Mount Alvernia Hospital

BMI Mount Alvernia hospital is an acute independent hospital that provides outpatient, daycare 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. There are no critical care facilities which limits the scope of procedures that are available at the hospital.

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 Mount Alvernia Hospital on 12 and 13 November 2014. 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 and end of life care as these were the four 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.

As this was a pilot inspection and was undertaken to help develop the methodology we will use to inspect all independent healthcare providers, we have not given the hospital a rating.

The hospital has gone through a period of significant change and improvement over the past two years, with a new management team having been appointed by the organisation. Following a CQC inspection in January 2013, BMI Healthcare Limited had made a voluntary agreement with CQC to stop providing services for children; this agreement remains in force and children are not treated at the hospital.

Our key findings were as follows:

Are services safe?

• There were good Infection prevention and control procedures with staff having clear understanding of their own responsibilities.
• Pharmacy was well managed at the hospital with few medicines errors recorded. A dedicated inpatient pharmacist spends 90% of their working week on the wards meeting with patients to discuss their medication, reviewing all medicine charts daily and providing advice to ward staff and the RMO. Governance arrangements within the pharmacy department were good with a Medicines Management Committee that met bi-monthly and which fed into the Clinical Governance Committee. Pharmacists completed Continuing Professional Education in accordance with the requirement of the General Pharmaceutical Council.
• The level of senior medical and nursing input to patient care was limited overnight and at weekends. The hospital used an early warning scoring system (NEWS) to assist staff in identifying patients whose condition was worsening but these were not universally completed and the escalation policy was not always adhered to.
• The Resident Medical Officer (RMO) provided all medical cover over the 24 hour period and they could contact a consultant for advice, if they felt it necessary.
• We were not assured that patients were made fully aware of the limitations of care that could be provided at BMI Mount Alvernia Hospital in a systematic and consistent manner, such as the limitations in care that could be provided in the event of a deterioration in their condition. However, the hospital did have arrangements with a local NHS Trust to transfer patients should they be unable properly to care for any patient who unexpectedly deteriorated.
• The arrangements for handing over responsibility for patient care between consultants and for ensuring this was communicated effectively to staff were inconsistent and informal. Consequently, there had been an example where one consultant was not aware they were providing cover for another consultant.
• The duty night matron held a file that contained the essential information for them to undertake the role safely. However, there was no information about which consultants were providing cover for absent colleagues within this folder, which had potential to cause delays in seeking senior medical and surgical advice in an emergency.
• The systems for the reporting, analysis and dissemination of learning from incidents were insufficiently robust and failed to ensure that the risk of recurrence was minimised.
• There was very good uptake and completion of mandatory training by staff employed at BMI Mount Alvernia hospital. This did not include consultants who worked under practicing privileges; it was unclear how consultants were consistently made aware of hospital policies and safe working practices in relation to subjects covered by mandatory training and the hospital incident reporting and investigation policies.
• There was a good theoretical understanding across the hospital in relation to adult safeguarding but this was not always followed robustly in practice.
• The management of the catering arrangements and food safety was very good with clear audit trails and governance records relating to the safe purchase, storage and handling of food provided to patients and staff.
• The facilities management was very good with attention to detail in the monitoring of water safety, electrical safety and fire safety. Records were readily available to demonstrate the provider met the requirements of the Control of Substances Hazardous to Health Regulations (2002).

Are services effective?

• Local policies and care pathways followed national guidance. We found that the guidance and policies were followed except in the radiology department where there was some inconsistency in local guidance being adhered to.
• There was no local end of life care pathway. However, the hospital was following the local NHS trust interim end of life care pathway and discussed with the inspectors a draft BMI pathway and the proposed piloting of that. The Hospital managed all patients requiring end of life care on an appropriate pathway and this was supported by robust multidisciplinary team review.
• Data collation and analysis was not as well developed, which meant it was not possible to consider the patient outcomes related to individual consultants or procedures to measure effectiveness in a systematic and consistent manner.
• Good Surgical Practice 2014 (RCS) says that surgeons should take part regularly in morbidity and mortality meetings. This was not happening because at the time of the inspection there were no morbidity and mortality meetings being held at BMI Mount Alvernia Hospital, although it is acknowledged that there were few unexpected deaths at the hospital. There was no comprehensive follow up where patients had been transferred out due to deterioration in their condition and this meant that the opportunity to learn and improve practice as a result of such meeting was missed.
• The hospital worked with a local NHS trust to ensure good multi-disciplinary review of patients receiving treatment at BMI Mount Alvernia hospital from consultants who also worked at the trust. We were less clear about the assurance that there was effective multi-disciplinary input where consultants did not also work at the trust as there were no MDT meetings held at the hospital.
• Some staff had a very limited awareness and understanding of the Mental Capacity Act 2005 and how this impacted on their role. The hospital dealt with very few people who lacked capacity and some records showed that some staff and consultants considered lack of capacity as an ongoing and overall assessment of the person’s cognitive ability rather than being decision specific. Training in the care of people living with dementia was not offered to staff.

Are services caring?

• Without exception, patients reported a positive experience to us during our visit. Patient satisfaction surveys were benchmarked against other hospitals in the same ownership. The results for BMI Mount Alvernia showed high levels of patient satisfaction.
• Staff were caring and compassionate and treated patients with dignity and respect. They reported having sufficient time to provide good care based on individual needs and preferences.
• Observed interactions between patients and staff were good, with clear warmth and kindness.

Are services responsive?

• Operations and treatments were rarely delayed or cancelled.
• The referral to treatment times were good and in line with national targets.
• The hospital provided some NHS funded care. There was no differentiation between NHS and private patients. Few NHS inpatients were being treated at the time of the inspection, although the hospital had contracts for NHS physiotherapy services.
• Within the practicing privileges contract for consultants there was a paragraph that required each consultant to review the management of each of their inpatients on a daily basis. Whilst the consultant physicians met this requirement some of the consultant surgeons did not and left the daily review of their patients to the RMO. The chair of the Medical Advisory Committee (MAC) advised the inspection team that they disagreed with this aspect of the organisational policy on practicing privileges and therefore the committee did not monitor or enforce the contractual agreement.
• The hospital did not provide critical care; patients who required elective high dependency or intensive care were not admitted to the hospital. Patients who experienced a sudden and unexpected deterioration in their condition such that they required higher level care were transferred to a local NHS hospital by emergency ambulance. There was, however, no scope of practice document nor mention within the practicing privileges contract of the range of treatments and surgery that could be provided at BMI Mount Alvernia and the decision as to whether to admit remained the decision of the consultant. There was a lack of structured and consistent governance processes in place which ensured that no patient could be admitted whose needs would in fact be more complex than those that can be met by the facilities and staff in the hospital.
• There was very limited advice or guidance on how staff would met the wider needs of people with a learning disability. We were told that very few people with learning difficulties were admitted to the hospital; this is the reason there should be appropriate training and guidance for staff that are unfamiliar with this area of practice.

Are services well-led?

• We found that significant improvement had been made in areas of patient safety under the leadership of the current management team but more work needed to be done to improve some of the governance systems and processes, in particular learning from incidents.
• There were noticeable improvements in the organisational culture with staff reporting that they felt much more valued and respected under the current leadership than they had done previously.
• Complaints were not seen as a tool to drive service improvements, with learnings from complaints not being well shared. In addition, during the inspection there was little written information available to patients regarding how to complain.
• Specific activities were provided which allowed for increased inter departmental working. The introduction of ‘Lunch and Learn’ sessions allowed staff from across the hospital to come together to learn about specific topics such as pain management.
• The Resuscitation Committee operated in accordance with the recommendations made by the Resuscitation Council UK guidance. It was chaired by a senior clinician and had input from consultant anaesthetists and physicians. There were some documented concerns raised by the committee about the ability of the Resident Medical Officer (RMO) to respond to and lead resuscitation attempts identified during practice scenario during 2013; however no further concerns had been raised by the committee.
• There was a hospital Medical Advisory Committee (MAC) with consultant representation from across the specialities provided at the hospital. The Director of Nursing and Executive Director also attended. There were regular meetings with discussions around new applications for practicing privileges, hospital policies and complaints. We were told by senior staff that there was not a formal process for how information was communicated to consultants who did not sit on the committee.

Was the hospital well-led?

• Staff of all grades reported a cultural change within the hospital and said they felt more empowered to challenge poor practice than they were prior to the current management team being appointed.
• The hospital’s vision and strategy was that of BMI Healthcare Limited, the provider organisation. There were clear strategic objectives that were known to staff.
• There was a clinical governance structure but the post of Quality and Risk Manager was unfilled at the time of the inspection. Although we were told the Director of Nursing reviewed all incidents, we found in practice that the management and processes for review of incidents was not found to be robust or consistent, with some having not been reviewed and investigated. In addition, systematic learning from incidents and feedback to staff was not embedded across the hospital.
• Patient surveys were undertaken and used to benchmark the hospital against other hospitals within the same ownership. The Key Performance Indicators covered many aspects of the care people had received including the quality of catering, customer service, staff attitudes and pain management.
• We were told that there was an, “understanding” between consultants and the management team, which meant there was no need to formalise concerns that were identified in relation to individual consultants. Whilst there were route for more formal processes, there were isolated incidents reported of unacceptable behaviour by individual consultants that were managed informally by members of the management team rather than taking more formal and recorded action.
• Part of the strategic plan for BMI Mount Alvernia was to improve efficiency through cost reduction. Whilst the Hospital’s strategy remained to recruit to permanent posts wherever appropriate, the Hospital also used bank staff to provide flexibility, particularly whilst occupancy levels were low.
• The hospital was operating below capacity. The strategic plan was addressing this and looking at ways to increase revenue through developing existing services and introducing new services.

We saw several areas of outstanding practice including:

• We saw that the hospital had systems and processes in place that supported staff in providing a good service. For example allocating time for post discharge telephone calls to check that all was well once the patient returned home and having adequate staff on duty which gave them time to interact with patients and their families. Patients and their families were cared for by kind and compassionate staff who went out of their way to support them.

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

• Incident reporting and learning from incidents was insufficiently robust to assure us that all incidents were reported. The organisational and hospital governance was not sufficiently developed to ensure proper learning from incidents and from trend analysis.
• Consultant surgeons were not routinely adhering to the contractual arrangements of their practising privileges agreements and this was not being monitored or addressed by the MAC.
• There were gaps in the staff and consultant’s understanding of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards and the staff understanding of the needs of people living with dementia.
• The arrangements for handing over responsibility for patient care between consultants and for ensuring staff are aware who holds responsibility at any time were unclear and informal.

Importantly, the provider must ensure that :

• The provider has not always notified CQC of serious incidents that have occurred. The provider must ensure that CQC is notified without delay if a patient receives an injury; Which has caused impairment, changes to the structure of a patient’s body, caused prolonged pain, psychological harm or has shortened the patient’s life expectancy; Or which requires treatment in order to prevent death or serious injury, any allegation of abuse or incident investigated by the police.
• The investigation and reporting of incidents and systems for organisational and local learning was insufficiently robust. The provider must consider feedback mechanisms following the reporting of incidents, and should review the arrangements for monitoring the implementation and efficacy of mitigating actions.
• The provider must review the process for monitoring compliance with practicing privileges.
• The service does not provide Level two critical care. The provider must amend the Statement of Purpose to ensure it reflects the service provided and the range of patients’ needs the service can meet.
• Mental capacity assessments were not always completed and recorded, when necessary, such as when considering consent or Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) orders. The provider must consider the formal arrangements required to support patients living with dementia or learning difficulties. This must include appropriate training and monitoring processes for the assessment of people who lack capacity to consent.
• The provider must ensure that the records relating to the safe use of lasers in theatre are updated and provide assurance that the consultants are trained in their use and the equipment is appropriately monitored following best practice guidelines.

In addition the provider should:

• The provider should develop clear antibiotic prescribing protocols as we were told, “Consultants like to do their own thing”. This increased the risk of resistant bacteria developing which could affect the wider community as well as the patients at BMI Mount Alvernia.
• The provider should review the use of the NEWS to ensure that hospital protocols are followed and that emerging concerns are appropriately escalated.
• The provider should consider how it combines development plans and projects for oncology services into a coherent, strategic whole.
• The provider should ensure that where risk assessments identify a patient at risk from harm appropriate action is taken and recorded in the medical and care records.
• The provider should ensure that they have clear admission guidelines in place adhered to in practice to ensure the hospital only admits patients they are able to provide a safe level of care to.
• The provider should consider the practice in the Ambulatory Care Unit for caring for patients undertaking “clean” and “dirty” procedures in the same space.
• The provider should consider reviewing how complaints are managed to ensure that all complaints are captured and recorded, and then following investigation any action taken is feedback to staff to enable learning and prevent future reoccurrences’.
• 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.
• Ward staff should be provided with training in the care of dying patients.
• The provider should maximise the opportunities to be more proactive in encouraging the development of all staff through regular appraisals and completion of competencies.

Professor Sir Mike Richards

Chief Inspector of Hospitals