Woodlands Hospital

BMI Woodlands Hospital serves the population of County Durham and surrounding areas. The hospital offers a range of outpatient services to NHS and other funded (insured and self-pay) patients including cardiology, dermatology, ear, nose and throat, gynaecology, oncology, ophthalmology, optometry, pain medicine, rheumatology and urology. Inpatient and outpatient surgical services include breast surgery, oral and maxillofacial surgery, orthopaedic surgery, general surgery, ear nose and throat, gynaecological surgery, urology, pain injections, ophthalmic and plastic/cosmetic surgery, spinal surgery and vascular surgery.

The hospital also provides consultation-only outpatient services for children and young people aged between three and 16 years. The hospital does not admit emergency patients. BMI Woodlands Hospital contracts services for catering, CT and MRI scanning, histology, infection prevention and control, medical records archiving, occupational health services, pathology, radiation protection and sterile services. These services do not form part of this inspection report.

We carried out an announced inspection visit on 23rd and 24th February 2016 and an unannounced inspection on 8th March 2016. This was the first comprehensive inspection of BMI Woodlands Hospital. CQC last inspected the hospital in April 2014 and reported compliance with all the standards inspected at that time.

We rated BMI Woodlands Hospital as good overall. We rated the service as good for safe, effective, caring, responsive and well-led.

Are services safe at this hospital/service

Overall, we rated safe as good.

Staff demonstrated an understanding of being open with patients when things went wrong. When talking to staff we saw evidence of a strong culture of being open with patients including verbal apologies and letters of apology. Incident reporting was well managed and robustly investigated using root cause analysis where required. There had been no never events at the hospital. There was evidence of discussion of incidents and shared learning at daily ‘comms cell’ meetings and through team meetings. We saw evidence of action plans being implemented and changes made in response to incidents, however there was inconsistent evidence of learning by consultant surgeon staff but good evidence of this being monitored and acted upon by the executive director. There was a safeguarding lead in place with Level 3 safeguarding training and all staff had Level 1 child and adult safeguarding training. A safeguarding referral had been made in the past year and was appropriately managed. The safeguarding lead was the point of contact for any issues around Female Genital Mutilation (FGM) and this was also covered in the safeguarding policy as per the FGM: Multi-agency practice guidelines, (2014). The hospital used the BMI Healthcare nursing dependency and skill mix tool as a guide to assist staff to assess required staffing levels. The areas we inspected had a sufficient number of trained nursing staff with the appropriate skill mix to meet patients’ needs. Use of agency was low and limited to the operating theatres only. Nurse handovers occurred three times a day. Shared information was clear, with discussion around individual patient’s needs and risks and the plan for their hospital admission and discharge. Two resident medical officers (RMO) alternately provided medical cover 24 hours per day over a one-week period each and had received appropriate induction training from the hospital. The RMO attended the morning and evening nurse handover as often as possible and received handover from consultants before they went off duty. The hospital was almost entirely staffed by surgical and medical consultants who were employed by NHS organisations and had practising privileges at BMI Woodlands Hospital. The arrangements for anaesthetic and surgeon cover out of hours are detailed in the Practising Privileges Policy. Staff we spoke with described the procedure for on-call arrangements for anaesthetic or surgeon consultants out of hours. When the RMO, consultants and nursing staff needed to seek advice or support out of hours, they contacted the patient’s consultant in the first instance. Consultants were expected to be no more than 30 minutes away according to their practising privileges. If a consultant was aware that they would be absent they informed key senior staff at the hospital in writing and confirmed their cover arrangements. We saw an example of this system in practice. Nursing and medical staff reported excellent working relationships and good communication about patient care and treatment plans.

However, staff did not have a full understanding of the requirements of the statutory duty of candour. No staff had received specific training on duty of candour and the grading of actual harm arising from incidents was not used to trigger the duty of candour process. There was a strong culture of being open and honest with patients and family members and we saw written apologies to patients. Consultant staff did not document a daily review of patients when we reviewed care records. The Resident Medical Officer (RMO) also did not write a daily review in the care record. Patients who stayed in hospital overnight did not receive a consultant review and this is in breach of the consultant practising privileges policy at BMI Woodlands Hospital. We found inconsistent recording of National Early Warning Scores (NEWS) which had also been identified in the hospital audit performed by nursing staff. However a action plan had been put in place at the time of inspection to improve accurate recording of patients' physiological observations.

Are services effective at this hospital/service

We rated effective as good.

Patients received care and treatment in line with national guidelines such as National Institute for Health and Clinical Excellence (NICE) and the Royal Colleges. The clinical governance committee managed the approval and distribution of policies and monitored audit findings. The hospital participated in national audit programmes such as performance reported outcomes measures (PROMs) and the National Joint Registry. Results showed patient outcomes were in line with the national average. The rate of unplanned readmissions and unplanned patient transfers to other hospitals was within expected levels when compared to other independent hospitals. Specific training to support staffs understanding of the application of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) had been received by all staff. There was a hospital designated lead for MCA and DoLS. The Medical Advisory Committee (MAC) monitored compliance with practising privileges and there was evidence of action taken by the MAC and executive director when competence issues arose. There were three consultants without NHS contracts. The corporate medical director was the revalidation officer for these consultants and their appraisal was carried out by consultants in BMI with appraisal training. A review of 16 consent forms found that the standard of documentation was inconsistent, for example there were gaps in recording the type of anaesthetic on two forms, lack of evidence of second stage consent and none recording that information about the procedure had been provided to the patient.

Are services caring at this hospital/service

We rated caring as good.

We observed patients being treated with compassion, dignity and respect throughout our inspection. Staff were courteous and helpful in all roles. All staff we met during inspection were approachable and friendly. We observed staff introducing themselves by name to patients and patients we spoke with knew the names of staff that were caring for them. We received 91 comment cards during the inspection, all of which contained positive comments about the standard of care, support and attitude of staff. Examples of comments included: “Customer care from consultant doctors, nursing staff and all unit staff caring and compassionate and so understanding”, “My physiotherapist is phenomenal with my treatment and improves my standard of living”. BMI Woodlands Hospital took part in the Friends and Family Test for measuring patient experience and satisfaction. The response rate (n90) was reported as low; however, it was very positive as reported in December 2015. 98.6%-100% of all patients would recommend the service and staff to friends and family. In 2015 the hospital implemented a ‘Patient Environment and Improvement Group’ (PEIG) on which, patient representatives and members from the local Health Watch Board sit. This group meets quarterly and seeks to make improvements in line with patient feedback and observations. Patients we spoke with were complimentary about the staff without exception. They told us that they felt informed and involved in their care and treatment. We observed patients in theatres and the anaesthetic room being given information in a way that would alleviate any anxiety or concern. The reception staff in the main ward area were helpful, friendly and professional. They gave the patients attending the ward the information they needed and communicated promptly with the ward staff any arrival of patients for admissions. Patients we spoke with felt able to approach staff if they felt they needed any aspect of support. There was access to specialist nursing advice services through individual consultants, for example cosmetic surgery support services provided by specialist nursing staff external to BMI Woodlands Hospital.

Are services responsive at this hospital/service

We rated responsive as good.

There were effective arrangements in place for planning and booking of surgical activity including waiting list initiatives through contractual agreements with the clinical commissioning group. Outreach outpatient clinics enabled ease of access to patients wishing to be treated at BMI Woodlands Hospital. Patients admitted to BMI Woodlands Hospital were assessed for admission suitability by their consultant and by using a risk stratification system in line with local and national guidelines. This meant the majority of patients treated at the hospital were considered “low risk”. Adults in vulnerable circumstances, such as patients with learning disabilities and those living with dementia were supported by open and overnight visiting arrangements for carers and additional staff if required. However, in most cases, assessment at the point of referral usually referred them to NHS establishments. Staff held a daily ‘comms cell’ meeting to discuss safety issues as well as patient flow, consultant cover arrangements and the availability of beds in the hospital. Ward nursing staff and the nurse manager reviewed planned patient discharges in handovers and throughout the shift to assess on-going availability of beds. At the time of our inspection, there were no pressures on the numbers of beds available, and there was an aspiration to expand the facilities to provide additional services. The hospital achieved the overall referral to treatment indicator of 90% of patients admitted for treatment from a waiting list within 18 weeks for the reporting period. It also achieved better than the indicator of 92% of incomplete admitted patients beginning treatment within 18 weeks of referral in the reporting period. Arrangements were in place with the local NHS trust to receive unplanned transfers for further care. Complaints were responded to in a timely manner and staff were familiar with the process. In some cases, it was not clear that assurance was obtained that actions arising from complaints were completed.

Are services well-led at this hospital/service

We rated well-led at this service as good.

There was a clear vision and strategy for the hospital which were understood by staff. A robust governance structure was in place with pharmacy, the infection prevention and control group and health and safety group reporting into the clinical governance committee. A comprehensive clinical governance report including patient safety and quality performance was reviewed by this committee and the Medical Advisory Committee. The hospital risk register identified 12 risks, of which two were clinical risks. There was limited evidence of documenting risks associated with clinical quality or performance; however, there was strong evidence of a response to risks identified through incident reporting. In response to the inspection, the executive director immediately developed an action plan, which was reviewed during the unannounced inspection. It demonstrated a comprehensive plan of improvement for the issues raised during initial feedback. The lack of clinical risks on the risk register was recognised by the corporate team and at local level. A new corporate risk management policy and risk register template was in the process of being implemented. Staff were well engaged across the hospital and reported an open and transparent culture and felt they were able to raise concerns. There was strong local leadership of the hospital from the executive director which was effectively supported by the chair of the Medical Advisory Committee, director of nursing and the heads of departments.

Our key findings were as follows:

• The hospital had infection prevention and control policies and an infection prevention and control team. Quarterly infection prevention and control committee meetings were held. There were links to the infection prevention and control team and microbiology at a regional NHS trust and we noted discussion of any infection control issues in minutes of meetings. A comprehensive annual report was published and available on the BMI Woodlands Hospital website. There were low rates of wound infection and no cases of Methicillin-Resistant Staphylococcus Aureus bacteraemia (MRSA), Methicillin-Sensitive Staphylococcus Aureus (MSSA) bacteraemia or Clostridium difficile infections at the hospital between October 2014 and January 2016.

• The hospital used the BMI Healthcare nursing dependency and skill mix tool as a guide to assist staff to assess required staffing levels. The areas we inspected had a sufficient number of trained nursing staff with the appropriate skill mix to meet patients’ needs. Use of agency was low and limited to the operating theatres only and we observed a good system for orientation and local induction of agency staff, which included a comprehensive record of competency. There were formal on-call arrangements for theatre staff to cover out of hours, should an unplanned return to theatre be required. Nurse handovers occurred three times a day and shared information was clear, with discussion around individual patient’s needs and risks.

• The hospital environment and equipment was visibly clean. All departments and patient areas were visibly clean and we saw staff wash their hands and use hand gel between treating patients. Separate hand washing basins, hand wash and hand gel dispensers were available in the departments and patient areas and were seen to be used appropriately. Cleaning audits included monthly and quarterly audits of room cleanliness in all areas, management of disposable curtains and carpet cleaning. Patient Led Assessments of the Care Environment (PLACE) audits were conducted annually. These assessments apply to hospitals, hospices and day centres that provide NHS funded care. This assessment rated the hospital as 100% for cleanliness (national average 97.25%) in 2015.

• The Malnutrition Universal Screening Tool (MUST) was used to screen patients and patients had a nutritional assessment at pre-assessment or on admission. The tool was fully completed in 13 records we checked at random. Staff we spoke with were knowledgeable around the need for accurate fluid balance and hydration in post-operative patients and the fluid balance charts we reviewed were completed appropriately. We observed a protected mealtime and the 10 patients we spoke with were happy with the catering. A variety of hot and cold food was available. There was good choice for patients including vegetarian, gluten-free, lighter options and multi-cultural food choices.

Workforce Race Equality

BMI Woodlands Hospital took part in a pilot review of implementation of the Workforce Race Equality Standard (WRES). Nine people were interviewed related to WRES during the inspection. The staff interviewed covered a range of roles in the organisation including corporate representation, executive director, employee relations and front line staff. The findings showed that WRES implementation at both corporate and local hospital level was at an early stage. However, the small number of Black and Minority Ethnic (BME) staff we spoke with during the visit clearly felt that there were no differences between how they were treated by management and colleagues. They felt that they had equal opportunities and were valued by both the organisation and management at all levels. The corporate and management representative felt that it had been difficult to capture data to meet the WRES framework, as the requirements were new to the organisation. A corporate WRES report and action plan had been drafted and was to be published at end of this business year. The action plan included working with NHS England to improve reporting of WRES indicators in independent hospitals.

We saw areas of outstanding practice including:

• The development of the Ambulatory Care Unit from October 2015 had provided additional capacity for endoscopy and surgical procedures. This was working well and staff we spoke with anticipated the potential for a planned expansion of ambulatory care services at BMI Woodlands Hospital.

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

The hospital provider should:

• Ensure that all staff have an understanding of Regulation 20: Duty of Candour and how this is applied. Additionally the hospital must utilise the systems in place to comply with this regulation.
• Ensure that fasting times are audited to provide assurance that patients are appropriately prepared for surgery.
• Ensure that staff document consent in line with national guidance from the General Medical Council and Royal College of Surgeons.
• Ensure that medical staff meet the requirements of the practising privileges policy in relation to daily patient visits and maintaining complete documentary records of these visits.
• Consider a regular staff survey to monitor staff engagement.
• Extend the mechanisms for learning from patient safety incidents to incorporate all consultant surgeons with practising privileges.

Professor Sir Mike Richards

Chief Inspector of Hospitals