We inspected BMI The Edgbaston Hospital as an announced comprehensive inspection. We inspected the core services 18 February 2016. We did not need to undertake an unannounced element of the inspection.

The hospital provides a range of surgery, outpatients and diagnostic services. On-site facilities include two suites Harborne that has 30 rooms and two observation beds, and Forelands which has 20 rooms but was not in use at the time of the inspection. There are three laminar flow operating theatres, one endoscopy suite, plus a consulting room with waiting area for ambulatory care patients. Within outpatients, there are 10 consulting rooms, two dedicated ENT rooms and one treatment room for minor procedures. Within the imaging department, there was one x-ray room, one ultrasound room and a mobile MRI on site two days per week, though this was supplied by another provider. Pre-assessment had four consulting rooms and a phlebotomy room. The physiotherapy suite has two consulting rooms and a dedicated gym.

Services offered included general surgery, orthopaedics, and gynaecology. Medical services offered were mainly endoscopy, diagnostic imaging and physiotherapy.

The BMI Edgbaston Hospital does not admit paediatric patients for surgery.

To meet the commitment we had made to inspect independent hospitals this service was scheduled and considered low risk. We had no prior concerns to make this service high risk. We inspected surgery and outpatients diagnostics. At the time of our inspection there were four medical patients receiving care via the Endoscopy suite, plus one patient on a ward for discharge that day. We have not written a medical report but referred to medical care within the surgical report. 56% of patients using the hospital were NHS funded.

The hospital was rated Requires improvement overall, we looked at two core services which were surgery and out patients and diagnostic imaging. We have written some of the medicine we saw at the time within the surgery report. This was because of the small numbers of patients in the hospital at the time of inspection.

Are services safe at this hospital

• Incident management process was robust.When incidents required investigation, the subsequent investigation was thorough and the root cause and learning identified. Learning was disseminated amongst the staff groups. The Director of clinical services reviewed all incidents to ensure correct next steps were taken. However, within surgery we did see two occurrences we thought should have been raised as incidents.

• Staff received duty of candour training and were able to describe the process required of them.The duty of candour is a regulatory duty that relates to openness and transparency and requires providers of health and social care services to notify patients (or other relevant persons) of certain ‘notifiable safety incidents’ and provide reasonable support to that person. However, although we saw some meeting of the regulation, where staff were open and gave verbal apologies.Not all the letters to patients were sent relating to duty of candour.Also we noted that not all the steps to comply with the regulation were consistently applied.

• The ‘five steps to safer surgery’ was not consistently followed.The inspection team found many errors and or omissions in the records. Following feedback, the provider undertook training with staff to improve engagement with this safety process.

• The hospital employed a lead infection control nurse to support the staff who was shared with the nearby sister hospital.We found the hospital was visibly clean in all areas.Staff followed the hospital infection control policy.The exception was theatres, where we noted staff were not always bare below the elbows and used incorrect doors to access theatres for example.

  Equipment was in good working order, maintained regularly and replacement plans were in place and adhered to. Safeguarding adult training level two was at 28%.The hospital had delivered level two training to 10 staff.We reviewed documents sent by the provider that identified 36 staff had professional registrations employed by the hospital (October 2015).This meant they were involved in clinical and assessment work, which would require them to be trained to level 2.We noted that the policy in place did not identify the staff that were required to be trained to level two.The hospital has since changed the training matrix which means that all clinical staff will be trained to level 2.

• The director of clinical services was trained to level 3 for safeguarding adults and children. Along with another member of staff who worked with children. The number of children in the hospital represented 4% of the work in outpatients department, so this appeared adequate.Children were not treated as inpatients within the hospital. At the time of the inspection, the senior management had made contact with the local safeguarding board to ensure their practices were in line with multiagency protocols.

• Mandatory training figures demonstrated that staff were able to access and complete the training the provider had identified as mandatory.95% of staff had completed the training the target was 85%.

• The hospital used an acuity tool to identify the numbers of staff required; this is based on clinical hours used compared to those covered.When there was a shortfall agency staff were used.We noted the area which used the highest number of qualified agency staff was in Theatres.The hospital used one main agency to maintain continuity.

• At the time of the inspection, there were some vacancies still outstanding in Theatres, Outpatients and one the suites. The hospital had undertaken an initiative to employ newly qualified nurses direct from a university, which it linked withStaff turnover rate which was extremely low at 1% (October 2014 to September 2015).

• The hospital had one Resident Medical Officer (RMO) for the hospital. RMO's worked one week on and one week off. Staff were confident in the clinical support they received. Staff had good access to the consultants who reviewed their patients daily and were contactable by the nursing staff and RMO’s to seek advice for their patients.

Are services effective at this hospital

• We noted that patients received care in line with national best practice and guidance. We noted the American Society of Anaesthesiologists (ASA) physical status classification system was in use.Effective patient pathways were also in use by physiotherapy staff.

• Polices are written by BMI head office, if there were local variance a standard operating procedure would be produced. The hospital had produced a policy directory, available in all clinical and non-clinical areas.

• The hospital took part in national audit activity mostly related to joint surgery.The results demonstrated that results were above the England average.

• An enhanced recovery programme was in place to reduce length of stay.

• Other clinical audit took place across the hospital; we saw that audit activity in diagnostic imaging resulted improved outcomes for patients.The hospital had annual audit plan identifying the audits to take place on a month-by-month basis.

• There was a comprehensive programme to ensure practicing privilege criteria was met.The nearby sister hospital undertook this function on behalf of The Edgbaston.

• Revalidation was undertaken by the NHS employer where the consultant held their substantive post.Where consultants only worked in the private sector the Group Medical Director undertook their revalidation.

• Pain relief was managed effectively for patients. At pre-assessment, pain control was discussed.We saw that complimentary therapies were used in addition to analgesia to reduce and control pain.

• Consent was sought for all procedures; patients were given sufficient information to make informed decisions.Staff sought verbal consent to deliver any care interactions.

• Staff had received mental capacity training, but had little opportunity to use the knowledge.Due to the process of access to the hospital, there were little occasions where patients mental capacity was required to be tested.

Are services caring at this hospital

• The hospital participated in the Friends and Family Test for the period of April 2015 to September 2015.100% of NHS patients would recommend the hospital to friends or family.The response rate for this feedback was on average 38% of patients.

• All interactions we observed demonstrated that staff treated patients with compassion and with dignity.Patient privacy was maintained, however, in outpatients where there was a risk that patients could be overheard at the reception desk.Mitigation was in place as there was an office behind main reception where patients can utilise if they have confidential details to discuss.

• Patients were given ample information to make informed decisions about their care.

• Patients were emotionally supported by staff especially if they were delivering upsetting or difficult news.

Are services responsive at this hospital

• Service planning to meet the needs of the patients was evident as the majority of the service was elective.This meant that patients both private and NHS had choice when accessing the service they required.

• The hospital worked with local clinical commissioning groups to develop services for NHS patients.

• The services responded to individual patient needs by offering appointments outside of core business hours.

• The outpatient department was meeting its referral to treatment time (non-admitted) pathway and 100% of patients were seen within 18 weeks.

• We saw there was very little issues relating to waiting times and access to appointments and treatments.However, there was only one area where slight delays were seen for patients waiting for x-ray due to there being one x-ray room and, as radiographers were undertaking analogue imaging which took 90 seconds as opposed to digital which were processed immediately.

• There was very little exposure for staff to people living with dementia or a learning disability within the service. The patients attending this hospital were cared for in rooms rather than wards, as this would present an elevated risk for vulnerable people.At the referral stage risk assessments were undertaken to identify people requiring additional support and recommended for NHS care.

• Translation services were available to support patients whose first language was not English.Printed information was available on request in other languages and in large font, braille or audio. The numbers of complaints were very low.In outpatients and diagnostic imaging there had not been any complaints for over a year.Complaints were appropriately recorded and responded to. Staff felt empowered to respond to verbal complaints by acting on them quickly to resolve them and thus prevent them from escalation to formal complaints. Between October 2014 and September 2015 the hospital received 33 formal complaints related to slow discharge process, surgical outcomes or charges, and poor food.

Are services well led at this hospital

• There was a vision and strategy for the hospital; we noted that staff were committed to their areas of work. During induction, staff were introduced to the BMI brand promise to be “serious about health, passionate about care”.

• The Edgbaston and a nearby BMI hospital provided similar services.The two hospitals were looking at ways to collaborate and support each other.Executive and corporate managers were considering options to site individual specialist services at one or other of the hospitals.

• Records were not always available on site in outpatients as some consultants removed notes or saw patients both on and off site, this was for some private patients only.This was the same issue for analogue x-rays which were also removed from the premises.

• The Executive Director (ED) from the nearby BMI hospital oversaw the practicing privilege process.However, the ED from the Edgbaston attended each meeting.

• The Medical Advisory Committee (MAC) meetings took place and followed a set agenda.The format reflected a Verita report published March 2014 recommendations.This had been commissioned by another independent healthcare group but had implications for all independent health hospitals.We saw that the MAC meeting were run largely in line with the recommendations within that report.The hospital had representation in another regular meeting with other local NHS and independent hospitals as they shared a consultant body.This enabled them to share information, which may be a trigger and enable them to start preliminary investigations / discussions with a consultant, if there was cause for concern relating to their practice.

• The governance structure was robust in the most part, having a committee structure in place.Meetings took place to share information such as daily ‘Comm-Cells’ which hospital staff attended.Each department held regular meetings, which were minuted.We noted that regular agenda items included incidents and complaints.

• When investigations took place, the appropriate committees including the Medical Advisory Committee (MAC) reviewed them.We noted where incidents or complaints involved a consultant they were supported by the chair of the MAC.Either consultants were interviewed or they undertook a period of reflection.

• Learning from incident investigations had action plans associated with them and we saw these were completed.They included the sharing of learning mechanisms required to share the learning with appropriate staff.

• The hospital risk register held both clinical and risks associated with the fabric of the building.We noted that some of these were for escalation; however, the mitigation in place appeared reasonable to control the risk.

• There was a risk associated with carpet in clinical areas.There was a programme for refurbishment in place and housekeeping were maintaining the carpet including access to spill kits.

• One consultant insisted on using analogue x-rays rather than digital, they thought the images were better.This was despite all other consultants move over to digital and the Royal College of Radiographers recommending this practice.

• The leadership was very stable, the Executive Director had worked in a number of different roles so knew the hospital and the staff very well.Staff we spoke with were very complimentary of the leadership.There was a Director of Clinical Services in post, who at the time was an allied health professional.Nursing specific support was available from both BMI Head of Nursing and a team of clinical specialists who supported the Directors of Clinical Services.

• Within the core services staff felt supported by the management within their service.We saw this role required someone who could hold both consultants and staff to account to ensure policies are followed appropriately.At the time of the inspection, this was not happening in full.

• We were not able to check the fit and proper persons regulations compliance, as all the senior management documents were held at BMI head office.

Our key findings were as follows:

• Staff were not following the infection protection controls, not being bare below the elbows as per the company policy. Staff were using incorrect doors to enter and leave areas in the theatre suite.

• Care delivered was seen to be of a high standard.Patient complaints were very low.Staff felt empowered to deal with complaints initially before they became official complaints.

• We also observed that although the ‘5 steps to safer surgery’ audits showed 100% compliance, our observation of practice was not in line with the results.

• Audit activity results were above (better) than the England average for national audits relating to surgery.

• Incident management was good.The culture was one of safety and learning.The investigation process was of a good standard.

• Medications kept in refrigerators were not always maintained at the correct temperatures to maintain drug efficacy.

• Outpatient and diagnostic imaging was rated good for all the domains.

• Some patient records and x-rays were removed from outpatients and diagnostic imaging, which was not meeting regulations.

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

• The hospital was not meeting the regulations relating to the duty of candour.An apology was being given verbally, but the rest of the regulation practice was inconsistently applied.

• The surgery checklist appeared to be more of a tick box exercise, as our observations did not match the audit results.

Importantly, the provider must:

• The hospital must ensure that governance systems were in place, which ensures safe practices were followed in theatres, and the ‘five steps to safer surgery’ are complied with.

• Theatre staff must comply with hospital policy and be bare below the elbow, which is considered best practice in preventing and controlling infections.In addition, staff must wear facemasks when undertaking tasks for which it is required.

• Medicines storage records indicated that the refrigerators were not being maintained within the recommended range.

In addition the provider should:

• Compliance with the surgical safety checklist should be improved with attention to detail and auditing to ensure attention to detail in order to ensure patient safety.

• Duty of Candour is regulatory duty that requires providers of health and social care services to notify patients (or relevant persons) of safety incidents involving their care. The hospital should ensure that that it is consistently applied.

• All patients should have pre-operative assessments undertaken prior to surgery.

• Ensure that when the NEWS tool is used when scores meet the escalation point they are raised appropriately.

• The hospital should ensure that they meet and can demonstrate all parts of the regulations is met consistently.

• The hospital must ensure that all patients notes and diagnostic results are kept securely on the premises.
• People were not given the choice to self –administer their own medication if they wished to do so. We did see some people continuing to take their own medicines but there was no self-administration policy in place.

Professor Sir Mike Richards

Chief Inspector of Hospitals

When we inspected 21 people were using the service as in-patients, eight people were day care patients and out-patient clinics were taking place. Some people had received private treatment whilst others had been funded through the NHS. We spoke with six people who had been treated at the hospital and six medical professionals who worked there. We also spoke with senior managers and the registered manager.

People were positive about their care and treatment. One person said: “I’ve always recommended them, I’ve no complaints.” Another person said: “This particular hospital is extraordinarily good with their relationships with patients.”

We found that people had been provided with enough information to make informed decisions about their care and treatment. People who were self-funding had been provided with information about the costs of their treatment. People told us they had been treated with dignity and respect.

Care had been planned and delivered in ways that ensured people’s safety and welfare. Care plans had been maintained and reviewed regularly. When people’s condition changed their care had been reviewed. We saw that medical professionals at the hospital had co-operated with other medical professionals to deliver a person’s treatment.

The provider had an effective system for checking the quality of the services they provided. We also found that complaints had been investigated.

During our inspection we spoke with eight people in person or by telephone who had received treatment at BMI The Edgbaston Hospital. We also spoke with six members of staff from various hospital departments.

All the people we spoke with were satisfied with the care and treatment they had received. People told us that they were given sufficient information to enable them to make informed choices about their treatment before giving consent to it. They also told us that the staff were attentive and that they had been kept comfortable following surgery. Comments that we received included:

“It (the service) has been very good, the staff can’t do enough to help you and reassure you.”

“I have had two consultants, both have been very good at breaking things down in layman’s terms. They explained different options and gave information in terms of success.”

“The surgeon was excellent.”

Appropriate checks were undertaken before staff commenced work at the hospital. This ensured people were cared for by suitably qualified and experienced staff. Equipment reviewed was well maintained ensuring that it was safe to use and systems were in place to monitor the quality of service provision and take action where necessary to improve the service.