The Blackheath Hospital

BMI The Blackheath hospital is an acute independent hospital that provides outpatient, day care and inpatient services. The hospital is owned and managed by BMI Healthcare Limited.

A range of services such as physiotherapy and medical imaging are available on site. The hospital offers a range of surgical procedures and cancer care as well as rapid access to assessment and investigation. The hospital does not provide Level 2 critical care services as defined by the Faculty of Intensive Care Medicine standards 2013.

Services are available to people with private or corporate health insurance or to those paying for one off treatment. Fixed prices, agreed in advance are available. The hospital also offers services to NHS patients on behalf of the NHS through local contractual arrangements.

We carried out a comprehensive inspection of BMI The Blackheath Hospital on 10 – 12 and 20 February 2015. The inspection formed part of a pilot programme of inspections in independent healthcare settings. The inspection reviewed how the hospital provided outpatient, medical care, surgical services, care to children (outpatients from birth and interventional from aged three to 15 years) and young people and urgent care services as these were the five core services provided by the hospital from the eight that that are usually inspected by the Care Quality Commission (CQC) as part of its approach to hospital inspection.

Prior to the inspection, in December 2014, the hospital a new Executive Director was appointed. One of the first decisions they took was to stop terminations of pregnancy being carried out due to the low numbers carried out in the last two years.

This location has been awarded a shadow rating. Shadow ratings apply to inspections which are undertaken during the development of our approach and before our final methodology is confirmed and published.”

Our key findings were as follows:

Are services safe?

• The hospital was using an incident reporting system which had both a paper and electronic stage. Incidents are initially recorded on a paper form and then recorded and managed electronically in the Quality and Risk Department. The quality of investigation reports into incidents varied but where recommendations had been made we found they had been actioned. The hospital risk register included mainly environmental risks;the only clinical risk related to the endoscopy unit.
• Medicines were well managed. The hospital had a pharmacy manager, a pharmacist and three technicians. A pharmacist and pharmacy technician visited the wards twice daily. Medicines and controlled drugs were stored safely and regular audits including missed doses and medicine errors were carried out and the results shared with staff.
• The infection prevention and control (IPC) nurse had been in post for four months at the time of the inspection and although the results of IPC audits, use of personal protective equipment and cleanliness of mattress, showed good practice, staff attendance at training needed to improve.
• The endoscopy unit was an area of concern as it did not comply with national guidance, which had been published in 2012, for the decontamination of endoscopes.
• The environment in inpatient areas did not always comply with national guidance for infection prevention and control.
• Staff were aware of their responsibilities in relation to safeguarding children and who to contact if they had any concerns.
• Although the hospital admitted children and young people as day cases and on occasion as inpatients, it did not have a dedicated area to care for them. They were nursed in private rooms on the same wards. The hospital told us they carried out specific risk assessments yearly as a minimum but we did not see them during our inspection.
• There was a lack of clarity about the level of care provided by the hospital. Although the hospital states it has a high dependency unit (HDU), it had a two bed area where it could provide Level 1 enhanced patient care. Staff confirmed it operated as an extension of the recovery unit the service did not meet the requirements for Level 2 critical care in terms of staffing, equipment, environment and training, as outlined by the standards of the Faculty of Intensive Care Medicine 2013. .
• Service level agreements were in place to transfer both children and adults to NHS hospitals should their condition deteriorate and they required high dependency care.
• The area dedicated for patients requiring high dependency care did not comply with modern building standards (HBN 04-02 Health Building Note for critical care units)
• There were sufficient nurses employed to care for adult inpatients and outpatients, with bank nurses used to cover vacancies and sickness absence.
• Although the hospital treated children and young people it only had one paediatric trained nurse and used bank or agency paediatric trained nurses to supplement this.
• Over 300 doctors worked at the hospital under practising privileges and there was 24 hour 7 day cover by a Resident Medical Officer (RMO) for inpatients and a separate RMO. When not in the hospital, consultants were available via phone and the RMO told us they were available if needed.
• The hospital used paper records for patient care and most of the ones we reviewed were up to date. Records that were incomplete and or/inaccurate were due to omissions that had occurred on the night shift.

Are services effective?

• Care and treatment was informed by national guidance and local policies and procedures we reviewed were up to date. Most nursing staff were aware of policies and guidance except some of those caring for children having surgery.
• The hospital was carrying out some audits including national audits and readmission rates following treatment were low.
• Good Surgical Practice 2014 (RCS) says that surgeons should take part regularly in morbidity and mortality meetings. The hospital did not have a dedicated mortality and morbidity meeting. Expected and unexpected deaths were reported and investigated as incidents and were an agenda item at the Clinical Effectiveness meetings along with a list of other agenda items. There had had been seven deaths in the last year but none of them were unexpected.
• All nursing staff working in theatres and recovery had received specific training and been assessed as competent to care for children. Experience and training for RMOs in caring for children varied.
• Information provided by the hospital demonstrated that only one nurse had been trained to care for patients requiring Level 2 critical care.
• Nutritional assessments were carried out on patients.
• Although staff had attended training on the Mental Capacity Act 2005, some staff had very little awareness about their role and responsibilities in relation to assessing patient’s capacity. Staff were also unaware of the hospital's policy for Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders and the template did not include sections to record an assessment of a patient’s capacity or discussions with patients and their relatives.
• There was a multidisciplinary approach to care with range of multidisciplinary meetings in place. The hospital did not have a permanent occupational therapist and social work services response times varied.

Are services caring

• All of the patients, children and young people we spoke with were positive about the care they had received at the hospital.
• Parents told us they were involved in all aspects of their child’s care and staff used appropriate
• Forms of communication to explain procedures to children. Patients told us their consultant explained their diagnosis and discussed their treatment options with them including the risks and benefits.
• We observed staff speaking with patients in a caring manner and maintained their dignity and respect.

Are services responsive?

• The hospital was meeting the national standards for referral to treatment times for NHS funded patients.
• The hospital had specific operating days for children and they were prioritised at the beginning of the list. Where appropriate, treatment could be arranged to minimise disruption to attendance at school.
• The hospital had generic information about procedures and there was no specific information for children.
• The majority of patients attending the urgent care centre were seen within 15 minutes, of being registered, by either a nurse of doctor.
• Service level agreements were in place to transfer both children and adults to NHS hospitals should their condition deteriorate and they required high dependency care.
• The hospital was experiencing delays with pre-assessment and some patients were not seen till the day of their procedure. Some discharges were delayed due to the lack of an occupational therapist.
• There were limited resources and training for staff to care for patients with complex needs such as those living with dementia or learning disabilities. Although staff told us the hospital did not admit patients with complex needs. Staff had access to an interpreter service but awareness of this was variable.

Are services well-led?

• Some services had experienced vacancies in key leadership roles including the inpatient manager, infection prevention and control (IPC) and theatres and endoscopy. An inpatient manager had been in post for three months at the time of the inspection and IPC lead nurse part time for four months
• The impact of the lack of an endoscopy lead and IPC lead are reflected in some of the concerns found during the inspection.
• Many staff told us their manager was visible and they were supported to do their job and felt able to raise concerns.
• Although there some systems in place to minimise risk to patients and monitor the quality of care provided they needed to be strengthened. Some aspects of infection prevention and control needed further development. 
• There was a lack of clarity about the level of critical care provided. Some senior staff confirmed that they did not provide Level 2 critical care. The hospital provided Level 1 enhanced care or extended recovery care.
• The hospital had a Medical Advisory Committee chaired by a consultant with representation from each of the specialities. The Director of Clinical Services also attended the meeting. The agenda had standing items which included applications for practising privileges, practising privileges renewed and practising privileges suspended or withdrawn.
• Support and resources for children and young people were limited and there was a reliance on one permanent member of staff who was paediatric trained to deliver the service albeit with some support from bank staff.

Was the hospital well-led?

• Prior to the inspection there had been a change in the senior leadership in the hospital and a new Executive Director had taken up their post in December 2014. The hospital had also become part of a cluster of three hospitals and the current Director of Clinical Services was transferring to another hospital within the cluster. As well as managing BMI The Blackheath Hospital, the Executive Director would have oversight of all three hospitals within the cluster.
• The Executive Director was clear that one of the priorities was to review the services provided at each hospital and develop a clinical strategy that achieved the best from the three sites in terms of performance and quality of care. This work already had started with the decision to cease termination of pregnancies due to the low numbers being carried out.
• The Executive Director had established regular forums with staff to keep them informed about changes and address any questions/concerns they had. All of the staff we spoke with were positive about working at the hospital and the support they received from their manager. The Director of Clinical Services was the professional lead for nurses and attended many of the governance and management meetings including the Medical Advisory Committee (MAC).
• The MAC had representatives from all the clinical services provided at the hospital along with a GP from one of the clinical commissioning groups.
• Although some nurses had attended leadership courses, the Director of Clinical Services told us that nursing leadership needed to be further developed.
• Systems to monitor the quality of care and performance were in place but need to be further developed and more service specific.
• Although the hospital had collected information about some of its services, it was not using it to review and improve the quality of care provided, for example the Urgent Care Centre.
• The hospital was aware of some of the issues highlighted in this report but had been slow to take action.
• The Director for Clinical Services met with commissioners of NHS funded care and reviewed performance and quality information including incidents and waiting times.
• The hospital sought the views of patients about their experience through a range of surveys. and although the number of responses varied the majority of responses were positive about the hospital and staff. The hospital had identified themes from complaints and taken action including where the complaint involved a particular consultant.

We saw one area of outstanding practice:

• In May 2014 the Oncology Suite achieved the Macmillan Quality Environment Mark.

However, there were also areas of poor practice where the provider needs to make improvements

• Review and improve its systems to monitor and improve the quality of care for all of the services it provides.
• The hospital does not provided Level 2 critical care as defined by the Faculty of Intensive Care Medicine standards 2013.
• Arrangements for decontamination in the endoscopy unit were not in line the national guidance published in 2012.
• The environment did not meet the national guidance for infection prevention and control
• Staff were unaware of their responsibilities in relation to the Mental Capacity Act 2005. The forms for  Do Not Attempt Cardiopulmonary Resuscitation orders did not did not allow for the patient’s capacity to be assessed or to include information about best interest meetings.
• Staff had not received training about how to provide care and support for patients who had learning difficulties or who were living with dementia.
• Systems to monitor and improve the quality of care provided need to be strengthened.

Importantly, the provider must:

• Review and develop its systems to monitor and improve the quality and safety of care for all of the services it provides.
• Improve attendance at infection prevention and control (IPC) training and ensure the inpatient environment is compliant with national IPC guidance.
• Take action to improve the arrangements for decontamination in the endoscopy unit and the environment and hand washing facilities in inpatient areas to ensure they comply with national guidance.
• Clarify the level of care it provides and ensure it complies with national standards and accurately reflect this in any information provided to patients, members of the public and NHS commissioning groups.
• The provider must ensure staff are aware of their responsibilities in relation to the Mental Capacity Act 2005 and Do Not Attempt Cardio-Pulmonary Resuscitation orders.
• Provide training and support for staff to care for patients living with dementia or who have learning difficulties

In addition the provider should:

• Continue to recruit to vacant manager/lead posts
• Review the resources and training for staff ,including medical staff, for children and young people.
• Provide training and support for staff to care for patients living with dementia or who have learning difficulties.
• Ensure that information about patients care and treatment is recorded and is accurate and that staff are aware of the possible risks for patients if this is not done.
• Review and develop care pathways for patients admitted with medical conditions. 
• The provider should develop a more comprehensive policy around the care of the dying in areas such as the duties of the differing staff groups, withdrawal of active treatments, informing relatives and next of kin and organ donation would provide assurance that all patients were receiving the best possible care.

Professor Sir Mike Richards

Chief Inspector of Hospitals