BMI The Chiltern Hospital opened in March 1982 and is part of BMI Healthcare. The Chiltern Hospital is part of the BMI South Buckinghamshire Hospitals group. The senior management is shared between this hospital and two other services. We inspected one of these services, The Shelburne Hospital at the same time as The Chiltern Hospital.
The Chiltern Hospital has 66 inpatient beds with 55 in use, which are divided between three wards. These are Misbourne Ward, the oncology and endoscopy unit; Chalfont Ward for in-patients and for day cases and short-stay Shardeloes Ward.
The operating department consist of three theatres. In out patients there are 11 consulting rooms with the additional supporting services of audiology, a minor operations room, colposcopy and treatment rooms. The hospital also provides pathology service, has a radiology department providing x-rays, ultrasound scans, Computerised Tomography (CT), Magnetic Resonance Imaging (MRI), bone density scanning, and mammography, a physiotherapy department with a hydrotherapy pool, and pharmacy.
The hospital provides a range of services to patients who are self-funded or use private medical insurance. Some treatment was available for NHS funded patients through the NHS e-Referral Service. Services include general surgery, orthopaedics, cosmetic surgery, ophthalmology, ENT, gynaecology and urology, oncology, physiotherapy and diagnostic imaging. The hospital was not providing services for children and young people.
The executive director, had recently moved from another hospital within the group, was applying to become the registered manager. They were supported by a director of clinical services, a director of operations and a team of heads of departments.
We inspected the hospital as part of our planned inspection programme. This was a comprehensive inspection and we looked at the three core services provided by the hospital: medicine, surgery, outpatients and diagnostic imaging.
The announced inspection took place on 26 and 27 July and an unannounced visit on 1 August 2016.
The hospital was rated good for caring and responsive and requires improvement for safe, effective and well-led services.
Our key findings were as follows:
Are services safe at this hospital?
By safe, we mean people are protected from abuse and avoidable harm.
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Staff were clear about their responsibilities to report incidents, however the process for the management of reported incidents was not robust and investigations and the sharing of learning did not always take way in a timely way.
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Processes to protect people from harm, such as infection control, the safe handling of medicines and equipment safety checks were being followed. However staff in theatres did not always follow systems and processes to keep patients safe.
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Patients were assessed and action was taken in response to risk. This included the assessment of patients to ensure only patients who the hospital could safely support received treatment.
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Patient records were stored securely. However, medical staff did not always achieve the required minimum standard of documentation in patient records.
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Staff were aware of safeguarding and were clear about their responsibilities to safeguard people at risk. However training to safeguard children was not currently being provided to the level described in the hospitals policy or safeguarding children and young people: roles and competencies for health care staff Intercollegiate document : March 2014.
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In general staffing levels and skill mix were planned, implemented and reviewed to keep people safe at all times. This was not the case for the operating departmentwhere staffing levels were not always in line with national guidance. Staff in the operating department were also undertaking dual roles without the support of a local hospital policy or risk assessments.
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The hospital compliance target for mandatory training was 85%. As of April 2016, compliance with mandatory training for staff working at the hospital was less than 50% compliant.
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There was a good understanding of the principles of the duty of candour, and the need to be open and honest.
Are services effective at this hospital?
By effective, we mean that people’s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence.
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Patients’ care and treatment was planned and delivered using evidence based guidance.
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Most staff were qualified and had the skills needed to carry out their roles effectively. Some theatre staff were undertaking the role of surgical first assistant without fully completing a recognised competency based course. There was no assurance that staff were competent to undertake the role.
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There was good multidisciplinary working across all teams in the hospital so patients received co-ordinated care and treatment.
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The hospital provided care to inpatients seven days a week, with access to diagnostic imaging and theatres via an on-call system.
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Staff had access to the information needed to assess, plan and deliver care to people in a timely way.
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Consent to care and treatment was obtained in line with legislation and guidance, and staff had an understanding of the principles of the mental capacity act.
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The hospital had systems in place for granting practicing privileges to consultants and when necessary suspended or removed these. However, the process for the biennial reviews was not being effectively managed.
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The hospital routinely collected and submitted data on patient outcomes. Although senior staff discussed this information at regional level, there was no evidence of how the hospital shared and used the information locally to improve outcomes for patients.
Are services caring at this hospital?
By caring, we mean that staff involve and treat people with compassion, kindness, dignity and respect.
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Nursing, theatre and medical staff were caring, kind and treated patients with dignity and respect.
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Patients felt they received sufficient information about their planned treatment and were involved in decisions about their care.
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Patients consistently told us they would recommend the service to friends and family.
Are services responsive at this hospital?
By responsive, we mean that services are organised so they meet people’s needs.
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The hospital planned and delivered services in a way that met the needs of the local population. The importance of flexibility and choice was reflected in the service.
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Patients had timely access to initial assessment, diagnosis and urgent treatment at a time to suit them.
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The needs of different people were generally taken into account when planning and delivering services including cultural, language, mental or physical needs. The service had strict selection criteria to ensure only patients whom the hospital had the facilities to care for were referred
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Discharge arrangements were planned but flexible, and care was provided until patients could be discharged safely.
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The hospital dealt with the majority of complaints promptly, and there was evidence that the complaints were discussed amongst staff. Complaints were used to improve the quality of care.
Are services well-led at this hospital?
By well-led, we mean that the leadership, management and governance of the organisation assures the delivery of high-quality person-centred care, supports learning and innovations and promotes an open and fair culture.
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There was a corporate vision in place, supported by a hospital business plan. Senior managers were aware of the key risks that may affect them achieving the vision.
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Governance processes were not always effective in monitoring the quality and safety of the service at a local level. Practices were taking place in the operating department that were not reflective of corporate polices or current national guidance.
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Managers and staff did not use the hospital risk register effectively to identify and manage risks within the service and there were no risk register at department level.
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The lack of a consistent and experienced theatre manager to lead and manage the operating department had resulted in no-one taking clear accountability and responsibility for the quality and development of the service. Local leadership was being developed with some department managers being new to the organisation.
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Heads of department found the daily senior team meeting an effective way to share key information with them.
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Staff felt they supported each other well in their teams and this had helped during a number of senior staffing changes at the hospital.
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They valued the changes the new executive director had made, particularly improving the appearance of the hospital and listening to their concerns.
After the inspection the provider was issued with a requirement notice letter, as we had identified potential failings to comply with two regulations relating to good governance and staffing; the detail of which is contained within the report and listed in the must actions at the end of the report. We asked the provider to submit an action plan to show how they would address these concerns and demonstrate how they would reduce the associated risks to patients and staff. The provider submitted a detailed action plan within the agreed timeframe which we felt was sufficient to comply with the requirement notice. A responsible person was allocated to each action, with a date for completion. Compliance with the action plan will be monitored through regular engagement meetings with the provider.
There were also areas of where the provider needs to make improvements.
Importantly, the provider must:
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The provider must ensure that all staff acting as a surgical first assistant have been assessed as competent for the role. In addition, the evidence of completed competencies and log of cases should be available in accordance with the BMI Healthcare Surgical First Assistance policy.
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The provider must ensure it completes regular reviews of compliance with BMI Healthcare policies, with action taken for areas of non-compliance, including the renewal of practising privileges.
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The provider must ensure that staffing levels in theatres are in line with current national guidance and the BMI Healthcare policy.
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The provider must ensure when staff are undertaking a dual role this is supported by a local policy and risk assessment.
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The provider must ensure staff in the operating theatre fully comply with the Five Steps to Safer Surgery at all times.
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The provider must ensure there is robust monitoring of the safety and quality of the surgery service at a local level, with risks identified and timely action taken to manage the risks.
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The provider must ensure the hospital risk register reflects the current risks faced by the hospital and in sufficient detail to show how they are monitoring the risks.
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The provider must ensure there is robust monitoring of the safety and quality of the outpatients and diagnostic imaging service at a local level, with risks identified and timely action taken to manage risks.
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The provider must ensure that all incidents are monitored at each hospital and individual clinical location to be able to identify trends.
In addition the provider should:
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The provider should ensure a trend analysis of all incident reports is completed, with action plans devised as a result.
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The provider should ensure all patient chairs have a wipeable surface to ensure they can be appropriately cleaned.
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The provider should ensure all floors in the operating department are kept clear so they can be cleaned and there are no trip hazards to staff.
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The provider should ensure all areas in the operating department meet fire safety regulations.
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The provider should ensure all patient care records are completed in full, by the multidisciplinary staff providing care and treatment
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The provider should ensure all staff are up-to-date with all of their mandatory training.
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The provider should ensure all staff complete safeguarding children training appropriate to their role.
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The provider should ensure all the key recommendations of the Perioperative Care Collaborative Statement on Surgical First Assistants have been considered, with action taken as indicated.
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The provider should ensure patient surgical outcome data is shared and discussed at relevant departmental meetings so changes can be made to practice where necessary.
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The provider should ensure for all audits there is a clear action plan, with accountability for completion of any actions, by an agreed date.
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The provider should ensure all theatre staff receive an annual appraisal.
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The provider should ensure formal written on-call arrangements are in place for all relevant teams.
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The provider should ensure the gastroenterologists explain to patients the need for possible transfer to the NHS hospital should complications from the procedure occur.
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The provider should consider arranging an external review of its theatre service to seek an independent review of the standards of the service.
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The provider should consider reviewing the layout of the changing rooms in diagnostic imaging to ensure it meets the needs of all patients.
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The provider should consider displaying safety thermometer information in all clinical areas as considered best practice.
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The provider should train staff in line with the BMI Safeguarding Children policy. All staff who have some degree of contact with children should complete a minimum of level 2 safeguarding training.
The provider should consider formalising arrangements for diabetic specialist nurses from the NHS to assess and treat patients at both the Chiltern and Shelburne hospitals
Professor Sir Mike RichardsChief Inspector of Hospitals
Professor Sir Mike Richards
Chief Inspector of Hospitals