Mount Alvernia Hospital

Updated 11 April 2022

Mount Alvernia Hospital is an independent hospital which is part of the recently rebranded Circle Health Group Limited. It is situated in Guildford, Surrey. Approximately 10% of patients are provided care through the NHS and all other patients are privately funded. The hospital provides care for adults aged 18 and over.

At the time of inspection Mount Alvernia Hospital was using two surgical wards with 25 beds, most of which are private rooms with en-suite bathrooms. There was an additional ward which was not in use. The hospital has three operating theatres an ambulatory care unit which included a six bay endoscopy suite, endoscopy theatre and a minor operation theatre and consultant rooms.

Mount Alvernia Hospital also had an oncology ward which had nine patient bedrooms, six pods and two consultation rooms.

The Imaging department offers magnetic resonance imaging (MRI) scanning, x-ray, positron emission tomography (PET), computerized tomography, nuclear medicine, Dexa scanning, ultrasound and digital mammography

Mount Alvernia is regulated to carry out the following actives:

• Diagnostics and screening
• Treatment for disease, disorder or injury
• Surgical procedures
• Family planning

The current registered manager has been in post for eight years. Mount Alvernia was last inspected in July 2016 and rated good overall. We inspected Mount Alvernia Hospital using our comprehensive inspection methodology. We carried out a short notice announced inspection on the 1 February 2022. On this occasion, we inspected surgery, medical care, diagnostic imaging and outpatients using our comprehensive inspection methodology.

The hospital provides day case surgery, inpatient surgery and cancer treatment services. The service offered a range of different surgical specialties, including orthopaedic, ophthalmology, urology, gynaecology, and ear, nose, and throat (ENT).

Activity (February 2021 to January 2022):

• There were 7523 day and inpatient admissions to the hospital; of these, 7.9 % were NHS funded.

• The top two surgical specialities were orthopaedic 1371 procedures and gynaecology with 411 procedures.

• There were around 3000 day case Systemic Anti-Cancer Therapy (SACT) episodes between February 2021 to January 2022 and between 60 and 90 endoscopy procedures each month under medical care.

The main services provided by this hospital was surgery and medical care. Where our findings on surgery and medical – for example, management arrangements – also apply to other services, we do not repeat the information but cross-refer to the surgical core service.

Updated 11 April 2022

Our rating of this service stayed the same. We rated it as good because:

• The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them.
• Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week in the surgical and medical areas and six days a week in outpatients and diagnostic imaging.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families, and carers.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported, and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However;

• In outpatients actions found from the most recent IPC standard precaution audit (November to December 2021) needed to be implemented to improve recent performance.
• Magnetic resonance imaging (MRI) referral paperwork for scans did not always have completed safety information and there was not a mechanism for the department to identify this prior to a patient appointment.
• Chairs in the positron emission tomography-computerized tomography (PET-CT) clinical rooms were not safe and required replacing.
• The diagnostic imaging department did not have a documented oversight of pharmacy activities when renewing medications.

Updated 11 April 2022

Our rating of this service stayed the same. We rated it as good because:

• The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them.
• Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

Medical care forms a main part hospital activity alongside surgery. Where arrangements were the same, we have reported findings in the surgery section.

We rated this service as good because it was safe, effective, caring, responsive, and well-led.

Updated 11 April 2022

Our rating of this service stayed the same. We rated it as good because:

• The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service-controlled infection risk well. Staff acted on risks to patients and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
• Staff provided good care to patients and monitored their pain. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available six days a week.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for a diagnostic procedure.
• Leaders ran services well, using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However,

• There was not a mechanism or audit process that ensured information on referral forms is fully completed before a patient attended the department.
• Chairs in the molecular imaging clinical rooms were not safe and require replacing with a timeframe for action.
• The department did not have a documented oversight of pharmacy activities when renewing medications.

Diagnostic imaging is a small proportion of hospital activity. The main service was surgery and medical care. Where arrangements were the same, we have reported findings in those services sections.

We rated this service as good because it was safe, effective, caring, responsive and well led.

Updated 20 February 2015

Palliative and end of life care specialist input was via the Palliative Care medical consultants and the Palliative Care nurse. The end of life care delivered was a consultant led service with the Palliative care consultants reviewing patients daily as well as being contactable by telephone if staff required support. Out of hours and over the weekend the Palliative Care consultants provided on –call cover and undertook any reviews necessary. This meant that patients had access to specialist advice 24/7.

The care people receive at end of life was a whole team approach with the ward nursing and medical staff and the palliative care team all working together to deliver holistic care. Medicines were provided in line with the Adult Palliative Care Guidance 2nd edition 2006. The choice of medications at the end of life had been aligned to local community guidelines to support safe and consistent practice between care providers. A fast track process is in place to support patient’s wishes and preferences to achieve their Preferred Place of Care.(PPC)

The nursing staff we spoke to on the wards had not received end of life training and no end of life care link nurses were present on the wards. At the time of the inspection BMI Mount Alvernia did not have an end of life pathway to support staff to identify and care for people at the end of life. End of life patients were placed on the generic medical pathway with specialist input from the palliative care consultants and nurse.

Leadership of the specialist palliative care team was good and quality and patient experience was seen as a priority.

Updated 11 April 2022

Our rating of this service improved. We rated it as good because:

• The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service-controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. The service managed safety incidents well and learnt lessons from them. Staff collected safety information and used it to improve the service.
• Staff provided good care to patients. Managers checked the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients and had access to good information. Services were available six days a week.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs and helped them understand their conditions. They gave emotional support to patients, families and carers.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for a diagnostic procedure.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. Leaders focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients.

However,

• Actions found from the most recent IPC standard precaution audit (November to December 2021) need to be implemented to improve recent performance.

Outpatients is a small proportion of hospital activity. The main serviced were surgery and medical care. Where arrangements were the same, we have reported findings in the those sections.

We rated this service as good because it was safe, effective, caring, responsive and well led.

Updated 11 April 2022

Our rating of this service stayed the same. We rated it as good because:

• The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them.
• Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families, and carers.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported, and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.