St Edmunds Hospital

Updated 1 March 2019

BMI St Edmunds is operated by BMI Healthcare. The hospital opened in 1980 and became part of the BMI group in 2008. It is a private hospital in Bury St Edmunds, Suffolk. The hospital primarily serves the communities of Suffolk, Norfolk and Essex. It also accepts patient referrals from outside this area.

The hospital building has two floors and provides a range of elective surgeries for adult self-funded, insured and NHS patients, which include, but are not limited to, orthopaedics, general surgery, urology, ophthalmology, ENT, gynaecology and cosmetic surgery. BMI St Edmunds does not treat children.

The hospital has had the present registered manager in post since September 2009.

The hospital/service has been inspected four times. The most recent inspection took place in March 2017 which found that the hospital was not meeting all standards of quality and safety it was inspected against. The hospital was rated as requiring improvement for safe, effective and well led and good for caring and responsive, and was rated requires improvement overall. There were breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 relating to good governance, appraisals and up to date competency records for staff, complete, and completion of contemporaneous notes on each patient. Three requirement notices were served relating to Regulation 17 and 18 of, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

There were no special reviews or investigations of the hospital ongoing by the CQC at any time during the 12 months before this inspection.

Updated 1 March 2019

BMI St Edmunds is operated by BMI Healthcare. The hospital/service has 26 beds although at the time of reporting eight rooms were not in regular use. Facilities include three operating theatres, a three-bed level two care unit (recovery room), and X-ray, outpatient and diagnostic facilities.

The hospital provides surgery, and outpatients and diagnostic imaging. We inspected the surgery and outpatient services.

We inspected this service using our comprehensive inspection methodology. We carried out an unannounced inspection on 6 November 2018, along with a further unannounced visit to the hospital on 12 November 2018.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

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

Services we rate

Our rating of this hospital improved. We rated it as Good overall.

We found areas of good practice in relation to surgery and outpatient care:

• The hospital had systems and processes in place to protect patients from avoidable harm and abuse.

• The environment and equipment were clean and suitable for use and staff ensured patients were protected from infection by using the appropriate infection, prevention and control measures.

• Staff knew how and when to record incidents and there were systems to identify, monitor and share learning from incidents.

• Risk assessments were appropriately completed for people who used the hospital and staff protected confidentiality with well organised and managed individual care records.

• Outpatient contemporaneous consultation records were completed on triplicate forms and staff ensured there was always a copy in the patient records. This was a significant improvement since our last inspection.

• The hospital had comprehensive internal audit programmes in place to monitor services and identify areas for improvement and the hospital participated in national audits where applicable.

• Patient care and treatment was delivered in line with national guidance.

• Staff were competent for their roles and were encouraged to develop further. This was an improvement since our last inspection.

• Staff treated patients with care, kindness and compassion.

• Patients were appropriately assessed prior to surgery and there were processes in place to transfer patients should they require a higher level of care.

• Complaints and concerns were taken seriously, responded to in a timely way and managed with face to face meetings with the complainant where needed.

• Managers were visible, approachable and performed well. This was an improvement since our last inspection.

• Staff we spoke with enjoyed their work and were proud to work at the hospital. They described an open culture and felt supported and listened to by their immediate managers.

• There were clear and effective processes for managing risks, issues and performance.

And some areas for improvement:

• Although overall mandatory compliance was generally good some courses showed poor compliance such as; manual handling on the ward (42.9%).

• Records showed that patients were fasted for longer than necessary to accommodate operating theatre list changes.

• Consent forms were sometimes completed on the day of surgery which did not follow best practice guidance.

• Consultants did not always record post-operative reviews in inpatient notes.

• There was inconsistent governance of consultant practising privileges in ensuring appraisals were submitted in line with the practising privilege policy.

Following this inspection, we told the provider that it should make improvements, even though a regulation had not been breached, to help the service improve. Details are at the end of the report.

Amanda Stanford

Deputy Chief Inspector of Hospitals

Updated 1 March 2019

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

Updated 1 March 2019

Surgery was the main activity of the hospital. Where our findings on surgery also apply to other services, we do not repeat the information but cross-refer to the surgery section.

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