BMI Coombe Wing is operated by BMI Healthcare Limited. Facilities include one ward and a small outpatients department, located within Kingston Hospital in south west London. The service has 22 beds and four outpatient consulting rooms.The service provides care for patients with medical conditions and post-operative surgical care. At our last inspection in October 2016, the service was rated as Good overall. Effective was rated as Requires Improvement, with all other key questions rated as Good. At our last inspection, we found areas of concern where the provider needed to improve; these included:

• Improving education and training to improve audit compliance rates of venous thromboembolism assessment and treatment.
• Ensuring that all staff and visiting consultants within the outpatients department comply with 'bare below the elbow' guidance.
• Considering auditing patient outcomes for all conditions treated on the ward.
• Ensuring records of nursing clinical supervision are documented.
• Improving mandatory training completion rates.
• Improving audit compliance for medical records.

This is a report of a focussed inspection, which looked at the areas identified as requiring improvement at our inspection. As this inspection was focused on specific areas of concern, we did not look at all aspects of all key questions, and we have not re-rated this service.Our key findings from this inspection were as follows:

• The service had implemented regular clinical supervision for staff and kept records of themes discussed, in order to inform training and development on the ward.
• The provider had completed work to address the infection prevention and control risks in the ward corridor, patient rooms and outpatients department.
• Venous thromboembolism (VTE) assessment rates had improved, and the latest audit in July 2018 showed there was 100% compliance with patient assessment for venous thromboembolism.
• All clinical staff who saw patients complied with ‘bare below the elbow’ guidance.
• Staff understood their responsibility to report incidents and concerns, and complied with their responsibility under the duty of candour. The service had clear systems to prompt staff to consider the duty of candour.
• 96.3% of staff were up to date with mandatory training, and the service performed well for overall training completion rates compared to other BMI units at the time of our inspection.
• While the service had reported two never events since our last inspection, they had completed joint investigations with Kingston Hospital, and produced thorough action plans to ensure learning was captured and processes updated.
• While the service was due to transfer back to Kingston Hospital in April 2019, and therefore, did not have a defined long-term strategy, staff were fully aware of proposed changes, managers were engaged with Kingston Hospital staff regarding the future of the ward and the service vision was displayed in the reception area on the ward.

However:

• The reception area in the outpatients department was relatively small, and staff speaking with patients in the area and on the telephone could be sometimes be overheard by others in reception. Staff were not always mindful of their volume when speaking with patients.

Dr Nigel Acheson 

Deputy Chief Inspector of Hospitals

People we spoke with told us that they were happy with the information they were provided with about their treatment and in the way they were treated. One person told us: “The doctors explain everything in a clear way and it helps to know that the nurses are also very clear as to what is required”. We found that people had access to detailed information on all treatments and care services.

People we spoke with told us that they felt confident in the care they received. One person told us: “The care is second to none”. We saw that patients’ needs were assessed and care and treatment was planned and delivered in line with their individual treatment plan.

People were supported to be able to eat and drink sufficient amounts to meet their needs. All the patients we spoke to described the catering service and food and drink as either “very good” or “excellent”. We saw that the Operations Manager worked closely with the catering company and both described the good communication and open culture as contributing to the quality of meal provision.

There were effective systems in place to reduce the risk and spread of infection. Surgical and medical procedures were up to date and there were governance controls in place to ensure that the quality of infection control was effectively monitored.

Appropriate arrangements were in place in relation to the obtaining, recording and handling of medicines. We found that medicines were held safely and prescribed and administered to people appropriately.

Staff received appropriate professional development and staff were able, from time to time, to obtain further relevant qualifications.

The provider had an effective system to regularly assess and monitor the quality of service that people receive and had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who use the service and others.

Patients, their representatives, and staff were asked for their views. Patients told us that they were being listened to and that their individual needs were assessed and met. One patient told us "the staff are attentive and they have answered all my questions". Patients gave examples of information provided to support their decision making. They described staffing levels as good. One relative we spoke to said "I never have any hesitation in using the call bell to summon assistance". Call bells were answered promptly.

Individual nutritional needs were assessed and met. Patients were supported in selecting a balanced diet, and in their eating and drinking. Patients described the food and drink and catering as "very good". Snacks and drinks were readily available in between meal times. Patients with swallowing difficulties were referred to the speech and language therapist and dietitian.

Safeguarding policies and training were in place. Staff were clear about reporting arrangements. Emergency equipment was clearly labelled and accessible and checked daily. Staff were clear about what to do in an emergency.

Staff induction, ongoing training and development and appraisal were readily available, with clear monitoring systems in place.

Audits were carried out on a regular basis, with outcomes from them and from incidents shared with staff. There were clear incident reporting systems in place. Changes had taken place as a result of patient and staff feedback.

BMI Coombe Wing is operated by BMI Healthcare Limited. BMI Coombe Wing operates one ward, located within Kingston Hospital and provides beds for patients with medical conditions, following surgery or for mothers after delivery of their baby. The ward has 22 beds and four outpatient consulting rooms.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 4 and 5 October 2016. We did not carry out an unannounced visit because we had obtained all the evidence required to make judgements, during the announced visit.

We did not inspect any of the services that are provided under Service Level Agreements by Kingston Hospital as these are services from another provider. Kingston Hospital NHS Foundation Trust was inspected and rated separately, and the report was published in July 2016.

To get to the heart of patients’ experiences of care and treatment, we always ask the following five questions:

• Is it safe?
• Is it effective?
• Is it caring?
• Is it responsive to people’s needs?
• Is it well led?

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 medicine. Where our findings on medicine – for example, management arrangements – also apply to other services, we do not repeat the information but cross-refer to the medicine core service section.

Services we rate

We rated this service as good overall. This deviated from the aggregation principles that we apply when rating services, however we were satisfied that prompt action had been taken by the provider to rectify the issues that were raised for the safe domain so this was considered when rating the service overall.

We rated the services for medicine and outpatients and diagnostic imaging and used these ratings to rate the service overall.

We found good practice in relation to medicine and outpatients and diagnostic imaging:

• The quality handover was an effective method of communicating information to staff and learning about incidents, complaints and changes of policy and practice.
• The service managed staffing well with a flexible approach that meant there were always enough staff with the appropriate skills, experience and training to keep patients safe and to meet their care needs.
• The service had a robust admission policy which meant that there were limited occasions when a patient was inappropriately admitted.
• All incidents were investigated and lessons shared with staff.
• We observed effective multidisciplinary team (MDT) working to provide holistic care for patients which was confirmed by feedback from different staff groups.
• Patients were positive about the way staff treated them
• There were good systems in place to manage patient flow. Admission and discharges were multidisciplinary focused to ensure all the needs of patients were met.
• Staff spoke positively of the leadership and this was reflected in the culture across the service. Clinical leads were visible, approachable and supportive.

However, we found the following issues that the service provider needs to improve:

• There were no clinical handwashing basins within any of the patient rooms or along the patient corridor and hand sanitiser gel was not always positioned ideally within a room. This meant that there was potential for hand hygiene not to be undertaken in a best practice manner. However the service did have a risk assessment with mitigation actions and had a plan for four new sinks and 11 additional hand sanitiser dispensers to be installed within a month of our inspection. Evidence was provided following the inspection to show that this was completed in October 2016.
• The corridor floor of the ward was lined with carpets. This was an infection control and prevention risk. However, permission had been obtained to have the carpets changed to vinyl and this was evidenced as completed by the provider in December 2016.
• There was a low compliance level in the monthly audits reported of venous thromboembolism assessment and treatment.
• Some visiting consultants working in the outpatients department did not comply with bare below the elbow guidance.

Services we do not rate

The surgical activities conducted by the provider consisted mainly of diagnostic scoping. Only 36% of the activities logged were in fact surgical cases (93 procedures in total).

Due to the small size of the maternity service and the nature of the surgical services conducted at BMI Coombe Wing, we did not have sufficient evidence to rate these services. However, we have highlighted good practice and issues that the provider needs to improve.

We found the following areas of good practice:

• All patients were followed up within 24 to 48 hours from discharge with a phonecall from a ward nurse.
• There was clear evidence of learning from incidents, including the review and update of a policy when required.

Information on our key findings and action we have asked the provider to take are listed at the end of the report.

Professor Sir Mike Richards

Chief Inspector of Hospitals