We spoke with several patients who were in-patients in the hospital on the day of our visit. Everyone told us they were happy with the care and treatment provided. For example, one patient said, “staff are in and out of my room all of the time, they are amazing.” All patients we spoke with said their pain had been well controlled and said they would definitely recommend the hospital to others. Patients had received clear information and explanations of care and confirmed that the risks and benefits of surgical procedures had been explained to them and they had been asked to give their written consent.

Patients told us they considered the service was clean and hygienic. For example, one patient said, “the hospital is spotlessly clean.” There were effective systems in place to reduce the risk of infection.

Records kept by the service were accurate and fit for purpose. There was an effective system in place for assessing and monitoring the quality of the service and the premises were maintained in a way that made them safe for patients, staff and visitors.

We spoke with four patients on the in-patient ward. They were happy with the care and treatment they had received. Patients told us that staff were friendly and approachable and responded quickly to their needs. One patient described the standard of care and treatment as “phenomenal”. Staff were described as “brilliant” and “really lovely”. Patients knew what medicines had been prescribed for them and what they were for. They were satisfied with the meals provided.

Staff underwent the necessary checks before starting work or being granted practising privileges (admitting rights). Staff were supported to deliver care and treatment safely and to an appropriate standard.

The patients we spoke to during our visit to the hospital were very positive about the care and treatment they received. Nurses were described as ‘excellent’ and ‘fantastic. Another patient said of staff, ‘I couldn’t fault them in any way’. Patients were provided with the information they needed and told us that care and treatment was fully explained to them. Patients had a choice of meals on the menu and could request drinks and snacks when they wanted them.

BMI The Kings Oak Hospital is an acute independent hospital in Enfield that provides outpatient, day care and inpatient services. It has 52 registered beds. The hospital is owned and managed by BMI Healthcare Limited.

The hospital provides a range of services including surgical procedures, outpatient consultations and diagnostic imaging services. Services are provided to both insured and self-pay private patients and to NHS patients.

We inspected the hospital on 11-13 October 2016 as part of our independent hospital inspection programme. The inspection was conducted using the CQC’s comprehensive inspection methodology. It was a routine planned inspection. We inspected the following three core services at the hospital: medicine, surgery and outpatients and diagnostic imaging.

Prior to the inspection, the hospital's senior management team took the decision to restrict the treatment of children to outpatients only, with the exception of over 16s who were on an adult care pathway.

Facts and Data

The hospital had 42 beds (registered to have a maximum of 52), split across three wards; Hadley ward with 18 beds, Ridgeway ward with 16 beds and six beds on the short stay ward which were not in use. All rooms had ensuite facilities.

There were 5,304 inpatient and day case episodes of care recorded at the hospital from July 2015 to June 2016; of these 44% were NHS funded and 56% were private or self-funded. There were 42,476 outpatient total attendances in the same reporting period; of these 37% were NHS funded and 63% were private or self-funded.

BMI The Kings Oak provided an outpatient service for various specialties. This included, but was not limited to, gynaecology, cardiology, dermatology, oncology, ophthalmology and orthopaedics. Outpatient services were provided from 12 consulting rooms, in addition to a minor procedures room, minor treatment room and phlebotomy room.

There were two operating theatres (one with laminar airflow) and an intervention radiology suite adjacent to the recovery area. There were 4,968 visits to the theatre between July 2015 and June 2016. The five most common surgical procedures performed were:

Image-guided injection(s) into joint(s) (985)

Dorsal root ganglion block (407)

Facet joint injection (263)

Hysterescopy (170)

Multiple arthroscopic op on knee (inc meniscectomy) (166)

Inpatient and day patient endoscopies were undertaken in the theatre department and beds on the wards were used pre and post procedure for recovery. Procedures undertaken included oesophago-gastro duodenoscopy (OGD), colonoscopy, and flexible sigmoidoscopy. There were 379 endoscopy procedures carried out in the twelve months before our inspection.

There were 259 doctors with practising privileges at the hospital and 104.6 whole time equivalent employed staff.

Patients were admitted and treated under the direct care of a consultant and medical care was supported 24 hours a day by an onsite resident medical officer (RMO) Patients were cared by registered nurses, health care assistants and allied health professionals such as physiotherapists and pharmacists who were employed by the hospital.

The hospital Accountable Officer for Controlled Drugs is the Executive Director.

BMI The Kings Oak was last inspected by the CQC in October 2013.

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 at this hospital?

We rated safe as requires improvement overall because:

• The environment did not always meet the requirements of Health Building Notice (HBN) 00-09: Infection control in the built environment. For example, patient rooms and some ward corridors had carpeted floors.
• In the pharmacy, there were no dispensing benches or work surfaces provided for counting or checking items.
• The hospital's target for staff having completed their mandatory training was 90%. Across the hospital 74% of all staff had completed their mandatory training. This was below the hospital's target.
• We identified risks relating to infection prevention and control. There were no signs to encourage hand washing and hand gel dispensers were not clearly marked. In patient rooms some of the carpets had dirty marks and there were marks on the walls, in corners and on skirting boards.
• Suction equipment which required to be stored in sterile packaging was left open in all patient rooms.
• Records were not always completed fully. We saw operation notes that were not dated and did not contain the name of the surgeons or anaesthetist. There were inconsistencies in recording National Early Warning Scores (NEWS) on the observation charts.
• Cleaning products were not stored in locked cupboards as required by the Control of Substances Hazardous to Health Regulations 2002 (COSHH).
• There was no established system for monitoring cleaning within the department including the cleaning of trolleys.

However,

• There was a good incident reporting culture. We saw that incidents were investigated and learning was shared with staff.
• Staff had a good understanding of processes for safeguarding adults and children.
• The RMO provided medical cover 24 hours a day, seven days a week. This meant concerns regarding a patient could be escalated at any time of the day.
• Staffing levels and skills mix were planned using an acuity tool and there were enough staff on duty on every shift to ensure patient received safe care.
• There had been no hospital acquired infection in the reporting period and we saw evidence surgical site infection was closely monitored.
• The diagnostic imaging department complied with policies and procedures based on the Ionising Radiation (Medical Exposure) Regulations (IR(ME)R).
• There was evidence of the WHO checklist being completed and audited in interventional radiography. Patient protocols were in place in radiology.

Are services effective at this hospital?

We rated effective as requires improvement overall because:

• Although the hospital completed consent form audits, no action had been taken to rectify the findings from previous audits that patients were not receiving written information about their procedure.
• There was no audit of national early warning score (NEWS) systems to identify deteriorating patients which meant the hospital was unable to identify if improvements in practice and outcomes were required.
• It was not clear who was responsible for providing the resident medical officers (RMOs) with clinical supervision.
• The nurses working in the endoscopy room had not been endoscopy trained.
• There was no formal audit programme reviewing the use of guidelines in practice.

However

• The hospital used a combination of professional guidance produced by the National Institute for Health and Care Excellence (NICE) and the Royal Colleges
• Patients’ needs were assessed and their care and treatment was delivered following local and national guidance for best practice.
• Pain scores were recorded and patients told us their pain was well managed.
• The hospital measured patient outcomes via a range of measures which included mortality, transfers out, infection rates, readmission rates, referral to treatment times, patient satisfaction scores, incidents, complaints, staff questionnaires, audits, Friends and Family Tests, and mandatory training rates.
• Patient surgery outcomes were within the expected range, although the small number of patients meant it was difficult to compare against national data for specific procedures such as joint replacements.
• Staff were suitably qualified and skilled to carry out their roles effectively and in line with best practice (except for endoscopy, see below).
• Staff obtained written and verbal consent to care and treatment which was in line with legislation and guidance.

Are services caring at this hospital?

We rated caring as good overall because:

• We observed that patients and their families were treated with kindness, dignity and respect
• Friends and Family Test (FFT) scores were consistently high with good response rates.
• Patients we spoke with were consistently positive about the care they received.
• The privacy and dignity of patients was maintained with the use of closed doors and windows and signs on doors to indicate personal care taking place within.
• Patients and their relatives felt involved in their care and were clear on how to contact the hospital if they had any concerns following their discharge.
• Staff offered emotional support to patients and provided encouragement and reassurance to help patients achieve their recovery goals.

However,

• Patients did not have access to information on how to access further emotional support if needed.

Are services responsive at this hospital?

We rated responsive as good overall because:

• Services were planned to meet the needs of patients and to ensure contractual requirements were met. Patients could book a convenient date and time for their appointment.
• Weekend and evening outpatient clinics were regularly being provided to offer flexibility in the service.
• For patients undergoing surgery, the hospital consistently met the referral to treatment target (RTT) of 90% for NHS admitted patients waiting less than 18 weeks from the time of referral to treatment.
• The hospital was meeting national waiting times for diagnostic imaging within six weeks and outpatient appointments within 18 weeks for incomplete pathways for their NHS patients.
• Complaints were investigated in line with the BMI policy and we saw patient mostly received acknowledgment and response within agreed timescales. Learning from complaints was shared with staff.
• Staff had attended training on dementia and had access to resources to assist them in caring for patients living with dementia.
• Patients had single rooms that provided privacy and comfort with en suite facilities and there was no restricted visiting times for patients.

However,

• The ward environment was not suitable for the care of patients living with dementia.
• We did not see evidence of any actions taken to ensure all patients underwent a pre-operative assessment, despite operations being cancelled due to the lack of pre-assessment.

Are services well led at this hospital?

We rated well led as requires improvement overall because:

• Senior managers were not aware that regular endoscopy procedures were being carried out at the hospital and also showed limited knowledge of how many or what types of medical patients were admitted to the hospital.
• There was a lack of stability in the management team as the physiotherapy manager post was vacant and several members of senior management were quite new in post.
• Some staff felt the recent changes in leadership of the hospital were unclear.
• Not all staff were positive about their local leadership.
• Staff told us of some instances of bullying behaviour by senior staff towards more junior staff.

However

• There was a clear management and operational structure within the hospital that worked across the two hospital sites.
• Most staff were aware of BMI’s corporate strategy aiming to deliver best quality care, best practice, and best outcomes for patients.
• There was a clinical governance structure in place and we saw the senior management team understood the key risks and kept an up to date risk register. The hospital risk register included corporate and clinical risks.
• Staff said they felt supported by their colleagues and there was evidence of good team-working.
• Most staff we spoke with told us they received good support from the senior team, who were very visible and approachable
• Patient satisfaction was monitored and reported on monthly through the patient satisfaction dashboard.
• We saw evidence of actions taken to improve findings from the Patient-led Assessment of the Care Environment (PLACE) audit.
• The senior management team and departmental leads were aware of the risks of the hospital and had plans in place to mitigate and eliminate these risks.
• Monthly meetings were in place for all levels of staff. 

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

The provider should:

Surgery

Ensure all clinical areas comply with the requirements of Health Building Notice HBN) 00-09: Infection control in the built environment.

Ensure all cleaning products are stored in locked cupboards as required by the Control of Substances Hazardous to Health Regulations 2002 (COSHH).

Ensure all staff are clear and consistent on the scoring of NEWS to avoid delays in escalating deteriorating patients.

Medical care

Ensure a system for monitoring the cleaning of the endoscopy department is in place including the cleaning of trolleys.

Ensure the endoscopy room is no longer used for storage.

Ensure that signage is place to encourage hand washing and identify hand gel dispensers.

Ensure controlled drugs are disposed of in a timely way.

Should provide dispensing benches or work surfaces provided for counting or checking items.

Improve the environment in patient’s rooms and bathrooms.

Ensure staff completed their mandatory training.

Undertake audits of national early warning score (NEWS) systems to identify deteriorating patients.

Ensure that the resident medical officer RMO’s has regular clinical supervision.

Outpatients and diagnostic imaging

Ensure the hospital's target for mandatory training is met.

Improve staffing in radiology for sonographers.

Professor Sir Mike Richards

Chief Inspector of Hospitals