The Winterbourne Hospital

BMI The Winterbourne Hospital was opened 1982 and is one of 62 hospitals and treatment centres provided by BMI Healthcare Ltd.

The hospital provides a range of surgical and diagnostic services. There are a limited number of medical procedures; the oncology service was recently discontinued.

The facilities include two operating theatres with laminar airflow, two treatment rooms, and eight consulting rooms supported by an imaging department offering X-ray and ultrasound. There is a ward of 31 beds, in single rooms, with an extended recovery unit in the centre for up to two patients requiring a higher level of observation post surgery. The hospital offers physiotherapy treatment as an inpatient and outpatient service in its own dedicated and fully equipped physiotherapy suite and hydro therapy pool. A mobile MRI scanner, provided by an external company, visits the hospital twice a week.

Services offered include general surgery, orthopaedics, cosmetic surgery, refractive eye surgery, gynaecology, ophthalmology, oral and maxillofacial surgery, general medicine, dermatology, physiotherapy, endoscopy and diagnostic imaging. Most patients are self-pay or use private medical insurance. Orthopaedic, ophthalmology and general surgery services are available to NHS patients through NHS e-Referral service.

The announced inspection took place between 5 and 6 January 2016, followed by a routine unannounced visit on 7 January 2016.

This was a comprehensive planned inspection of all core services provided at the hospital: surgery, and outpatient and diagnostic imaging. Medical services were not inspected as a core service as a limited number of patients mostly treated in outpatients or theatre. Oncology services had discontinued. One patient attended for completion of a course of chemotherapy during the unannounced visit and appropriate staff were on duty to oversee their care and treatment.

There is no critical care facility or emergency department at the hospital and no maternity services. There are no services for patients under 16 years, a few outpatients are aged 16 -18 years, and the majority of patients are adults.

The Winterbourne 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.

The overall rating for this service was ‘Requires improvement’.

The services at this hospital were rated as good for caring and responsive but there where were areas for improvement in surgical services, in particular the operating department, where more robust safety processes, staff training and competency assessment was required. Patients were consistently positive about the care and treatment received. They were appropriately assessed and received treatment from caring and compassionate staff, following best practice and national guidance. The registered manager provided positive leadership, but quality monitoring and identification and management of risk needed to improve across the hospital.

Our key findings were as follows:

Are services safe at this hospital?

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

• The hospital protected patients from the risk of abuse and avoidable harm. Most staff reported incidents and openness about safety was encouraged, however there were some inconsistencies in reporting of incidents in the operating department.

• Incidents were monitored and reviewed but staff in some departments did not consistently receive feedback and learning from incidents.

• Staff understood the principles of Duty of Candour regulations, and senior managers were confident in applying the legislation.

• All clinical areas were appropriately equipped to provide safe care, but in surgery several items of medical equipment were not serviced or appropriately tested.

• The departments were visibly clean and there were good infection prevention and control policies to reduce the risk However, some staff did not consistently adhere to the organisations policies. There were lapses in adherence to ‘bare below the elbows’ and use of personal protective equipment

• The NHS Safety Thermometer is a local improvement tool for measuring, monitoring and analysing patient harms and 'harm free' care. The surgical ward participated in the NHS Safety Thermometer for NHS patients. Senior staff conducted monthly audits in respect to patient falls, pressure ulcers, catheters and urinary tract infections. Information about the audits was not displayed. This is not mandatory, but is considered good practice.

• Medicines were stored securely and managed correctly in most areas, but some medicines in the operating department were not stored appropriately and some had passed their expiry date. Whilst three monthly audits were undertaken of controlled drugs held by wards or departments, similar processes were not undertaken within the pharmacy department.

• There was regular monitoring of patient records for accuracy and completeness. They were securely stored and available when needed.

• Staff undertook appropriate mandatory training for their role and electronic records showed more than 90% compliance across the hospital. However, ward and theatre staff had not all undertaken and completed patient moving and handling update training with in the last year.

• Safeguarding policies and procedures and staff were appropriately trained and knew how to respond to safeguarding concerns. The director of nursing was the safeguarding lead for the hospital.

• Nurse staffing levels and skill mix were planned appropriately, implemented and reviewed. Staff shortages were responded to quickly and adequately.

• There was sufficient medical cover provided by resident medical officers (RMOs) who covered the hospital 24 hours a day for all specialities. Consultants were available daily and provided on call cover and advice out of hours if necessary.

• There were suitable arrangements for handover between shifts, and all staff attended the daily ‘huddle’ for a brief update on patients and relevant information for the day.

• Clinical staff identified and responded to patients’ risks. They received simulation training to ensure they could respond appropriately if a patient became unwell. A sufficient number of staff were trained to provide advanced resuscitation skills.

• In diagnostic imaging, local rules and safe systems of work were in place. There was a nominated Radiation Protection Supervisor (RPS) and Laser Protection Supervisor (LPS), who had received appropriate training. There were good communication and support from Radiation Protection Adviser and NHS medical physics team.

• Emergency business contingency plans were in place and regular fire drills practised.

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.

• Most staff were competent, skilled and knowledgeable. However, there was not documented evidence of training or assessed competency for some roles in the operating department. There was no evidence of competency assessments for theatre staff or nursing staff assisting with endoscopy.

• Theatre nurses worked as surgical first assistant (SFA) under supervision as partway through the training and assessment.

• Most staff were supported in their role through appraisals. However, appraisal rates varied across the services, the majority of operating department staff had not completed an annual appraisal. Some staff reported a lack of support in accessing training they believed would enhance the care they provided to patients in their department.

• Care and treatment followed best practice and evidence-based guidance across services. The medical advisory committee reviewed policies and guidance and advised on effective care

• The medical advisory committee was actively involved in reviewing outcomes and renewal of practising privileges of individual consultants. However not all departments were aware of the competencies for individual consultants and there was no record kept within outpatients.

• Outcomes of patient care and treatment was monitored in surgery and outpatients. Patient outcome data was reported for comparative analysis for surgical services. Surgical services performed well in national audits. Unplanned readmission and return to theatre was not higher than expected.

• Patients had access to different methods for effective pain relief. Patients’ pain was monitored and the effectiveness of pain management evaluated.

• Patients had comprehensive assessments of their needs, which included consideration of clinical needs, mental health, physical health and wellbeing, and nutrition and hydration needs.

• There was evidence of good multidisciplinary working and information sharing across the hospital and with the local NHS trust. Out-of-hours services were provided when needed

• The consent process for patients was well structured, with written information provided prior to consent being given. Consent was regularly audited.

• Staff were trained in the Mental Capacity Act 2005 and there was appropriate guidance and tools to assess patient mental capacity.

Are services caring at this hospital?

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

• Feedback from patients about their care and treatment was always positive and we observed staff being supportive and compassionate to patients.

• Patients told us they felt they had sufficient information to allow them to be involved with their care and had their wishes respected and understood.

• Staff treated patients courteously and respectfully, and maintained their privacy and confidentiality.

• Patients were contacted by the hospital after they had been discharged offering help and advice if required.

• Staff demonstrated they were passionate about caring for patients and clearly put the patient’s needs first, including their emotional needs.

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 a way that met the needs of the local population. The importance of flexibility and choice was reflected in the service and there were ongoing plans for development. The hospital worked with Dorset Clinical Commissioning Group (CCG) in developing services for NHS patients.

• Some aspects of the environment did not fully support privacy; the hospital was taking steps to address these issues.

• Patients were able to access services when needed, waiting times, delays and cancellations were minimal. Services were responsive to meeting individual patient needs, including patients living with dementia, or with a learning disability. NHS and private patients’ experienced the same levels of care.

• There was information on specific procedures, conditions and hospital charges, but not in other languages or formats, such as braille. The hospital had minimal numbers of patients who could not understand English. There was a translation service available if needed.

• The hospital had a system for responding to and managing patients’ verbal or written complaints. However, guidance on how to make a formal complaint was not on display at the time of inspection . There was evidence of learning from complaints

Are services well-led at this hospital?

By well-led, we mean that the leadership, management and governance of the organisation, assure the delivery of high-quality person-centred care, supports learning and innovation, and promotes an open and fair culture.

• There was a clear vision and strategy for development at the hospital, which aligned with the corporate strategic vision for high quality and convenient patient care.

• There was a governance structure in place, with a range of committees. The clinical governance committee met bimonthly to discuss a range of governance issues across the hospital.

• The medical advisory committee (MAC) met regularly; membership included consultant leads across specialities. The MAC was involved in quality assurance of medical staff and monitoring of clinical issues. There was a supportive working relationship between the MAC chair and the registered manager and director of nursing.

• The registered manager regularly reviewed a BMI quality dashboard which compared a range of performance and quality metrics across hospitals.However there were not robust systems to monitor quality across all areas of the hospital.

• A BMI provider visit pre inspection had identified some quality issues particularly in the operating department. However these and the issues identified at inspection had not all been identified through the hospital governance and quality monitoring processes. The director of nursing sought reassurance of quality through knowing and working with staff and walkabouts.

• The registered manager had a good understanding of risk management but there was not understanding by all managers at other levels, or across all departments. Some managers were not aware of all the risks specific to their areas of work, not all had training in risk management and there were no departmental risk registers. The hospital risk register followed the corporate policy and was designed to capture health and safety risks and not all types of risk.

• In most departments staff valued and had confidence in their local leaders and there was a strong ethos of team working. However there was low morale amongst staff in the operating department, without local leadership they were looking forward to the arrival of a new theatre manager.

• The registered manager was accessible to staff and encouraged a positive, open culture within the hospital.

• There was evidence of innovation and development of services, particularly in the physiotherapy and diagnostic imaging departments.

• Results of the latest patient survey showed a high level of meeting patient’s expectation, with the hospital scoring 98.1%.

There were areas of poor practice where the provider needs to make improvements.

Importantly, the provider must ensure:

• learning from investigations, incidents and complaints is appropriately shared across the hospital.

• clinical equipment checks and servicing are carried out in accordance with the hospitals policy.

• all staff consistently adhere to best practice in infection prevention and control

• staff complete all mandatory training, including training in patient moving and handling.

• systems and processes are in place to ensure out of date medicines are identified and replaced

• medicines being stored in freezers are kept at the correct temperature, as recommended by manufacturers

• working practices in the operating theatre reflect the hospital policy and procedures and are in line with current national guidance. Theatre and endoscopy staff must have appropriate competencies and supervision in relation to their role.

• Staff have the opportunity to contribute to yearly appraisals

• risks are identified, assessed and managed effectively across all areas of the hospital

• there are processes in place to effectively monitor the service provision and identify areas for improvement

• there are effective systems in place to assess, monitor and mitigate all risks relating to the health, safety and welfare of service users.

In addition the provider should ensure:

• all equipment used by the service is clean and properly maintained. There should be a clear process in place to demonstrate the hoist slings have been cleaned, with appropriate dates and times recorded.

• all staff adhere to the ‘bare below the elbow’ guidance to allow thorough hand washing and reduce risk of cross infection.

• the risks associated with the use of heat pads in the microwave are identified, assessed and managed effectively.

• that medicines are appropriately labelled.

• appropriate arrangements for monitoring and auditing the management and use of controlled drugs by the Controlled Drugs Accountable Officer, in all areas including the pharmacy, are in place

• the local identification, planning, action, review and records relating to Central Alert System (CAS) notifications for medicines

• all departments are made aware of the practising privileges and any restrictions on practice of medical consultants

• all staff have the opportunity for appraisals and regular supervision

Professor Sir Mike Richards

Chief Inspector of Hospitals