BMI Bath Clinic is operated by BMI Healthcare Limited. The hospital has an outpatients department, which provides diagnostic and screening services, including an MRI scanner. There are three operating theatres and an endoscopy unit.

The hospital provides surgery, medical care including oncology, outpatient and diagnostic services. Specialties include general surgery, orthopaedic surgery, ear, nose and throat procedures, gynaecology, oncology treatment, ophthalmology and urology services.

We previously inspected this hospital in May 2016 and gave it an overall rating of requires improvement. We inspected this service, unannounced, on 15 May 2018 using our focused inspection methodology. This inspection focused on specific parts of the service that were identified as needing improvement at our last inspection.

The key questions we asked during this focused unannounced inspection were, was it ‘Safe’ in outpatients and diagnostics and was it ‘Well Led’ in medicine, surgery, outpatients and diagnostics.

We were not able to change the overall rating of this hospital as this inspection only focused on the specific areas that were identified at the last inspection as needing improvement.

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 also apply to other services, we do not repeat this information but cross-refer to the surgery core service.

Services we rate

We have rated this hospital overall as Requires Improvement.

We found good practice in relation to outpatient and diagnostics care:

• The service managed staffing effectively and services always had enough staff with the appropriate skills, experience and training to keep patients safe and to meet their care needs.
• Outpatients and diagnostic environments were visibly clean and well maintained and there were measures to prevent the spread of infection.
• Systems had been implemented to keep patients safe and to learn from serious incidents.
• There was a comprehensive system for the management of quality and governance and managers were aware of the risks and challenges they needed to address.
• There was a designated lead for safeguarding children and vulnerable adults. Staff were trained appropriately to recognise and report suspected abuse.
• Patient records were maintained in one place, up to date and stored securely.
• Medicines were managed safely and stored securely.
• Risks were identified and managed with ongoing monitoring and review.

We found good practice in relation to medicine and surgery:

• There was a comprehensive system for the management of quality and governance and managers were aware of the risks and challenges they needed to address.
• Risks were appropriately identified, recorded, monitored and actions taken to minimise these.
• There were systems to keep patients safe and to learn from serious incidents and complaints.
• For surgery an enhanced recovery programme had been reviewed and changes made to meet the needs of patients.

We found areas of practice that require improvement in outpatients and diagnostics.

• Not all staff were aware who the safeguarding lead for the hospital was.
• Feedback to staff from simulation events of patient emergency did not always take place.
• There was no system that enabled leaders to obtain evidence from staff when they had completed mandatory training with other health care providers.
• Not all staff were up to date with fire awareness training.

Following this inspection, we told the provider that it should make some 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 (South)

Patients we met at BMI Bath Clinic were happy with their care and treatment. We were told by a regular patient the arrangement and organisation for their treatment was "brilliant." They said: "I arrive and everything is ready." They said of staff: "they are good, kind and very caring. They are efficient, cheerful, and most importantly, keep you informed." Another patient said "care is fantastic. It's absolutely first class and I could not wish for better."

To support patients, we found the hospital cooperated with other providers of health and adult social care. This ensured care of patients who were admitted from or transferred to the care of other providers was handled in their best interests. It was also coordinated and efficient. The hospital had good infection prevention and control systems and procedures. There were a few areas that needed some general maintenance and attention to cleaning arrangements.

Staff were well trained and supported in their roles. They were formally appraised twice each year so their managers could assess if they were competent to perform their duties. We found the hospital was well run. Senior management regularly assessed and monitored the quality and safety of care provided. They took into account the views of patients and staff, including consultants. Audits and reviews were carried out and actions taken to reduce risks and avoid recurrence of adverse incidents.

We visited the BMI Bath Clinic on 25 September 2012 and spent the day at the hospital. We met with patients who had come for a consultation, a medical procedure or had completed their treatment and were preparing to go home. These patients told us staff treated them with dignity and respect. They said staff knocked on the door of their room and waited to be invited in. One patient said of staff: “I cannot fault them on their politeness”. Another patient said: “they have been very respectful and very aware of preserving my dignity”. One female patient told us how a male nurse had been very reassuring and had made her “feel no embarrassment or discomfort whatsoever”. Another patient said nursing staff made sure all their family and visitors had been asked “very nicely” to leave the room when care was being given”.

Patients felt their confidential information was kept private. They had not heard their information being discussed with or given to anyone not authorised to have the information. They had also not overheard or seen anyone else’s private information. Patients said all staff “kept their voices low” and “always closed doors” when they wanted to talk with a patient. Staff also made sure the patient was happy with any visitors being in the room before discussions were held.

Patients said the treatment and care had been “good” and “really excellent”. We were told patients had been given plenty of advance information about their visit to the hospital and what to expect. Patients said they were asked to complete a questionnaire before they came to the hospital and all relevant information was gathered and discussed. We were told nurses and doctors were not too intrusive but made sure they had all the relevant facts to hand.

Patients said staff were calm and did not appear rushed when the patient was admitted. We were told the consultants and anaesthetists met with the patient before the procedure was carried out. All risks and benefits had been explained to patients and consent sought or, where it had been discussed at an earlier consultation, revalidated with the patient. We were told the nursing staff were “brilliant” and the theatre staff were “kind and reassuring”. Two patients we talked with said staff checked on them regularly and discussed pain management. A patient said “I feel really safe here and well cared for”.

We were told staff at the hospital were “very thoughtful”. One patient and their relative who had arrived early in the morning after a relatively long journey said they had been offered breakfast and “made to feel nothing was too much trouble”. Another patient said “I’ve been really impressed with the whole experience”.

We visited the BMI Bath Clinic at the end of June 2011. On that visit we found that we had concerns with outcome 9 of the essential standards. We found in one patient record that the recording of a known allergy or intolerance to a drug was not done effectively. We also found that the patient had been administered this drug during their stay at the hospital.

We revisited the hospital on 3 October 2011 and reviewed 12 sets of patient records. We found that there were a number of small areas that could be improved upon, but that these were not areas that were putting patients' at risk.

We did not talk with any patients on this return visit to the BMI Bath Clinic.

We met and talked with patients, people visiting or supporting other patients at the hospital, members of staff, and members of the executive team. People who were patients or were being admitted for treatment told us that things that mattered were “being seen on time and not kept waiting, as hospital visits are often stressful”, and “the visit being problem-free”, and not having treatment “cancelled at the last moment”. People said that they felt “reassured” that their experience of the hospital had been positive and met their expectations.

We were told that the welcome by reception and other waiting area staff had been “pleasant” and “a bit like being in a hotel”. People told us that they found the hospital very clean, well appointed and “equipped to a high standard”.

We were told that members of staff had been “very caring” and “put me at ease”. We were able to see a session of physiotherapy delivered with patience, but also firmness and resolve.

We were also told by patients that they did not feel pressurised to leave before they were ready. Patients said that they were given plenty of information about their treatment and information about their medication on being discharged. One person said that staff from the pharmacy had been “very professional and gave me a lot of confidence”.

One person told us that they had “been treated with respect” and that members of staff “always knocked on my door before entering the room”. We were told that at some times during the day the hospital felt very busy and there was a feeling that staff were perhaps “too busy” or gave “an air of being very rushed”, and then at other times it was “almost too quiet”. One patient told us that this did not seem to have affected their care, but there was “just occasionally the feeling that it would not have been appreciated if I wanted some help”.

People told us that they felt that they were treated in confidence. Their consultations were not interrupted, and held in private. Patients said that they appreciated tests or investigations that were needed being attended to often without delay, and the results being available quickly.

BMI Bath Clinic is an independent hospital and part of BMI Healthcare Limited. It provides care and treatment to both privately funded patients and NHS funded patients.

The hospital provides surgery, medical care, including oncology, outpatient and diagnostic services. Specialties include general surgery, orthopaedic surgery, ear, nose and throat procedures, gynaecology, oncology treatment, ophthalmology and urology services.

The hospital has an outpatients department, which provides diagnostic and screening services, including an MRI scanner. There are 67 beds of which 24 were for inpatients, three operating theatres and an endoscopy unit.

We carried out a comprehensive announced inspection of the Bath Clinic on 3, 4 and 5 May 2016 and an unannounced inspection on 16 May 2016.

We inspected and reported on the following three core services:

• Medical care

• Surgery

• Outpatients and diagnostic imaging

We rated the hospital as requires improvement overall. Our key findings were as follows:

Are services safe?

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

We rated safety overall as requires improvement:

• Only 85% of endoscopy staff were up to date with their mandatory training.

• Anaesthetists were not always documenting that they had obtained consent from patients.

• There was one incident of venous thromboembolism or pulmonary embolism in 2015.

• Staff completed care records for patients attending for follow up appointments in the outpatient department, but these were not kept in one folder and were in different locations. This meant there was not a complete record of patients’ care and treatment available to clinical staff.

• The fire risk assessment was out of date even though a new service with a potential risk of fire had been introduced. Staff were unsure of evacuation procedures for patients with reduced mobility from the first and second floor of Longwood House, in the event of fire.

However:

• Staff acted upon the principles of the duty of candour. They were open, honest and apologised to patients when things went wrong.

• Staff were trained to recognise and respond to signs of abuse of vulnerable people. The director of clinical services had overall responsibility for safeguarding people, and was trained to the appropriate level.

• There was a good culture of incident reporting, and learning from incidents.

• There was a safe level of both nursing, medical and support staff with a good mix and range of skills and experience. The resident medical officer was available 24 hours a day, seven days a week.

• There were no hospital acquired infections from January 2015 to December 2015

• The infection control and prevention lead was improving education and learning around infection prevention and control and took a proactive approach to ensure learning was effective for staff.

• Staff recognised and responded quickly to any deteriorating patients.

• The imaging department had efficient restricted access policies and practices, and staff complied with these.

Are services effective?

By effective, we mean people’s care, treatment and support achieves good outcomes, promotes a good quality of life, and is based on the best-available evidence.

We rated effectiveness overall as good.

• Patients gave valid informed consent where they were able to do so. There were assessments and procedures following legal requirements for patients who might have reduced mental capacity to make their own decisions.

• There were low levels of surgical site infections.

• The hospital monitored all aspects of employment and practising rights for medical staff. These were up to date.

• There were appropriately trained staff to safely care, treat and provide support for patients.

• Patient’s receiving chemotherapy had access to a 24 hour, seven days a week support line.

• An enhanced recovery programme was used for patients undergoing hip or knee replacements.

• There was an effective on call rota for imaging staff that ensured emergency screening could take place out of hours.

However:

• There was varied compliance with annual staff appraisals being completed ensuring staff were competent and up-to-date with their professional development.

Are services caring?

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

We rated caring overall as good.

• Patients were given care and compassion that treated them as individuals. Staff respected their human rights including their privacy and dignity.

• There was a high level of patient satisfaction with the service, including the Friends and Family Test results. All the feedback we received from patients about their care and support was positive and highly complementary.

• There was good emotional support for patients, particularly if they were anxious or nervous. Staff recognised and responded to these patients with compassion and kindness.

• People were involved with arranging appointments to suit their needs and circumstances

Are services responsive?

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

We rated responsiveness overall as good.

• Services were planned to meet local needs and provide timely independent medical care to both private and NHS patients.

• People were treated as individuals. This included taking time to support people living with dementia and meeting different levels of need.

• There was good physical access to and around the hospital for patients and visitors. Parking was available.

• Good bed management led to few cancelled or delayed operations. Surgery services met their referral to treatment times (monitored for NHS patients).

• The hospital was commissioned and established to treat non-emergency patients and provide elective medical care and surgical services. The only excluded patients were children and young people under the age of 16.

• There was an appropriate response to complaints. There was learning and action taken from any complaints.

• Referral to treatment time exceeded targets and meant that 100% of patients were seen within 18 weeks from referral.

However:

• The environment did not always meet the needs of patients with dementia, visual impairment or learning disabilities. Staff were unable to tell us about reasonable adjustments that had been made to the environment to meet the needs of patients with additional needs.

Are services well led?

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

We rated well-led overall as requires improvement.

• Whilst there was an environmental and corporate risk register, there were no clinical risks mentioned.

• There was no departmental clinical risk register, which meant the services could not proactively manage clinical risks.

• The hospital did not have systems in place to make sure all the consultants were aware of updates, changes in practice or general hospital guidelines.

• Issues around quality and risk management were not being identified or addressed in a timely manner.

• There was a lack of continuous monitoring around quality and improvement in the surgical department with infection prevention and control audits.

• There was a lack of understanding amongst staff in relation to their accountability for driving continuous quality and improvement in the surgical department.

• There was no proactive approach, to monitoring the implementation of actions following areas of service performance that required improvement following incidents.

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However:

• The staff always strived to make every patients experience an excellent one. There were supported in doing this through an open and supportive culture within the hospital.

• There were clear governance arrangements in place.

• Staff at all levels felt support by their line managers and by the hospital executive team.

• There were staff forums which engaged with staff and helped shape the culture and environment of the hospital.

• There was a systematic programme of internal audit used to identify and monitor quality and performance.

We saw areas of outstanding practice including:

• The infection control and prevention lead was improving education and learning around infection prevention and control and took a proactive approach to ensure learning was effective for staff.

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

Importantly, the provider must:

• Ensure a single patient record is held in outpatients for each patient which contain patients' complete treatment and care histories.

• Introduce a clinical risk register throughout the hospital.

• Ensure the fire risk assessment is reviewed, and actions previously identified are put in place.

• Ensure staff are fully aware of evacuation procedures for patients on the first and second floor.

• Ensure all action points from risk assessments associated with eye laser treatment is achieved.

In addition the provider should:

• The hospital should ensure that anaesthetists consistently complete the anaesthetic chart and document when consent has been obtained.
• The hospital should ensure that there is a service level agreement in place with the local microbiology department at the local NHS trust.
• The hospital should ensure that yearly staff performance appraisals are carried out to ensure staff competence and ongoing development within their role.
• The senior managers should be more visible around the hospital.
• The hospital should ensure the staff understand their role and accountability to ensure ongoing monitoring of performance and quality.
• The hospital should ensure that there is a risk management system in place to address current and future risks to ensure a proactive approach to risk management.
• Review nurse staffing requirements of the outpatient department as there is a high reliance on bank staff and no clear deputy for the manager
• Review opportunities to collect patient outcome measures to help evaluate the effectiveness of services in outpatients and diagnostic imaging
• Continue to ensure regular department meetings are held in diagnostic imaging to facilitate sharing of information and learning.
• Ensure the imaging department develop local standard operating procedures in line with the recommendations set out in the National Safety Standards for invasive Procedures
• Review opportunities to use and display patient feedback to improve outpatients and diagnostic imaging services
• Review practice in the physiotherapy department regarding documentation of obtained consent.
• Increase staff awareness of the WHO checklist for safer surgery in outpatients and diagnostic imaging
• Review compliance with cleaning schedules in outpatients and diagnostic imaging.
• Ensure staff are aware of who the appointed laser protection supervisor (LPS) is and that staff understand their role.
• Review uniform policy to include nurses wearing belts and the effects this may have on infection control and prevention.
• Increase awareness of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards amongst staff

Professor Sir Mike Richards

Chief Inspector of Hospitals