The Princess Margaret Hospital

The Princess Margaret Hospital is one of 59 hospitals and clinics provided by BMI Healthcare Ltd. It is located in Windsor, Berkshire, and on-site facilities include 78 registered beds, four theatres (three laminar flow), and an endoscopy suite. There is an outpatient suite offering consulting and treatment rooms, and an imaging department offering X ray, magnetic resonance imaging (MRI), computed tomography (CT) and ultrasound.

BMI Princess Margaret Hospital provides a range of medical, surgical and diagnostic services to patients, who pay for themselves, are insured, or are NHS-funded patients. Services offered include general surgery, orthopaedics, cosmetic surgery, ophthalmology, general medicine, oncology, dermatology, physiotherapy and diagnostic imaging, ophthalmology, endoscopy and orthopaedic services.

Medical services can be thought of as those services that involve assessment, diagnosis and treatment of adults by means of medical interventions rather than surgery. The medical service consists of two separate components; oncology chemotherapy treatment, and a diagnostic endoscopy service. Endoscopy or chemotherapy services undertaken as a day case are therefore included within medical care in this report.

The announced inspection took place on 13 and 14 September 2016, followed by a routine unannounced visit on 23 September 2016.

This was a comprehensive planned inspection of all core services provided at the hospital: medicine, surgery, outpatient and diagnostic imaging. There are some surgical and outpatient services for patients under 16 years, and these are reported within the surgical report by Specialist Advisers, but the majority of patients are adults.

The Princess Margaret Hospital was selected for a comprehensive inspection as part of our routine inspection programme. The inspection was conducted using the Care Quality Commission’s new inspection methodology.

Our key findings were as follows:

Are services safe at this hospital?

By safe, we mean people are protected from abuse and avoidable harm.

• Patients were protected from the risk of abuse and avoidable harm across all inspected services.
• Staff reported incidents, and openness about safety was encouraged.
• Incidents were monitored and reviewed in most services and staff clearly demonstrated examples of learning from these.
• Clinical areas were visibly clean and tidy. Hospital infection prevention and control practices were followed and these were regularly monitored, to reduce the risk of spread of infections. Where necessary, action was taken to address any identified learning.
• Staff received appropriate training for their role, were supported to keep their skills up-to-date and were further supported in their role through a corporate performance review process. BMI set a target of 90% compliance with mandatory training. Records provided by the hospital showed that the compliance rate for medical care staff was 89%.
• Staff followed national and local guidance when providing care and treatment.
• Equipment was maintained and tested, in line with manufacturer’s guidance. There were appropriate checks and maintenance on the hospital building and plant.
• Medicines were stored securely and chemotherapy was prepared safely. Nursing staff were trained to administer chemotherapy.
• There was regular monitoring of patient records for accuracy and completeness. They were securely stored and available when needed.
• Staffing levels and skills mix were planned, implemented and reviewed to keep patient’s safe at all times. There was sufficient medical cover provided by resident medical officers (RMOs) who covered the hospital 24 hours a day for all specialities. Consultants were also available daily and would provide support and advice out of hours if necessary.
• Plans were in place to respond to emergencies and major situations.

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.

• We found there were arrangements to review guidance from national bodies such as the National Institute for Health and Care Excellence (NICE), and that care was delivered in line with best practice.
• There was a system for reviewing policies and these were discussed at the medical advisory committee (MAC) and other governance groups at the hospital.
• Care was continually monitored to ensure quality and adherence to national guidelines to improve patient outcomes and the hospital participated in relevant national audits.
• We found arrangements that ensured the doctors and nurses were compliant with the revalidation requirements of their professional bodies. All consultants had clear practising privileges agreements, which set out the hospitals expectations of them, and ensured they were competent to carry out the treatments they provided.
• Systems for obtaining consent were compliant with legislation and national guidance, including the Mental Capacity Act (2005) and these were adhered to by staff.

Are services caring at this hospital?

By caring, we mean that staff involve and treat people with compassion, kindness, dignity and respect.

• We observed that patients were treated with dignity and respect and their privacy was maintained.
• Patients who shared their views were very positive about the care they received and spoke of kind and welcoming staff.
• Staff helped patients and those close to them to cope emotionally with their care and treatment
• Staff described how all children were involved in the discussions and decision making processes about their treatment and care, in a way which supported their understanding.

• Patients and relatives commented positively about the care provided and said they were involved in decision making.

• The hospital took part in the Friends and Family Test (FFT). For the reporting period November 2015 to February 2016, 100% of patients said they would recommend the hospital to their friends and families. Between 25% to 50% of patients responded to the FFT.

Are services responsive at this hospital?

By responsive, we mean that services are organised so they meet people’s needs.

• Services were planned and delivered in ways which met the needs of the local population. Patients told us there was good access to appointments, and at times which suited their needs.
• Waiting times, delays, and cancellations were minimal and managed appropriately. Facilities and premises were appropriate for the services being delivered.
• The hospital was a provider of Choose and Book which is an E-Booking software application for the National Health Service (NHS) in England: this allows patients needing an outpatient appointment or surgical procedure to choose which hospital they are referred to by their GP, and to book a convenient date and time for their appointment.

• There was openness and transparency in how complaints were dealt with, and staff could demonstrate where learning and actions had taken place. Patient’s comments and complaints were listened to and acted upon. Information on how to make a complaint was provided on the BMI Princess Margaret Hospital website. However, we did not see any guidance, posters or leaflets instructing patients on how to make a complaint.
• A complaints database enabled the executive director and the director of nursing to track progress and close complaints when the complainant was satisfied.
• For the reporting period March 2015 to April 2016, the hospital consistently met the target of 95% of non-admitted patients beginning their treatment within 18 weeks of referral.
• Patients were able to access services when needed and we found services responsive to meeting individual needs. They were satisfied with the appointments system. Most patients told us it was easy to get an appointment when they needed it.
• Patient Led Assessments of the Care Environment (PLACE) for 2015 showed comparable results to the previous year and above the England average. In the PLACE audit carried out in March 2015, dementia services at the hospital scored 83%. This was above the England average of 81% for independent sector acute hospitals but the hospital was devising a plan to provide more dementia-friendly facilities.

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.

• We found that most staff were conversant with the corporate and local vision and values and strove to demonstrate these in their daily work.
• There was an appropriate system of governance and managers knew the key risks and challenges to the hospital and were taking steps to mitigate the impact of these. Staff attended governance meetings and committees such as infection prevention and control meetings. Staff received feedback from hospital-wide meetings in emails and we saw team meeting minutes were available to all staff.
• Practising privileges were received, authorised and granted in conjunction with the Medical Advisory Committee (MAC) and kept under review. There was effective governance and oversight of the consultant’s performance and behaviours through the MAC and by close working with the local NHS trust, where many of them worked.
• There were effective governance structures, and a hospital- wide risk register, which was updated regularly. Departmental risk registers also identified specific risks in that area which may affect staff, patients and visitors. The risk registers reflected actions to be taken to mitigate any risks. However in Surgery we found, although there were systems for identifying and managing risk, some were rudimentary with limited ability to spot trends. Risks were recorded and mitigations put in place. However, mitigations were not always checked to ensure they were effective.
• There was a culture of collective responsibility between teams and services. Information and analysis was generally used proactively to identify opportunities to drive improvement in care. However, in Surgery we found senior nurses did not always use the quality data generated to drive change and service improvement.
• All policies were approved at local and corporate level. Staff had access to policies in hard copy and on the intranet and signed a declaration to confirm they had read and understood the policy relevant to their area of work.
• There were clearly defined and visible local leadership roles and managers provided visible leadership and motivation to their teams.
• Senior managers were visible and had a thorough understanding of how services were provided at the hospital. They were open and honest about what they did well and where they knew there were areas for improvement. However, some senior staff did not feel empowered to drive positive change and lacked the confidence to challenge poor practice where this was seen. Some staff we interviewed found it difficult to challenge senior staff or consultants due to cultural differences.
• Consultants we spoke with were positive about senior members of the hospital and described good working relationships.

• Patients were encouraged to leave feedback about their experience by the use of a patient satisfaction questionnaire and for NHS patients by the Friends and Family Test
• The executive team knew and understood their main market very well and ensured that services developed to meet the needs of the local community.

We saw one area of outstanding practice including:

• The provider has access via the Consultant users to electronic information held by community services, including GP’s. This meant clinical staff could access up-to-date information about patients, for example, details of their current medicine.

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

Importantly, the provider must:

• Ensure all mitigations to risks identified are put in place and then monitored to ensure compliance. For example, in Surgery we found although a crossover of clean and dirty surgical instruments had been escalated to the risk register, processes to mitigate this were not being followed.

In addition the provider should:

• A suitable system is put in place to screen patients over 75 years of age for dementia, in line with national guidance.
• Pregnancy safety posters to be displayed in the diagnostic and imaging waiting area.
• The complaints procedure is made to be more easily accessible for patients.
• Stocks of medicines need to be checked to ensure they are in date and suitable for use.
• Patients undergoing an endoscopy should have comfort scores recorded.
• Staff should have access to a recognised visual analogue pain assessment tool, for people with a cognitive impairment.

Professor Sir Mike Richards

Chief Inspector of Hospitals