hospital andcollated to identify themes.

• Patients were able to contact the hospital for advice andinformation at all times. Patients provided informed,written consent before commencing their treatment.

However;

• Appraisals of theatre staff was low.


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• We saw relevant and current evidence based guidance,standards, best practice and legislation were identifiedand used to develop how services, care and treatmentwere delivered.

• Care was provided in line with National Institute forHealth and Care Excellence (NICE) CG50 for acutely illpatients in hospital. We saw examples of patientstransferred out in accordance with the guidance. Wesaw that physiological observations were recorded atthe time of admission in the seven sets of patientrecords we looked at. The audit against the guidancecarried out in February 2016 demonstratedimprovement in eight of the 16 areas looked at from theprevious audit in August 2015. For example, appropriateescalation had improved from 70% to 90%; all entriessigned had improved from 90% to 100%. Six areasremained at 100% for both audits. In two areas theresults were worse than the previous audit withreduction from 100% to 90% in both. Appropriateactions were identified.

• We saw examples of guidelines in use such as NICEQS24: nutrition support in adults, QS3: VTE in adultsreducing the risk in hospital, and QSD77: urinaryincontinence in women.

• NICE guidance was reviewed at clinical governancemeetings and if relevant discussed with clinicians toensure best practice.

• We were shown examples of the Nursing and MidwiferyCouncil guidelines followed by staff with up-to-dateprotocols on the hospital intranet.

• The hospital participated in a variety of national audits,for example the National Joint Registry (NJR), the NHSsafety thermometer and the Patient Reported OutcomeMeasures (PROMS) which assesses the quality of caredelivered to NHS patients from their perspective.

• There was an annual audit plan. We were provided withthe two most recent quarterly audit reports covering theperiod January to June 2016. There were seven monthlyaudits that included medical records, the WHOchecklist, VTE screening and hand hygiene. Results weredisplayed as well as issues identified andrecommendations. These included, for the medicalrecords audit, findings such as no copy of consultantclinic notes where compliance had got worse, and poorcompliance with documentation of the consultant dailyprogress notes which had improved. There were clear

recommendations that the results were to be discussedat the clinical effectiveness committee and the medicaladvisory committee (MAC) with continued audit andreporting over the next quarter.

• Other audits with different time frames were carried out,such as resuscitation audits every quarter and biannualblood transfusion audits. Improvements and clearrecommendations were included in all audits.

• We saw evidence of a number of regular departmentalaudits carried out. In theatres, the care bundle toprevent surgical site infections review tool wascompleted quarterly on 20 randomly selected cases. Asharps audit completed by an external companyshowed theatres scored 100%. The urinary catheterinsertion audit in June scored 100%.

• The monthly WHO checklist audits identified the mainarea of focus to be the importance of each teammember identifying themselves at the start of everyprocedure. This had been discussed at theatre meetingsand was subject to on going audit.

• The wards carried out falls audits with learningdiscussed at ward meetings.

• We also saw the most recent resuscitation checklistthree monthly audit with no issues identified.

Pain relief

• We saw the pain descriptor information provided forpatients on the wards. This meant that patients coulduse this to accurately respond when asked about painby staff.

• Patients we spoke with told us that their pain had beenwell controlled.

• We saw that pain scores were recorded in the patientrecords we looked at with management by the RMO. Wewere told that anaesthetists were available to managepain control where necessary.

• A pain relief audit of documentation was carried out inMay 2016 and will continue to be done twice a year. Thisshowed 81% for day case and 88% for inpatients. Theresults were considered alongside patient feedbackcompleted on discharge and analysed externally. Therewas indication of improvement from previous patientsurveys and identified the importance of all methods ofpain management being considered. Feedback wasthrough the ward meetings and clinical governancecommittee.

Nutrition and hydration

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• Nutritional screening was done at pre-assessment andon admission so that dietician advice could be soughtwhere required. The Malnutritional Screening tool(MUST) was used and we saw evidence that this wascompleted in patient records we looked at.

• The dietetic service was provided on a sessional basisby the local NHS trust and formed part of themulti-disciplinary team caring for patients.

• We saw food and fluid intake was monitored using foodcharts and fluid balance charts. We were told patientswho were unable to feed themselves were assisted bythe nurses and health care assistants. At the time ofinspection all inpatients were independent and did notrequire assistance with feeding.

Patient outcomes

• The hospital participated in Patient Reported OutcomeMeasures (PROMs) which is a tool used to measurehealth gain in patients undergoing hip replacement andgroin hernia surgery in England. The hospital's averagehealth gain for groin hernias and hip replacement couldnot be calculated for this hospital as there were lessthan thirty records

• The hospital provided us with mortality and morbidity(M&M) data from April 2015 to June 2016 which includedunplanned transfers out, unplanned readmissionswithin 28 days and unplanned returns to theatre.

• We were also provided with surgical complications datawhich showed 33 for the period July 2015 to March 2016.Where complications were within the M&M criteria thesewere reviewed and presented at clinical governancemeetings.

• There were 11 unplanned transfers of patients duringthe reporting period April 2015 to March 2016. Five ofthese related to surgical procedures. All wereinvestigated fully, reported and discussed at the medicaladvisory committee where appropriate. Learning wasidentified and disseminated appropriately. One relatedto the outpatient department. This meant there were 10unplanned transfers out of 5,377 day case and inpatientattendances across the hospital for that period.

• There were eight cases of unplanned readmission within28 days of discharge in the reporting period April 2015 toMarch 2016. The assessed rate of unplannedreadmissions (per 100 inpatient attendances) was nothigh when compared to a group of independent acutehospitals which submitted performance data to CQC.

We saw two examples of the full root cause analysis ofincidents. Learning was clearly identified with actionstaken. Where it was due to a known risk/complication ofthe procedure a full investigation and discussion wasalso done.

• There were seven cases of unplanned return to theoperating theatre in the same reporting period. Welooked at three sets of patient records and found earlyrecognition of known risks/complications and promptmanagement for the patients.

• Physiotherapy patients agreed goals and monitoredoutcomes for individual patients. We saw evidence forthree patients that demonstrated both symptom andcondition improvement.

Competent staff

• Staff we spoke with told us they felt well skilled to carefor both surgical and medical patients on the wards.

• We saw that induction was completed for new staff. Wewere told that staff were welcomed and they met theexecutive director and director of nursing as part ofinduction.

• Staff were able to access training and told us they werewell supported and encouraged to attend courses fortheir learning and development. We saw exampleswhere administration staff had moved into differentdepartments for development. Examples of furtherdevelopment included courses such as acute illnessmanagement and cognitive behavioural therapy.

• We saw the massive blood transfusion protocol intheatres and that staff were appropriately trained.

• One ward, one pre-assessment and two theatreregistered nurses we spoke with said they had theirappraisals. We saw examples of completed appraisals.

• However, data for the year October 2014 to September2015 showed only 55% of theatre staff receivedappraisals. The numbers were low for the current yearfrom October 2015 to September 2016 with 40%appraised so far.

• Staff said they had regular meetings with their linemanager and felt well supported. They also receivedmonthly emails with updated information.

• The MAC was responsible for granting and reviewingpractising privileges for medical staff. The hospitalundertook robust procedures which ensured surgeonswho worked under practising privileges had thenecessary skills and competencies. The surgeonsreceived supervision and appraisals. Senior managers

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ensured the relevant checks against professionalregisters and information from the Disclosure andBarring Service (DBS) were completed. The status ofmedical staff consultants practising privileges wasrecorded in the minutes of the MAC notes.

• The agency that supplied the RMO provided the CV for anew RMO and this included their training records. Thiswas reviewed by the director of nursing. Each new RMOundertook a full hospital induction.

• The RMO confirmed they had an appraisal andundertook continuous professional development. Thiswas monitored by both the hospital and the agency.

Multidisciplinary working (in relation to this coreservice only)

• We found good bed management and forward planningwith daily meetings and an online system which allowedall staff to plan and see patients booked for admission.These were attended by the executive director, directorof nursing and heads of department.

• The pre-assessment nurses, physiotherapists andoccupational therapists worked together to ensurecompleted risk assessments and other preparation wasin place prior to the patient being admitted.

• Inpatient wards had a multi-disciplinary communicationsheet. This was completed on a daily basis forinformation to be passed to members of staff onsubsequent shifts. For example a reminder of meetingsor specific information relating to a patient. Staff had tosign the forms to show they had read the informationand action had been taken.

• A service level agreement with the local NHS trustmeant that patients could be referred to a full range ofallied health professionals including speech andlanguage therapy and dietetics.

Seven-day services

• The hospital had medical cover from an RMO and seniornurse 24 hours a day seven days a week as a contactpoint for both staff and patients.

• Patients had access to telephone advice 24 hours a day,seven days a week.

• The pharmacy was accessible 24 hours a day, sevendays a week. Out of normal working hours a seniornurse and RMO had access to the department. Thepharmacy provided an on call 24 hour service for adviceand medical information. The on call pharmacist wouldattend the hospital if required in an emergency.

• There was also an on call rota operated by radiologyand physiotherapy teams should support be requiredout of hours, as well as an on call emergency theatreteam.


• The hospital monitored the availability of medicalrecords for patients admitted for surgery. This showedthat for the last three months there were no incidents ofthe records not being available. This meantpre-assessment information, including past medicalhistory and test results, were all in place for clinical staff.

• Morning ‘huddles’ were held to review admissions anddischarges planned for the day. This meant thatindividual patient requirements were communicated toall staff.

• The hospital electronic tracking system meant that allclinical and administrative staff were aware of patientbookings.

• We saw discharge letters to GPs providing informationregarding procedures and aftercare in patient recordswe looked at.

• The hospital held a breast implant register whichrecorded every breast implant used on every patient.

• Wards had folders with consultant contact details andother relevant information for patient care.

• Immediate diagnostic reporting was available through aservice level agreement with the local NHS hospital forcancer patients, for example sentinel node biopsies, asthese were sent by courier.

• We saw that policies and procedures were readilyavailable to staff.


• The hospital had a Safeguarding Adults Policy thatincluded the Mental Capacity Act (MCA) 2005 legislation,Deprivation of Liberty Safeguards (DoLS) and set outprocedures that staff should follow if a person lackedcapacity. The policy included the process for consent,documentation, responsibilities for the consent processand use of information leaflets to describe the risks andbenefits. MCA training was a part of the widersafeguarding training.

• We looked at the consent forms for all the procedureswe observed and all records we looked at. The formswere fully completed and included any relevant risksand complications. We observed consent discussions.

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• Patients told us they had been consented by thesurgeon and the anaesthetist.

• We spoke with two registered nurses in theatre aboutMCA and DoLS. They demonstrated a good knowledgeand understanding of mental capacity and the consentprocess. We were told it was very rare that patients wholacked capacity to consent for a procedure to be treatedat the hospital but they knew the process to followshould this occur.

• Ward staff demonstrated understanding of MCA. Otherstaff told us that they would contact the patient’s GP orconsultant if they had concerns about their capacity toconsent.

• We saw that patients were always informed before acare action, such as taking blood pressure, wasundertaken.

• The PLACE score for dementia care in the hospital was85%. This was the same or higher than the Englandaverage.

Are surgery services caring?

Good –––

We rated caring as good because:

• We observed patients treated with compassion, careand dignity. Patient feedback was positive and staffdemonstrated commitment to continuousimprovement.

• Patients told us they were well informed and were ableto ask for further information.

• Patients were well supported.

Compassionate care

• We saw that staff were courteous and treated patientswith dignity and compassion.

• We spoke with six patients who said staff handled theirdignity very well, were caring and very efficient.

• The hospital scored 100% for Friends and Family Test(FFT) in the reporting period October 2015 to March2016 with the exception of December 2015. These referto NHS patients only and are reported by NHS England.However, the hospital provided reports with their FFTresults of all patients, NHS and private funded. Thesewere comprehensive monthly reports that covered thewhole patient journey and allowed comparison withother BMI hospitals in the region as well as BMI as a

whole. The report for March 2016 showed positiveresults with high satisfaction score of 99.9% for beingtreated with respect and dignity and the lowest score of75% for the choice of food. This was one of only tworesults scoring less than 82% out of 46 data items.

• Areas that the FFT demonstrated had improved, as wellas any issues, were identified and reported on. Thereport showed that out of the 55 BMI hospitals, MountAlvernia had improved from position 35 the previousmonth, to position 19 in March 2016.

• We saw approximately 80 thank you cards displayed onSt Clare’s Ward and patients frequently sent in gifts suchas chocolates to express their appreciation.

• Four CQC comment cards were completed by patientsduring the inspection. They were all positive stating, forexample, that staff were attentive and friendly and thatcare from all staff was “beyond exceptional”. Thisincluded housekeeping and catering staff as well asclinical staff.

• Patients told us that they were really well looked afterand that staff had the time to care for them.

Understanding and involvement of patients and thoseclose to them

• We observed clinical staff involving patients in their careplanning. This included doctors, registered andnon-registered nursing staff.

• Patients on the wards had a named nurse caring forthem.

• We observed a member of staff providing clearinformation to a patient on the telephone.

• Patients we spoke with told us they had been providedwith sufficient information and that there was enoughtime for explanations and any further questions.

• One completed comment card said that they had beenreassured by the information provided at theirpre-assessment appointment. Another stated that staffwere, “warm and responsive to my needs”.

Emotional support

• A multi-faith chapel was available for patients, staff andvisitors. There was a book for people to leave commentsand messages and we saw several entries for July 2016.

• We saw there was a leaflet on pastoral care in patientrooms we looked at.

• If required, counselling could be arranged through aservice level agreement with the local NHS trust.

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• Patients told us they felt well supported and would beable to request any further support or pastoral care ifthey required it.

• Staff told us they could contact local religious leadersshould this be required. They demonstrated awarenessof the needs of different religions such as Jehovah’sWitnesses and Islam. One member of staff told us of apatient request to see a priest and this had beenarranged by the sister in charge.

Are surgery services responsive?

Good –––

We rated responsive as good because:

• The services were delivered in a way that met the needsof the local population and allowed patients to accesscare and treatment when they needed it.

• Waiting times, delays and cancellations were minimaland well managed. Patients told us staff wereresponsive to their needs.

• Complaints management was a priority in the hospital.The process was transparent and open with learningcommunicated across the hospital.


• The services provided reflected the needs of localpeople. Orthopaedic procedures and pain treatment forjoints were among the most common procedurescarried out at the hospital in response to an increase inolder people.

• NHS patients accounted for about 10% of total inpatientand day case activity. We were told of ongoing work withthe Clinical Commissioning Groups to increase thesenumbers.

• The hospital had introduced a bariatric service forpatients with a high body mass index. This includedlaparoscopic gastric sleeves. Planning for this serviceinvolved other specialties such as dietetics and woundcare professionals.

Access and flow

• Patients were generally booked two to three weeks inadvance with a policy of not booking a patient withinfive days of surgery. This meant that all information,investigations and pre-assessment were carried out andresults received in time for the date of operation.

• Bookings for procedures were sent to theatres to ensuresuitability and availability of staff. Decisions to admitwere based on clear criteria as the hospital did not havehigh dependency or critical care beds.

• Once this information was taken the booking waspassed to pre-assessment and patient services toarrange with the patients and pre-assessment clinicstaff.

• All patients had pre-assessment before being admitted.Patients having operations such as hips, knees andgynaecological procedures were telephoned and anappointment date agreed for them to come topre-assessment clinic. They were seen by the registerednurse as well as the anaesthetist, physiotherapist andoccupational therapist where relevant. Blood tests andother screening and investigations were done duringthis visit.

• The RMO checked results the next morning and made areferral to the consultant if required.

• Patients for less complex procedures had a telephonepre-assessment with a registered nurse. If there wereany concerns the patient would be offered anappointment in the clinic.

• Patients were booked for pre-assessment on thehospital’s electronic tracker system and we saw the listfor clinic on the day of the inspection. This meant allstaff could access the information.

• The medical secretaries booked the operation dates onthe hospital’s electronic system. The list order wasconfirmed with the surgeon, theatre teams and wardstaff the day before patients were admitted.

• There were exceptions to the five day rule for patientswith cancer or in more urgent need. In these casesstaffing and equipment availability were checked toensure everything was in place for the whole processbefore accepting the booking.

• A colour coding system was in place to highlight to staffwhere changes had been made to the operating list. Thefirst list was printed on green paper. If the order changedit was reprinted on yellow paper. Any further changesand the list was reprinted on red paper. This ensuredthat all staff were updated and aware.

Surgery

Surgery

Good –––


• The hospital reported one cancelled procedure for anon-clinical reason in the last 12 months. The patientwas offered another appointment within 28 days of thecancelled appointment.

• Surgery was also carried out on Saturdays whichprovided further flexibility for patients.

• Waiting times for NHS patients were managed withinthe requirements of the referral to treatment pathway.BMI Healthcare policy set a standard of 92% of patientstreated within that time. Data provided stated that BMIMount Alvernia achieved almost 94%. However, for theperiod April 2015 to March 2016 the months of May,June and July fell well below with 70% in June. Wespoke with management and they assured us that thishad been due to a data entry error which had beenidentified and subsequently corrected. The waitingtimes were monitored closely and there had been nofurther issues.


• A GP summary was provided for elderly patients treatedin the hospital. This meant that past medical history andcurrent conditions were known to staff atpre-assessment and onward.

• Any additional patient needs were identified atpre-assessment.

• We saw the information pack sent out to all patientsprior to their pre-assessment. This included a medicalquestionnaire and pre-surgery information, for examplefood intake and what to bring.

• We saw a range of patient information to supportpatients.

• Patients were given the choice, where possible, ofwalking to theatres or being taken in a wheelchair.

• One patient told us they were provided with “a lot ofhelp” in the night following the procedure and staffresponded promptly whenever this was requested.

• Patients told us that the hospital accommodated theirdates for surgery and that there were no delaysexperienced. This included NHS patients.

• Staff had access to a translation service should this berequired.

• There was open visiting hours on the wards which thepatients we spoke with appreciated.

• There was also a garden area for patient use as a quietplace to sit.

• An occupational therapy furniture height checklist wassent to patients booked to have a total hip replacement.

This was completed either prior to or at pre-assessmentand meant that the therapist was able to provideappropriate advice on care required following theprocedure, together with advice on aids and equipmentto help everyday activities once home.

• We saw there was an individual room opposite thenurses’ station on all three inpatient wards. This roomhad space for an additional bed. Staff told us this wasappropriate for relatives who wished to stay with apatient who was living with dementia or learningdisabilities.

• The multi-faith chapel catered for religions such asChristianity and Islam that included mats and washingfacilities. It also served as a quiet place for those with noreligion.

• Rooms on the wards contained televisions, informationon patients’ rights and access to the internet. There wasalso a welcome letter and general hospital informationavailable.

• We saw patients on the wards well provided for with hotand cold drinks throughout the day with staff bringingjugs of fresh water into rooms in the very hot weather atthe time. Drinks machines were available in waitingareas.

• Patients told us that they were regularly offered hot andcold drinks.

• We saw a menu with a selection of choices that includedcultural requirements and individual needs such asgluten free options. Patients were able to order mealsthat were not on the menu.

• Patient allergies were recorded on a form that waspassed to the ward hostess to take a copy for thekitchen. This meant that catering and nursing staff wereaware of all allergies.

• Catering services were outsourced and there had been achange to another private provider. The Patient-ledassessments of the care environment (PLACE) for theperiod February to June 2015 showed that food scored77% which was below the national average of 94% forward food, which reflected this change in provider. Thisscore improved to 85% in the next assessment.However, patients we spoke with said that the food wasgood. One patient told us they had requested extra fruitwhich had been provided.

Surgery

Surgery

Good –––


• We were told that the hospital were working with thecatering services to improve patient satisfaction and wesaw evidence of continued ways to improve discussedat the clinical governance committee minutes welooked at.

• We were told that the chef would come to the ward todiscuss any particular requirements with an individualpatient.


• Complaints were managed and investigated by thesenior management team and relevant heads ofdepartment who all attended the daily morning‘huddle’. We were told that complaints were discussedat the huddle as they were received which meant staffwere aware immediately one was raised. We sawevidence that complaints were discussed at the clinicalgovernance meetings, medical advisory committee,heads of department committee, theatre departmentmeeting and ward meetings.

• Staff at all levels were encouraged and empowered toaddress any concerns whilst the patient was on site toresolve any issues as soon as possible for the patientand their relatives.

• We saw that 16 out of the 29 complaints hospital widefor the period March 2015 to April 2016 concernedsurgery. The most common concerns raised werearound communication, clinical care and finance. Thehospital collated and reported on incidents togetherwith action taken and learning to be disseminated. Thismeant managers were able to identify themes and putin place measures to improve services.

• The assessed rate of complaints (per 100 day case andinpatient attendances) was significantly lower than theother independent acute hospitals CQC holds this typeof data for.

• CQC directly received four complaints during the periodApril 2015 to June 2016.

• We saw the hospital’s Patient Guide in rooms we lookedat. This covered the formal complaints procedure. TheBMI leaflets ‘Please tell us’ were readily availablethroughout the hospital. Patients were given anopportunity to complete the hospital’s patient surveyquestionnaire.

• Patients we spoke with said they knew how to complainbut did not need to as the care and treatment was of avery high standard.

• The hospital held periodic patient satisfaction meetingsto review complaints, compliments and survey results.This was chaired by the executive director and identifiedtrends and benchmarking within BMI Healthcare.

• The three items of rated feedback on the NHS Choiceswebsite all said they were extremely likely torecommend this hospital.

• The BMI Healthcare complaints policy set out theresponse timeframes throughout the process and thesewere monitored and reported on as part of thehospital’s governance system. All complaints wereinvestigated and complainants were informed ofprogress. Information was provided about furtheralternatives should they remain unhappy at the end ofthe process.

Are surgery services well-led?

Good –––

We rated well-led as good because:

• There were clear organisational structures and roles andresponsibilities.

• There were good governance, risk and quality systemsand processes that staff understood. The committeestructure supported this with reports disseminated anddiscussed appropriately.

• There was a strong, open leadership throughout theorganisation. Staff felt confident about raising issueswith their direct line manager and the seniormanagement team.

• The hospital collected patient information and reviewedit alongside other performance data. This wasbenchmarked within BMI Healthcare.

However:

• The risk register was not compiled so that departmentalrisks could be identified.


• The hospital had a clinical strategy which was made upof six key themes. These were: putting patients at theheart of what they do; staff were the most importantattribute; quality should underpin everything they do;working together; engaging with consultants; and beingas cost effective and efficient as possible.

Surgery

Surgery

Good –––


• Staff we spoke with demonstrated clear understandingthat the patient was at the heart of what they do andworked together to achieve this.

• We were told of the on going work to engage with thevisiting consultants and to increase the numbers year onyear.

• There was an overarching BMI Healthcare strategy thatall hospitals worked to.


• There was a corporate strategy for governance thatprovided a framework for local governance procedures.

• There were a variety of monthly meetings that discussedrisk, incidents and complaints. These included thesenior management team and heads of departmentmeetings. Information from these meetings wasdisseminated to theatre group meetings and wardmeetings. In turn information from the departmentalmeetings was fed up to the heads of department. Thisensured that there was good communicationthroughout the hospital and staff were aware of specificincidents and causes for concern.

• The hospital had a clinical effectiveness committeewhich met every two months and fed into the clinicalgovernance committee (CGC) which also met everyother month. We saw samples of minutes thatdemonstrated departmental and other meetings fedinto the CGC such as theatre and ward meetings, patientexperience committee and resuscitation committee.Clinical quality as well as governance was discussed atthe quarterly Medical Advisory Committee (MAC) andattendance included the heads of departments such asthe theatre manager.

• Staff told us that the quality and risk manager hadimplemented much more robust processes and systemsfor governance, including incident reporting,investigation and learning.

• Each department had a clinical governance folder thatcontained recent minutes from, for example, the clinicalgovernance committee and the theatre group, patientsatisfaction data, complaints log and incident reports.There was also the monthly Quality and Risk News withshared learning across BMI. Examples of contentincluded the top three themes for learning such as theaccuracy and clarity of documentation. The February2016 edition included the areas for improvement foundat other BMI hospital inspections.

• We saw evidence that staff had signed that they hadread the folder.

• Theatre staff meetings and ward meetings were heldmonthly. We saw minutes that demonstrated goodattendance. Staff told us the meetings were useful withthe minutes circulated by email. This meant that staffunable to attend had access to the discussions andinformation.

• There was 100% completion rate of validation ofregistration for doctors and dentists working orpracticing under rules or privileges in the reportingperiod April 2015 to March 2016.

• We were told there were 118 regular visiting consultantsout of a total of 195. Consultant contracts, known aspracticing privileges, were managed jointly by thehospital management and the MAC. We saw evidence ofdiscussion of new applications and the outcomes in theJune 2016 MAC minutes. There was also evidence ofconsultants suspended when they had not provided therequired documentation requested by the hospitalmanagement and reinstated once they had.

• There was a hospital risk register on the hospitalintranet in respect of the whole organisation. Theexecutive director monitored the register in respect ofMount Alvernia.

• We saw the risk register for April 2016. The risks weredivided into categories: patient safety, informationmanagement, financial, reputation, governance,operational, leadership and workforce, workforce healthand safety, and facilities and infrastructure. The registerdescribed the risks involved with their impact, likelihoodand risk ratings. Existing risk controls and further actionswere linked to a responsible committee and key lead.

• We were told the risk register was reviewed at thegovernance committee meetings to ensure thatidentified risks were on the register and if any risks hadchanged they were re scored.

• However, the risk register was for the whole hospital andwas not divided into separate areas. Staff we spoke withwere unable to tell us what was on the risk register.

Leadership / culture of service related to this coreservice

• There was a clear management structure which staffwere aware of. This meant leadership and managementresponsibilities and accountabilities were explicit andclearly understood.

Surgery

Surgery

Good –––


• The management structure for surgical services at thehospital was the executive director and the director ofnursing who were responsible for the managers oftheatres and the wards. Heads of departments oversawthe running of their respective areas and reported to theexecutive director and director of nursing.

• We were told by all staff we spoke with that the seniorteam at the hospital were visible and approachable. Allstaff knew who the senior team were. All staff told usthey had seen change and improvement over the lasttwo years and were very positive about working at thehospital. One comment we received in respect of thesenior team was, “It feels totally different.” Anothermember of staff said the hospital was “forward thinking”.

• Staff spoke highly of their direct line management andwere able to raise issues with them.

• Staff described an open reporting culture with anemphasis on learning. A member of staff said they feltable to report on themselves, for example a medicationerror.

• No whistleblowing concerns had been reported to CQCin the last 12 months.

• All staff we spoke with described good team workingwithin all clinical areas in the hospital.

• Theatre and ward staff told us that they all worked verywell together. Several of the staff had been there over 20years and we also spoke with new team members. Wewere told that they also socialise together.


• The hospital monitored patient satisfaction in all areasof its service delivery. This was achieved throughobtaining patient feedback and views through the formsthey placed in each patients room and outpatient areas.The analysis of this information was provided by anexternal provider and this was arranged through thecorporate teams. The hospital received a corporatemonthly report which showed response rates, ratingwithin categories and ranking against all BMI hospitals.It also included all the freehand patient comments.

• The hospital had a patient satisfaction group was madeup of a number of employees around the hospital. Thisgroup continually reviewed the patient satisfactionscores and dealt with areas for improvement.

• The hospital encouraged social interaction for staffthrough a range of events organised specific to thehospital. For example, the Pin Awards, Above andBeyond Awards and charitable initiatives to encouragestaff engagement in a social context.


• The senior management were proactively working toincrease surgical activity for both NHS and privatepractice. We were told of on going discussions with thelocal Clinical Commissioning Groups and consultantsfrom local NHS hospitals.

• There was considerable emphasis on the patientexperience with all staff focussed on the patient at thecentre of everything. Constant efforts for improvementwere clearly demonstrated.

Surgery

Surgery

Good –––


Safe Requires improvement –––





Information about the serviceOutpatient services at BMI Mount Alvernia cover a widerange of specialities, including cardiology, dermatology,ear, nose and throat (ENT), general surgery, generalmedicine, gynaecology, haematology, neurology,neurophysiology, nephrology and oncology. From June2015 to June 2016, the outpatient department provided615 new patients appointments and 616 follow upappointments for NHS patients. They provided 8, 329 newpatient appointments and 13, 939 appointments forpatients with insurance or paying themselves.

The hospital told us they did not see children inoutpatients. The hospitals statement of purpose indicatesthe hospital offers outpatient and diagnostic services topaediatrics between the ages of 16 and 18. However, fromJune 2015 to June 2016, data given to us by the hospitalabout outpatient attendances showed that 71 childrenattended the outpatient department. The data indicatedone of these children was between 0 to two years old andone was aged three to 15 years old. The others werebetween 16 and 17 years old. In addition to this, we saw acomplaint which related to a 13 year old patient. Thehospital told us this was a data error and only 69 16-18 yearolds had attended the hospital.

The Consulting Room Suite has 11 consulting roomsincluding dedicated ENT, ophthalmic and cardiology roomsand audiology booth. Two nurse treatment rooms areavailable along with a registration desk, two waiting areasone with a coffee shop.

The outpatient department runs clinics from 8am to 9pmMonday to Friday, with occasional Saturday clinics between9am and 3pm

The imaging department provides a comprehensive rangeof diagnostic imaging services including all types of generalx-rays, digital screening, mammography, bonedensitometry, a full ultrasound service. The departmentalso has a 128 slice computerised tomography (CT) scanneran MRI scanner and the nuclear medicine departmentprovides a gamma camera and a mobile positron emissiontomography (PET) CT service.

The diagnostic imaging department provides a 24 hour aday, seven day a week service for urgent examinationrequests.

The Pharmacy Department provides outpatient servicesfrom 9am to 5pm, Monday to Friday and Saturdaymornings, when clinics are running.

Physiotherapy outpatients is in a dedicated location withindividual bays and a gym area. The staff providehydrotherapy off-site and physiotherapy services areprovided at satellite clinics in GP surgeries.

We spoke with four patients and 34 members of staffincluding, nurses, radiographers, physiotherapists,pathology staff, health care assistants, administrators andmanagers. As part of our inspection, we looked at hospitalpolicies and procedures, staff training records, and audits.We looked at 18 sets of notes, the environment andequipment staff used.


Outpatients and diagnosticimaging

Good –––


Summary of findingsWe found the outpatient and diagnostic imagingservices at BMI Mount Alvernia to be good. This wasbecause:

• The hospital had good systems and process in placeto keep patients from harm.

• A wide variety of modern equipment was availablefor staff to deliver a range of services andexaminations.

• Staff managed medicines in line with best practiceand stored them securely.

• The hospital had a comprehensive audit programmein place to monitor services and identify areas forimprovement.

• The outpatient and diagnostic imaging departmentshad sufficient numbers of appropriately trainedcompetent staff to provide their services.

• Staff dealt with patients in a kind, caring andconsiderate manner. Patients were happy with thecare they received.

• The hospital was responsive to the needs of the localpopulations. Appointments could be accessed in atimely manner and at a variety of times throughoutthe day.

• Results of investigations were available quickly anddouble checked by members of staff.

• Managers were visible, approachable and effective.• The hospital had a clinical governance committee

and medical advisory committee both responsiblefor ensuring there were robust systems andprocesses in place in relation to governance andassurance.

However:

• Children attended the outpatient department, butneither the safeguarding lead nor any staff hadattended level three safeguarding children trainingas per national guidelines.

• The assessment and response to risk was notmanaged consistently throughout outpatient anddiagnostic imaging services.

Are outpatients and diagnostic imagingservices safe?


We rated safety as requires improvement for the outpatientand diagnostic imaging services. This was because:

• Children attended the outpatient department, butneither the safeguarding lead nor any staff had attendedlevel three safeguarding children training as per nationalguidelines.

• The number of outpatient staff who had completedtheir mandatory training was not in line with thehospitals target.

• The assessment and response to risk was not managedconsistently throughout outpatient and diagnosticimaging services.

However;

• Staff had a good understanding of the incident reportingprocess. Staff discussed incidents regularly atdepartmental and governance meetings and learningfrom incidents was clearly demonstrated.

• Good infection control practices were in place anddemonstrated in line with national guidance.

• The outpatient and diagnostic imaging services had awide range of well-maintained equipment, which staffwere competent to use.

• Staff demonstrated good medicines management,storage and monitored the use of prescription pads.

• Records were accurate, legible, complete and werestored securely. The outpatient service was planning tocopy all outpatient records and was on track to start thisin September.

• The outpatient and diagnostic imaging service hadsufficient numbers of appropriately trained staff toprovide safe care to patients. The majority of staff hadcompleted the hospital’s mandatory trainingprogramme.

Incidents

• There were no ‘never events’ reported by the hospitalbetween June 2015 and May 2016. ‘Never events’ are



Good –––


serious, largely preventable patient safety incidents thatshould not occur if a hospital has implemented theavailable preventative measures. The occurrence of anever event could indicate unsafe practice.

• From December 2015 to June 2016, the outpatient anddiagnostic imaging departments reported 32 incidents,which were a mixture of clinical and non-clinical. Staffhad a clear understanding of the incident reportingprocess. We saw ‘incident triggers’ information on staffnoticeboards for staff to refer to.

• Staff discussed incidents regularly at departmentmeetings and we saw minutes of meetings whichindicated this was occurring regularly.

• Staff gave us examples of changes made because of anincident. A patient had received an increased dose of amedicine used in a diagnostic test. Staff reviewed thechecking process and identified where the erroroccurred. The department changed the way theychecked the medicine.

• Newsletters from BMI every 3 months detailed howincidents were addressed at the time and lessonslearned. We saw these newsletters.

• The hospital reported no ionising radiation (medicalexposure) regulations IRMER incidents to the carequality commission (CQC) in the last 12 months. Staffhad a clear understanding of what was a reportableincident. A Radiation Protection Adviser (RPA) wasavailable for advice, by telephone, if required.

• Staff had a good awareness of duty of candour but hadnot had to demonstrate it; they told us they were openand honest with patients. The diagnostic imagingdepartment gave us an example where they informed apatient immediately when they thought the patient hadreceived an increased dose of radioactive medicine.


• All the areas we visited in the outpatients and diagnosticimaging departments were visibly clean and tidy andthere were good infection control practices in place

• The most recent patient led assessment of the careenvironment (PLACE) score, completed in 2016 scored100% for cleanliness, which was better than the nationalaverage of 98%.

• Staff were bare below the elbow and demonstrated anappropriate hand washing technique in line with ‘fivemoments for hand hygiene’, from the World Health

Organisation (WHO) guidelines on hand hygiene inhealth care. Information was displayed demonstrating’five moments for hand hygiene’ near handwashingsinks.

• The last hand hygiene audit was discussed at theclinical governance committee in April 2016 and allareas had scored 100%.

• There were sufficient numbers of hand washing sinksavailable, in line with Health Building Note 00-09:Infection control in the built environment. Motionsensor taps were in place. Soap and hand towels wereavailable next to the sinks. Sanitising hand gel wasreadily available.

• We saw personal protective equipment was available forstaff to use.

• We saw disposable curtains used in clinic rooms, dateson them indicated they had been changed within sixmonths.

• We saw carpets in consulting rooms seven, eight, nine,the health screening room, cardiology room and theaudiology room. Clinical equipment was available in allthese rooms and ready for use. Staff told us clinicalprocedures did not occur in these rooms. If a procedurewas required, the patient would be taken to a treatmentroom which had flooring which was seamless andsmooth, slip-resistant, easily cleaned and appropriatelywear-resistant. This was in line with Health BuildingNote (HBN) 00-09: Infection control in the builtenvironment, 3.109.

• Managers told us the carpets were deep cleaned everysix months and sooner, if required. We saw recordswhich indicated the carpets in all areas had beencleaned the month before our inspection. Fabric chairswere cleaned every six months and we saw a cleaningschedule which indicated this had been done.

• We saw there was cleaning schedules in individualtreatment rooms which were fully completed andcomprehensive.

• Equipment was cleaned between each patient use anda green sticker placed on it. We saw equipment withgreen ‘I am clean ‘stickers on which indicated it wasclean and ready for use.

• Some equipment was cleaned using a triple wipecleaning system. This was a system of cleaningequipment which uses three types of cleaning wipe toensure thorough cleaning of equipment has occurred.At each stage of cleaning the type of wipe used, for the



Good –––


type of equipment and by which member of staff wasrecorded in a log book. We saw log books whichindicated all steps had been completed and by whichmember of staff.

• Waste in clinic rooms was separated and in differentcoloured bags to identify the different categories ofwaste. This was in accordance with HTM 07-01, controlof substance hazardous to health and Health and Safetyat work regulations.

• We saw sharps bins were available in treatment areaswhere sharps may be used. This demonstratedcompliance with health and safety regulation 2013 (Thesharps regulations), 5 (1) d. This required staff to placesecure containers and instructions for safe disposal ofmedical sharps close to the work area. We saw labels onsharps bins had been fully completed which ensuredtraceability of each container.

• In the diagnostic imaging department if a patient withan infectious disease required a scan, they would be putat the end of the day and the department would bedeep cleaned after.

• However, we saw a machine used for measuring thecapacity of a patient’s lung. Although it had disposablemouthpiece, the tube into which the patient blew wasnot. We asked how this was cleaned and were told itwas washed in soapy water. No risk assessment hadbeen done for this machine or cleaning schedule drawnup. Assurances could not be given; this piece ofequipment was cleaned adequately between patientuses.


• The outpatient service had 11 individual consultingrooms and two outpatient waiting areas.

• We saw tidy and spacious waiting areas. One outpatientwaiting area had access to a small garden. We sawadequate seating available at a variety of heights andspace available for patients to wait in wheelchairs. Thehospital had several wheelchairs available for patientsto use if required.

• Each consulting room was equipped with a treatmentcouch and trolley for carrying the clinical equipmentrequired. It had equipment in to provide physicalmeasurements. This was line with HBN 12 (4.18) whichrecommends a space for physical measures be providedso this can be done in privacy.

• An audiology room was available and sound proofed toenable hearing tests to be carried out.

• We saw the clinical room was visible clean, unclutteredand the temperature monitored continually. An alarmsounded when the temperature went out of the setrange.

• The most recent PLACE score in 2016 for condition andappearance of the department scored 94%. This wasequal to the England average.

• We saw copies of service records which indicated allequipment was serviced annually. We saw stickers onequipment which indicated it had been servicedrecently. Electrical equipment had portable appliancetest (PAT) stickers on which indicated it was safe for use.

• We saw certificates to indicate staff were competent touse equipment which was in line with the hospital’smedical devices policy.

• We saw an individual room for patients to have bloodtests in. This is in line with Health Building Note (HBN)12, 4.42, which recommends areas providing blood testsshould provide individual cubicles for patients.

• The resuscitation trolley was shared between theoutpatient and diagnostic imaging departments. Thetrolley was tamper proof and all consumables were indate. Staff checked the trolley daily; we saw completechecklists to confirm this was done. The resuscitationofficer completed an audit of the trolleys in the hospitalevery three months. The last two completed in Januaryand April 2016 were both compliant.

• The diagnostic imaging department had a variety ofmodern equipment to deliver high quality scans. In themammography room, the equipment had mood lightingto assist in relaxing patients whilst having the scan.

• The MRI and CT scanners were in locked rooms. Staffgained access by key pad and only the appropriate staffhad access to these rooms.

• We saw records of regular quality assurance tests ofdiagnostic imaging equipment. In addition to this aradiation protection committee reported annually onthe quality of radiology equipment, which we saw.These mandatory checks were based on the ionisingregulations 1999 and the ionising radiation (medicalexposure) regulations IR (ME) R 2000).

• Lead aprons were available in all areas of radiology.Regular checks occurred of the effectiveness of theirprotection. We saw spread sheets which showed checksoccurred regularly and equipment provided adequateprotection.



Good –––


• A wheelchair and trolley were available for theevacuation of a patient from the MRI and CT scannerarea in the event of an emergency.

• The emergency call bells were tested regularly and wesaw records which indicated this was being done.

• The physiotherapy department had a gym andindividual treatment rooms to provide a variety oftreatments. The gym was well stocked with a range ofequipment to suit patient’s different level of fitness andabilities.

Medicines

• Staff stored prescription pads in locked cupboards anda registered nurse held the key. We saw registers in placefor every clinic room which had prescription pads; thisindicated when a prescription had been issued, towhom and what for. This is in line with NHS Protect,Security of prescription forms guidance, 2013. Thehospital audited the use of prescription pads and themost recent audit in February 2016 indicated standardswere being met and pads were stored securely.

• Staff monitored and recorded the minimum andmaximum medicines refrigerators and roomtemperatures where pregnancy testing kits were stored.We saw records which indicated this was done regularly.

• In diagnostic imaging, medicines used to perform scanswere stored in a locked cupboard with key pad access ina locked room with key pad access. Only authorised,registered professionals had access to the medicinecupboard.

Records

• From June 2015 to July 2016, no patients had been seenin outpatients without the full medical record beingavailable. Consultants carried their own outpatientrecords. Medical secretaries prepared the notes andthey were kept in a sealed bag until the clinic started.After clinic, records were put into a bag which wassealed and we saw this being done.

• The hospital was working towards having a copy of thepatient’s outpatient record at the hospital. We sawminutes of meetings which detailed how this was to beachieved and was discussed regularly. We spoke withstaff in the medical records department who showed uswhat the record would look like and had a goodunderstanding of how they would manage the record,

so that all the appropriate information would be in it.The plan was to implement the duplication of recordson 5th September 2016. The minutes of the meetingsindicated this was due to be achieved.

• Records were stored in the medical records departmentwhich could be accessed by authorised personnel only.A register was completed to indicate if a record hadbeen removed and where it had gone to.

• We looked in 18 sets of patient records. We saw recordswere complete, legible and signed. They containedreferral letters, results of diagnostic tests and dischargeletters.

• In diagnostic imaging, records were stored on a patientarriving communication system (PACS). Only staff with apasscode could access them. Only staff authorised tohave access had a passcode.

• We saw confidential waste areas available inadministration areas, which indicated confidentialwaste was managed appropriately.

Safeguarding

• The responsibility of a safeguarding lead is to ensureproviders have the right systems and process in place tomake sure children and adults were protected from riskor actual abuse and neglect. National statutoryguidelines ‘Working together to safeguard children – aguide to interagency working to safeguard and promotethe welfare of children’ (2015) states safeguarding leadsare to be trained to level 3 for vulnerable children as thelead takes the responsibility for the organisationssafeguarding arrangements.

• The safeguarding lead with responsibility forsafeguarding was not trained to level 3 for children atthe time of the inspection, however there was a servicelevel agreement in place with a neighbouring BMIHospital facility for a Lead Registered Children's Nurse,who holds safeguarding level 3 and who was availableto the Hospital for advice, action and support forsafeguarding concerns.

• Sixty nine children aged 16 to 18 years attended theoutpatient department as patients between July 2015and June 2016. Clinical and staff working in thedepartment were only trained to level 2. This was not inline with the Safeguarding Children and Young People –Roles and Competencies for Staff IntercollegiateDocument updated in September 2010, whichrecommends that staff working with children should betrained to level 3.



Good –––


• In the hospital, 95% of staff had attended level onesafeguarding vulnerable adults which was better thanthe BMI target. Ninety three percent of staff hadattended level two safeguarding vulnerable adultstraining, which was better than the target of 90% andone member of staff was trained to level threesafeguarding vulnerable adults.

• Of all hospital staff 95% had attended level onesafeguarding children training, which was betterthan the BMI target. Ninety three percent of hospitalstaff had attended level two safeguarding childrentraining, which was better than the target score of 90%.

• The hospital did not have level three children’ssafeguarding training as part of its mandatory trainingprogramme at the time of our inspection.

Mandatory training

• Mandatory training was mainly on line learningsupported with practical sessions. Staff told us on linemandatory training was a good opportunity to readpolicies. They told us they did not experience difficultiesaccessing training or computers to complete on linetraining.

• In the diagnostic imaging department, 96% of radiologystaff had completed mandatory training, which wasbetter than the target of 90%. In MRI, 100% of staff hadcompleted mandatory training and in nuclear medicine,96% of staff had attended mandatory training.

• In the Physiotherapy department, 92% of staff hadattended mandatory training which was better than thetarget of 90%.

• In the outpatient department, 91% of staff hadcompleted mandatory training, which was better thanthe target of 90%.


• We observed good radiation compliance as per policyand guidelines during our visit. The departmentdisplayed clear warning notices, doors were shut duringexamination and warning lights were illuminated. Therewas key pad entry to examination rooms and onlyauthorised staff had access.

• A radiation protection supervisor was on site for eachdiagnostic test and a radiation protection adviser wascontactable if required. This was in line with ionisingregulations 1999 and regulations (IR (ME) R 2000).

• Departmental staff also carried out regular qualityassurance checks. This indicated equipment was

working as it should. These mandatory checks were inline with ionising regulations 1999 and the ionisingradiation (medical exposure) regulations (IR (ME) R2000). We saw records of these checks, for eachmachine, was completed each day.

• We observed good practice for reducing exposure toradiation in the diagnostic imaging departments. Localrules were available in areas we visited. Diagnosticimaging staff had a clear understanding of protocolsand policies. Protocols and policies were stored on ashared computer file which staff had access to. Staffdemonstrated their knowledge of where policies werekept.

• Signs advising women, who may be pregnant, to informstaff, were clearly displayed in the diagnostic imagingdepartments in line with best practice. In addition tothis staff completed forms to indicate whether patientswere pregnant. We saw three forms and this wascompleted on each.

• Staff used metal markers instead of digital to indicatewhether an examination was of the left of right sidedlimb. This ensures, if an image is turned around,electronically, the correct side can still be identified.

• The five steps to safer surgery is a core set of safetychecks, identified for improving performance at safetycritical time points within the patient’s intraoperativecare pathway. It is for use in any operating theatreenvironment, including interventional radiology.

• The diagnostic imaging department carried out regularaudit of the checklist and in April 2016, scored 100% ininterventional ultrasound. This indicated staffcompleted all steps.

• We saw ‘stop and check’ signs in all rooms of thediagnostic imaging department to remind staff to carryout patient identification checks.

• In the nuclear medicine department, toilets wereavailable for patients before and after they had receivedradioactive medicine. This minimized the exposure toradiation and was in line with best practice.

• To ensure nothing was missed, two different consultantstaff, read the results of screening mammograms; thiswas in line with best practice.

• The hospital had a risk register which departments’could add to. Managers told us each department wouldcarry out their own risk assessments.



Good –––


• In the diagnostic imaging department, we saw anumber of risk assessments had been completed. Theyincluded risks assessed for lone working, usingcomputers, temperature control, lighting, fire andseating.

• In the outpatient department, we saw risk assessmentshad been completed for the control of substanceshazardous to health (COSSH). We asked if there wereany other risk assessments in outpatients. The managertold us the sister had copies of these. However, the sistertold us the manager had them. This indicated no otherrisk assessments had been completed in the outpatientdepartment.

Staffing

• A registered nurse was available at each area ofoutpatients. There were six registered nurses and fivehealth care assistants (HCA’s). The department did notuse agency staff. The hospital’s own staff worked asbank staff when required. We saw nurse staffing rotaswhich indicated there were always registered staffavailable in each outpatient department.

• The diagnostic imaging departments did not use anyagency staff, but used their own staff on bank, ifrequired.

• The resident’s medical officer (RMO) would attend toany unwell patients in the outpatient or diagnosticimaging department if required.


• Staff in Physiotherapy told us they had recentlypractised the evacuation of a patient in the event of afire.

• Staff gave us examples of dealing with patients in anemergency and they felt the response from the rest ofthe hospital was immediate.

Are outpatients and diagnostic imagingservices effective?

Good –––

We inspected but did not rate effectiveness as we do notcurrently collect sufficient evidence to rate this.

• The hospital had an on-going, comprehensive auditprogramme, which monitored areas for improvementregularly.

• Treatments offered to patients were in line with NationalInstitute for Health and Care Excellence guideline (NICE)guidelines.

• Staff were competent to perform their roles and wereencourage to develop their skills further.

• Health professionals worked together to provideservices for patients.

• The diagnostic imaging and physiotherapy departmentsprovided an on call services,24 hour a day seven days aweek.


• The hospital had an on-going audit programme. In April,May and June 2016 they had completed all the auditson their programme. Regular audits included; patienthealth records, medicine management, hand hygieneand infection, prevention and control. We saw copiesand results of these audits. Findings were discussed atthe quarterly audit report and areas of improvementwere discussed. We saw copies of these meetings whichdemonstrated this was occurring and actions that arosefrom areas of improvement.

• The imaging department had policies and procedures inplace. They were in line with regulations under ionisingradiation (medical exposure) regulations (IR (ME) R2000) and in accordance with the Royal College ofRadiologists standards.

• We saw local rules available in each imaging room. Staffhad signed them to indicate they had read them.

• In the outpatient department, staff showed us how theyaccessed policies on the hospitals computer system.Paper copies were also available in a folder and staffsigned to indicate they had read them, which we saw.

• The physiotherapy department offered a knee exerciseclass and had equipment to enable patients to exercisein a variety of ways. This is in line with NICE,Osteoarthritis: Care and management, CG 177, 1.41.

Pain relief

• In the outpatient department doctors could prescribepain relieving medication as required.

• In the diagnostic imaging department, there were avariety of pads and supports to enable patients havingexaminations to be in a pain free position.



Good –––


• The physiotherapy department provided acupuncturetreatment for pain relief. In the Physiotherapydepartment, staff used a visual analogue scale for ratingpain. Patients rated their pain on a scale of one to 10,before and after treatment to see if an effect could bedemonstrated.

Patient outcomes

• The physiotherapy department asked patients tocomplete a patient reported outcome measure (PROM).This gave a self-rated score of a patient’s pain level,mobility and usual activities. The patient completed thescore before and after treatment which would indicate achange as result of treatment.

Competent staff

• We saw staff competency certificates for a variety ofareas such as; the use of a triple cleaning system,mandatory training and the use of very low temperatureliquids. We saw skills assessment for chaperoning,venepuncture and completed induction packs.

• Nursing staff told us they had access to local andnational training. This contributed to maintaining theirregistration with the Nursing and Midwifery Council(NMC).

• Allied health professional staff could access a variety oftraining within the BMI network to develop skills further.They also attended regular training sessions within thedepartment. We saw attendance sheets, signed by staff,which indicated they attended training regularly. Thiscontributed to maintaining their Health CareProfessions Council (HCPC) registration.

• Managers checked the registration of their staff with the(HCPC) and we saw copies of certificates whichindicated all staff required, had registration.

• Cannulation is a technique in which a cannula is placedinside a vein to provide venous access. This issometimes required to give medicines. We sawcomplete cannulation records, which was in line withthe hospitals cannulation policy.

• Some staff working in diagnostic imaging can givemedicine to patients for certain diagnostic tests. We sawcertificates which confirmed staff were competent to doso.

• In compliance with IR (ME) R regulations, certificateswere held for those staff in the hospital that were able torefer patients for diagnostic imaging tests. We saw

copies of these. This gave assurance that only thosequalified to request a diagnostic examination were ableto do so. In addition to this, we saw a list of people whocould refer for an examination.

• In the diagnostic imaging department, 100% of staff hadan appraisal in the last year.

• Four out of five HCA staff had completed an appraisal inthe last year.

• One registered nurse had completed an appraisal hadtheirs booked in the week of our inspection.

• Registered nurse had completed appraisals for theperiod they had worked

Multidisciplinary working (related to this core service)

• The hospital ran a one stop breast clinic, where a varietyof health professionals worked together. This included abreast nurse specialist, consultant breast surgeons,consultant oncologists and a consultant radiologist. Itenabled patients to see clinicians, have tests and get theresults of tests at one appointment.

• The physiotherapy department attended trainingsessions with other physiotherapists in the BMI network.

• The diagnostic imaging department received trainingfrom specialist radiographers from other hospitals.

• Staff told us they worked well together and had goodcommunication with other health professionals andadministrative staff. We saw staff engage in aprofessional and courteous manner.

Seven-day services

• The diagnostic imaging department provided an on callservice for inpatients, 24 hours a day, seven days aweek. The service had a system in place if aradiographer was called after midnight the protocolstated they did not work the following morning. Stafftold us the calls for the emergency service wereminimal.

• The physiotherapy department provided an on callservice for inpatients, 24 hours a day, seven days aweek.

• The pharmacy department is open every Saturdaymorning between 9 and 12 midday to ensure effectivetimely discharge for patients being discharged from thewards and to support any clinics that might be takingplace.




Good –––


• Staff in outpatients had morning huddles to shareinformation and discuss any problems from theprevious day.

• Staff could access a shared drive on the computerwhere policies and hospital wide information wasstored. They demonstrated this to us.

• The diagnostic imaging department could accessinvestigations from local hospitals by request and wastransferred to the hospital securely.

• The outpatient team were working toward copying alloutpatient records, so that information would beavailable even if the consultant was not in attendance.


• Staff described the process of dealing with a patientwho may not have the capacity to consent to treatment.They were aware of who to contact if they requiredfurther advice.

• We saw signed consent forms in medical records, whichindicated patients had consented to treatment; this wasin line with the hospitals consent policy.

• Staff had training in Mental Capacity Act training as partof their safeguarding vulnerable adults training.

Are outpatients and diagnostic imagingservices caring?

Good –––

We rated caring as good for the outpatient and diagnosticimaging services. This was because:

• Staff treated patients in a kind, considerate andprofessional manner.

• Patients told us they were very happy with the care theyreceived.

• The hospital had considered patients privacy anddignity in the design of the main reception area.

• Signs offering chaperones were clearly displayed, theservices held chaperone registers and staff were suitablytrained to chaperone.

Compassionate care

• The hospital completed its own friends and family testwhich it reported on each month, we saw copies of

these reports. The most recent report in March 2016indicated 99% of patients would recommend theoutpatient department at the hospital. On average 188patients responded each month, which equated to 10%of patients that attended the department.

• Patients told us they loved the hospital and receivedgreat care. They felt listened to and received goodexplanations about their care. We saw staff dealing withpatients in a kind and caring manner.

• Patients told us staff treated them with dignity andrespect. We saw staff introduce themselves to patientsand explain their role.

• Staff gave us an example of dealing with a patient whohad fainted in the outpatient department. They felt itunsafe for the patient to drive their own car home, soarranged for a taxi. In addition to this, they contactedthe local council and explained the situation. The localcouncil waived the car parking fees for the patient.

• We saw signs in patient waiting areas to inform patientsthey could have a chaperone, if required. We sawcertificates which indicated staff had chaperonetraining. Staff would record if a chaperone had beenoffered and document if a patient agreed or declined.They also recorded who had been a chaperone, towhich patient and the day that occurred in a register. Wesaw the chaperone register which indicated this wasoccurring. This was in line with the hospitals chaperonepolicy.

• In all the diagnostic imaging rooms, there were separateareas for viewing scan results. None of these areas couldbe overlooked, maintaining patient’s privacy andconfidentiality.

Understanding and involvement of patients and thoseclose to them

• All patients we spoke with told us they received clearand detailed explanations about their care and anyprocedures they may need.

• We saw a variety of health-education literature andleaflets produced by BMI. Some of this information wasgeneral in nature while some was specific to certainconditions. This literature was available in all waitingareas of the outpatient departments.

• Staff sent detailed information about the examinationpatients were booked in for with the appointment letter.We saw examples of this information and it was in clear,simple language.



Good –––


Emotional support

• Nurses attended clinic appointments with patients toprovide emotional support if required. They could givepatients and their families extra time needed, ifnecessary.

• Staff told us, if they had been present when bad newshad been broken, they gained support from members oftheir team.

Are outpatients and diagnostic imagingservices responsive?

Good –––

We rated responsiveness as good for the outpatient anddiagnostic imaging. This was because:

• The services offered a variety of appointment times tosuit the needs of patients.

• The physiotherapy department offered a variety ofexercise classes and treatments to suit the needs of thepatients attending.

• Waiting times for appointments and examinations wereshort.

• Waiting times for some types of scans were greater thanthe standard at the request of the referring consultant.

• Radiologists provided reports for scans in 48 hours orless. This indicated patients received their results in atimely manner.

• Staff told us how they could access interpreters andleaflets in other languages. They gave us examples ofdealing with people living with dementia and had linknurse within the service.


• The outpatient department was open from 8am andcould stay open as late as 9pm if required. It would alsoopen on Saturday mornings, if needed. Patients toldthey had been offered a choice of times and dates fortheir appointments.

• The pharmacy department is open every Saturdaymorning between 9 and 12 midday to ensure effectivetimely discharge for patients being discharged from thewards and to support any clinics that might be takingplace.

• The diagnostic imaging department was open from 8amto 7pm from Monday to Friday and from 9am to 12 pmon Saturday, which gave patients a range of times anddays for their appointments.

• The physiotherapy department was open from 8am to8:30pm, four days week and Friday until 5pm. Theyprovided a wide range of exercise classes to suit theneeds of the patients referred to them. They had acomputer package that enabled them to providepersonalised exercise plans to individual patients. Itenabled them to email videos to patients. Thedepartment had a range of equipment to help staffdeliver high quality care for patients.

• The outpatient department provided a health screeningservice which provided an appropriate range of testsand examinations based on clinical need. We looked in10 sets of patient records which indicated this was beingdone. Reports went to patients and their GP if furtherinvestigations were required.

• We saw comfortable looking waiting areas withrefreshments and magazines available for waitingpatients.

• One stop breast clinics ran which meant patients couldhave a consultation, examination and results on thesame day. This decreased the amount of times a patientwould have to attend the hospital.

Access and flow

• Referral to treatment (RTT) waiting times fornon-admitted patients beginning treatment within 18weeks of referral were above 95% in each month of thereporting period from April 2015 to March 2016, this wasbetter than the standard.

• Patients told us they were happy with the speed atwhich they had received their appointments.

• Physiotherapy patients received their appointmentwithin two weeks or sooner, which indicated theyreceived their treatment in a timely manner.

• A DEXA scan is a special type of X-ray that measuresbone mineral density. DEXA stands for ‘dual energy X-rayabsorptiometry’. The standard is that less than 1% ofpatients will wait for more than six weeks to have a DEXAscan. From April 2015 to March 2016, 28 patients waitedlonger than 6 weeks for a dexa scan. This equated toover 2% of patients waiting more than six weeks, whichwas worse than the standard. Three patients had waitedmore than 13 weeks in the same period.



Good –––


• At the time of inspection, we saw appointmentsavailable for a DEXA scan in two weeks’ time. Staff toldus when they received a referral; it was put onto thecomputer system. They told us patients who had brokenbones, did not want to have their scans until theirbroken bones had healed. This could be from 6 to 12weeks after the scan had been requested. Someconsultants had indicated on the referral form, they didnot want the patient to have the scan until severalweeks after the referral was sent. We saw 22 forms whichindicated they wanted the scan done more than 6weeks after the referral was sent. One was as late as 5months after the referral was sent. This indicated thereported diagnostic waiting times were not a truereflection of the actual waits patients could have. Wediscussed this with the manager, who was going to lookinto this practise, so true diagnostic waiting times couldbe reported in the future.

• Once a scan had been carried out, a radiologistprovided a report. An MRI took 48 hours to provide areport, a CT scan took 2 days and all other examinationswere reported within a day.

• Radiologists attended the hospital to provide reportsand one could access the hospitals computer systemremotely.

• An audit of medication turnaround times for outpatientscarried out in April 2015 indicated that on averagemedication was available in 6 minutes.

• We were told the outpatient department did notroutinely monitor clinic delays. The clinics we observedran to schedule, we did not see any patients wait morethan five minutes.


• We did not see any leaflets in any other languages, butstaff told us they could access these if required, from acentral database.

• The outpatient department had a service levelagreement (SLA) with a company which providedinterpreters. Staff had a clear understanding of how todo this should they need to.

• Staff gave us an example of caring for a patient livingwith dementia. They told us a member of the publicattended the hospital thinking their relative was in thehospital. Staff checked and found the family memberwas not in the hospital. Staff waited with the person,whilst other members of staff located a relative. Theygave another example, where a member of the public

entered the hospital, but was unsure where they were orwhy they were there. Staff contacted a relative to cometo the hospital and described how they calmed theperson while they waited.

• We saw a children’s bead toy available in a waiting area,but, we did not see any information leaflets specific forchildren.

• The diagnostic imaging department had two dementialink nurses for advice and support for staff and patients.

• Equipment in the physiotherapy department wassuitable for overweight patients to exercise on.


• The number of complaints received by the hospital fromApril 2015 to March 2016 was 25, which was a decreasefrom April 2014 to March 2015, when they received 43.One complaint had been referred to the Ombudsmanwhich related to a patient using the service in 2013.

• The assessed rate of complaints (per 100 day case andinpatient attendances) was significantly lower than theother independent acute hospitals CQC hold data for.

• CQC received three complaints from April 2015 to March2016.

• Complaints were discussed as they were received andreviewed in the daily morning “huddle”, which wasattended by the executive director, director of nursingand hospital heads of department.

• Complaints (and compliments) were discussed at themonthly senior management team meetings and wesaw minutes of these meetings which indicated this wasoccurring.

• Copies of the BMI leaflet ‘Please tell us’ were locatedthroughout outpatient waiting areas to make patientsand their relatives aware of how they can highlight anyconcerns.

• The BMI Healthcare complaints policy clearly set out therelevant timeframes associated with the various parts ofthe complaint response process. An initialacknowledgement is required within two working daysand a full response within 20 working days. Patientswere kept fully informed throughout this process if therewas a delay. We saw copies of complaints files whichindicated this was occurring.

Are outpatients and diagnostic imagingservices well-led?



Good –––


Good –––

We rated well-led as good for the outpatient and diagnosticimaging services. This was because:

• All staff were proud of the work they did at the hospital.They had a good understanding of the vision for thedevelopment of their services.

• There was a clear leadership structure which staff wereaware of. They told us their managers were visible andapproachable.

• The executive team engaged regularly with all staff andcommunication was clear and consistent.

• Governance processes were clear and effective fromdepartmental to executive level.

• Staff shared learning across the BMI network.

However;

• It was not clear that risk was consistently being assessedin the outpatient department.

• The management team were unaware young childrenwere being seen in the outpatient department.


• Staff were aware of the corporate strategy of ‘puttingpatients at the heart of what they do’. They felt thedevelopment of their services were a good reflection ofthis strategy.

• The outpatient department had an action plan in placewhich they reviewed regularly.

• They made a number of changes in the past year suchas removing carpet from the ear nose and throat (ENT)room and were looking towards increasing the skills ofthe nursing staff in order to be able to provide a widerrange of services for patients.


• The clinical governance committee was responsible forensuring that the appropriate structure, systems andprocesses were in place in the hospital to ensure thesafe delivery of high quality clinical services.

• The clinical governance committee met bi-monthly anddiscussed incidents, complaints, infection control issuesand reviewed the risk register. A member of a local

clinical commissioning group (CCG) regularly attendedthese meetings. During our inspection, we saw theminutes of four clinical governance committee meetingsheld.

• The hospital had clear governance processes in place.The hospital held meetings thorough which governanceissues were discussed. The meetings included medicaladvisory committee (MAC), heads of department (HOD)meetings, departmental meetings and infectionprevention and control meetings.

• The clinical effectiveness committee was a sub-group ofthe clinical governance committee with a focus on auditand policy.

• We saw a copy of the hospital audit plan. The head ofdepartments identified staff who could be the linkperson for these audits within the department. Thefindings of this audit were presented to clinicalgovernance committee and medical advisorycommittee. The heads of department disseminatedresults through team meetings.

• The clinical governance report had incident (andanalysis), complaints andpatient satisfaction as regularagenda items.

• The Medical Advice Committee (MAC) met quarterly andwe saw the minutes of the last four meetings. Theminutes showed the key governance areas such ascomplaints, incidents, health and safety and feedbackfrom the clinical governance committee were discussedeach time.

• The HOD met monthly and the minutes of the last fourmeetings were seen. The minutes showed itemsdiscussed included infection control, hospital activity,complaints and incidents.

• Regular quality assurance tests were carried out onequipment to test the output of machines.

• The physiotherapy department carried out a variety ofregular local audits to measure the quality ofdocumentation and we saw the results of these.

• The physiotherapy department used patient reportedoutcome measures (PROM’s) to measure the quality oftreatment interventions.

• The hospital had a risk register which each departmentcould add risk to. However, each department shouldhave its own risk assessments.



Good –––


• We saw a variety of risk assessments in the diagnosticimaging department, but in the outpatient departmentthere were only risk assessments relating to COSHH.This indicated risk was not consistently managed in allthe departments.

• However, managers told us they did not see children atthe hospital , we saw data which indicated children hadattended the hospital. Level 3 safeguarding childrentraining was not available for staff.

Leadership / culture of service

• There were clear lines of leadership and accountability.Staff had a good understanding of their responsibilitiesin all areas of the outpatient and diagnostic imagingservices.

• The outpatient manager reported to the director ofnursing who reported to the executive director.

• The imaging, physiotherapy and pharmacy managersreported directly to the executive director.

• Staff saw their managers every day and told us theexecutive team were visible and listened to them. Anychanges made were communicated through sub teamhuddles, newsletters and emails. We saw examples ofnewsletters on staff notice boards.

• The outpatient manager was particularly proud of thechanges within the outpatient department within thelast two years. They felt staff were engaging more andchanges within the department were being welcomed.

• Staff told us the hospital was a good place to work andeveryone was very friendly.

• They felt they had sufficient time to spend with patientsand were proud of the work they did.


• Morning ‘huddles’ had been developed, so not onlyhead of departments met together, but they also hadsub teams. This was to encourage teams to cometogether and share information.

• Staff told us managers shared information via email andnewsletter. We saw noticeboards displaying informationabout infection prevention and control, health andsafety, deprivation of liberties safeguards and lessonslearned.

• The hospital sought patient feedback by placingcomment cards in outpatient waiting areas, which wesaw. A monthly report was produced which detailedresponse rates and patient comments. We saw copies ofthe monthly report.

• The hospital had a patient satisfaction group which wasmade up of a number of employees around thehospital. This group continually reviewed the patientsatisfaction scores and dealt with areas forimprovement.


• Staff in the outpatient department were engaged indeveloping and delivering an action plan. This was aseries of points which detailed improvements thedepartment

• Areas for improvement had been identified andindividuals identified to action those areas.



Good –––


Areas for improvement

Action the provider MUST take to improve

• Ensure that staff are trained to the appropriate levelfor safeguarding children. Children attend thehospital as patients and visitors.

Action the provider SHOULD take to improve

• Provide each individual department with a separateand relevant risk register.

• Enable staff to attend major incident or businesscontinuity training and attend simulation exercises.

• Have a separate steering group for end of life.• Have policies in place for end of life care or

management of the deceased.• The outpatient department should adequately risk

assess environment and equipment.• The hospital should ensure outpatient staff achieve

the hospitals mandatory training target.

Outstandingpracticeandareasforimprovement

Outstanding practice and areasfor improvement


Action we have told the provider to takeThe table below shows the legal requirements that were not being met. The provider must send CQC a report that sayswhat action they are going to take to meet these requirements.

Regulated activity

Diagnostic and screening procedures

Surgical procedures

Treatment of disease, disorder or injury

Regulation 12 HSCA (RA) Regulations 2014 Safe care andtreatment

Safe Care and Treatment

12-(1) Care and treatment must be provided for in a safeway for service users.

(2) without limiting paragraph (1), the things which aregistered person must do to comply with this paragraphinclude-

(c) ensuring persons providing care or treatment toservice users have the qualifications, competence, skillsand experience to do so safely.

The provider must ensure that staff are trained to theappropriate level for safeguarding children, as childrenattend the hospital as patients and visitors.

Regulation

This section is primarily information for the provider

Requirement noticesRequirementnotices


Documents

BMI Mount Alvernia Hospital › sites › default › files › new_reports › AAAF66… · There was comprehensive assessment of patient needs. This included clinical needs, physical