The Highfield Hospital

We carried out an announced inspection of BMI Highfield Hospital on 2 and 3 August 2016. We also carried out an unannounced visit on 18 August 2016 to check the service had implemented improvements from the announced inspection. This was particularly to check that correct numbers of staff were on duty with the appropriate skills to meet the needs of patients and improvements had been made to infection control and environmental issues raised at the announced inspection.

We carried out this inspection as part of our comprehensive inspection programme of independent healthcare hospitals.

Overall, we have rated BMI Highfield Hospital as requiring improvement.

Are services safe at this hospital

• Reviews and investigations following incidents was not always sufficiently thorough and actions were not put in place to prevent the incident recurring. Consequently lessons were not being learned and similar incidents were repeatedly occurring.
• Premises and equipment were not visibly clean in the theatre area and cleaning schedules in theatres were not always completed. This meant the level of cleanliness required for a surgical environment was not being appropriately monitored. Two Department of Health standards for the clinical environment were not met.
• There were no hand washing facilities in the ultrasound room and the chair in this clinical area could not be cleaned following patient consultations.
• We raised these concerns with the executive director at the time of the inspection.
• Immediately following the inspection the hospital arranged a deep clean of the service areas. The areas were appropriately clean at the time of the unannounced inspection.
• Arrangements for the service, maintenance, renewal and replacement of premises and equipment were not adequate in the theatre department. Service records for electronic equipment were not up to date and some equipment was in a state of disrepair.
• We raised these concerns with the executive director at the time of the inspection. Immediately following the inspection the hospital contacted engineers who started the process of servicing and registering each piece of equipment, logging them all onto an asset register with dates of last service and next service due. We received a copy of this register within one week of the inspection ending, with assurance from the hospital that any equipment not up to date with servicing would not be used.
• Staffing levels in theatre did not meet the required standards as set out by the Association for Perioperative Practice (AfPP), the Association of Anaesthetists of Great Britain and Ireland (AAGBI) and in BMI’s own staffing policy. This posed a potential risk to patient safety.
• Documentation around the completion of VTE assessments and prophylaxis medication in patient records was inconsistent, despite the hospital reporting 100% completion rates.
• In surgical service despite issues being identified in an audit with the management of controlled drugs, there was no action plan in place and we found they had not been checked the previous day in one area.
• In the outpatient department a medication fridge was being used to store blood products awaiting collection. An additional fridge was in place when we returned for our unannounced inspection.
• Mandatory training figures including adult and child safeguarding courses were lower than the hospital target.
• Completion of the World Health Organisation (WHO) surgical safety checklist was variable also there had been no audit of the use of the World Health Organisation checklist in diagnostic imaging since September 2014.
• Records used in the outpatient department did not contain full details of patients’ medical history. This posed a risk that treatment could be unsafe or inappropriate.

However

• There was good cover by the responsible medical officer (RMO) and consultants.
• Incidents were reported. Staff understood the importance of being open and honest and the duty of candour.
• Medicines were stored securely. Patient group directives were in place and up to date where required.
• Staff knew how to respond to deteriorating patients. Training, systems and processes were in place to ensure risks to patients were minimised.
• Bank workers were used to supplement the establishment and add to the skill mix. Bank workers were inducted to departments appropriately.
• Apart from the theatre area, rooms on the wards were visibly clean and tidy.
• Record keeping was mostly good in the surgical department, with evidence of falls assessments, assessment of pressure areas and assessment of nutritional status in patients’ case notes. However, records used in the outpatient department did not contain full details of patients’ medical history. This posed a risk that treatment could be unsafe or inappropriate.
• There were processes in place for safeguarding patients and most staff were familiar with these.

Are services effective at this hospital/service

• Local policies and procedures were based on evidence and guidelines produced by Royal Colleges and the National Institute for Health and Care Excellence (NICE).
• Outcomes data indicated that the hospital was performing at a comparable level with other independent hospitals in terms of unplanned returns to theatre, unplanned transfers and unplanned readmissions.
• The hospital operated an enhanced recovery model to improve outcomes for patients following surgery.
• We saw good evidence of pain being assessed and treated accordingly.
• Assessments for nutrition and hydration were being completed and documented.
• There were opportunities for staff to undertake courses and work in different roles which allowed them to develop professionally.
• There were link nurses in place to represent their clinical areas at meetings in particular specialties, eg pathology and resuscitation, and cascade information from the meetings back to their teams.
• Audits of care and discrepancy meetings were in place in the imaging department.
• The diagnostic imaging service was working towards the Imaging Services Accreditation Scheme (ISAS).
• Staff were supported in their personal development and attended both internal and external courses to develop their skills and knowledge.
• There was a BMI policy in place for granting and reviewing the practising privileges of doctors. Consultant files we reviewed contained details of medical revalidation and an up to date appraisal.
• There was good multi-disciplinary working between consultants, nursing staff and allied health professionals.
• Staff we spoke to had an understanding of the need to consider mental capacity when taking consent, but not all staff fully understood the processes required if a patient lacked capacity to consent for themselves.

Are services caring at this hospital/service

• Patients were supported and were involved in planning their treatment and care.
• Patients understood their treatment and, where applicable, were informed of any associated costs prior to treatment.
• Feedback from patients and those who were close to them was positive about the way staff treated and cared for them.
• Staff were kind, caring and compassionate. They were sensitive in their communications with patients and understood and respected individual needs.
• Staff took steps to promote privacy and dignity. Patients told us they felt staff went above and beyond what was expected of them.
• Friends and family test results showed that 97.2% of patients would recommend the service to their friends and family.
• The hospital sought feedback from patients about the service using a BMI questionnaire and the NHS friends and family test.
• Staff in the MR department took time to provide emotional reassurance to patients, particularly those who were nervous or claustrophobic. Patients told us staff made them feel at ease.

Are services responsive at this hospital/service

• Services had been planned to meet the needs of local people. There was flexibility in treatment and appointment times and access to a one stop breast clinic.
• The hospital had an admissions policy which detailed criteria for patients who could be safely treated at the hospital.
• Patients’ needs were assessed through the use of a range of BMI clinical pathways, which included the use of a pre-operative assessment health questionnaire.
• Patients were kept informed of any delays and patients told us appointments ran to time.
• Overall, the 95% 18-week target for non-admitted patients was met between April 2015 and March 2016. Waiting times for diagnostic imaging were low.
• Individual needs were understood and considered when delivering care and treatment. Adjustments were made to remove barriers to people accessing services. Staff received training in dementia awareness and equality and diversity.
• Staff understood the complaints process and told us learning from complaints was discussed at departmental meetings and at the medical advisory committee.
• An interpreting service was available for patients who did not speak English and staff could access patient information sheets in different languages.
• There was an open visiting policy within the hospital.
• Patients were given opportunities to feedback on the care they received and we saw evidence that patient feedback was acted on.
• Patients agreeing to undergo cosmetic surgery could change their minds and cancel the procedure at any point prior to the commencement of surgery.
• National waiting time indicators for referral to treatment (RTT) were below the 90% indicator for admitted patients beginning treatment within 18 weeks of referral for each month in the reporting period (April 2015 to March 2016).
• Reasons for cancelled operations were not being investigated consistently, so there was no learning or actions in place to prevent the same issues recurring.
• Information about how to complain was not readily available in the departments we visited.

Are services well led at this hospital/service

• Frequent changes to leadership across the theatre departments and change in hospital manager had led to a lack of direction for staff and a need to improve governance systems.
• There was no strategic oversight of incidents so lessons were not always learned from these.
• Communication and sharing of action plans had been identified by the hospital as a problem. Communication meetings (comms cells) were being to improve this.
• A number of senior staff had not seen a risk register at the hospital.
• There was a risk assessment folder on Cedar ward, however this included several expired review dates and some incomplete assessments.
• Clinical governance meetings were not well attended and actions were not completed in a timely way. BMI clinical governance bulletins were not shared with the medical advisory committee.
• Not all consultants who held practicing privileges at the hospital had all the required documentation in place.

However;

• There was an open culture where staff felt confident to raise concerns if required. Staff spoke positively about their work and their colleagues.
• Leadership in the imaging department was good and staff felt well supported. Work was in progress to ensure the sustainability of the one stop breast clinic and to improve the service by gaining accreditation via the Imaging Services Accreditation Scheme (ISAS).
• ‘Comms cell’ boards displayed key information about the quality measurement and risk management.
• There was an experienced medical advisory committee (MAC) chair who was able to give examples of how the committee monitored and influenced clinical practice.
• The private healthcare information network (PHIN) had commenced outcome collection and covered hip, knee, hernia and cataract surgery.
• All the staff we spoke with felt supported by their managers, and were positive about their roles and about working at the hospital.

Professor Sir Mike Richards

Chief Inspector of Hospitals