On the day of the visit we looked at the hospital facilities, spoke with the manager, staff, relatives and patients. This helped us to gain a balanced overview of what people experienced receiving treatment at the hospital.

During the inspection we looked at patients care records, staffing levels, infection control processes and how the service monitored the performance of the hospital. Comments from patients and relatives were positive and included, “Great service from the start of my treatment to my post-operative care.” Also, “The staff from the receptionist to the consultants have been excellent.”

We saw that the hospital had a number of internal and external audit systems in place to monitor the quality of the service provided. The manager told us they responded appropriately when they were given information of concern. They reviewed their own processes as a result of concerns raised and made amendments to their systems if required.

There was evidence the service had systems in place to keep the hospital clean and meet infection control guidance documentation. Comments from patients and staff were positive about the cleanliness of the hospital. One patient said, “The hospital is kept clean, the staff do a great job here.”

Staff told us they enjoyed working in their particular departments, and they felt supported, both by their colleagues and the senior management team.

We spoke with a range of people about the hospital. They included, the registered manager, senior staff, nurses, patients and visitors. This is in order to gain a balanced overview of what people experience.

We spoke with patients about how they were treated and support they received. They told us staff were good at discussing all their treatment options and given time to make informed decisions. Comments included, "Excellent information was provided to me all the way through my treatment." Also, "All the nurses made me feel at ease and always made sure everything was ok." One patient recently recovering from surgery said, "We went through all the stages of my treatment from the start. They were very good."

Patients and visitors spoke highly of staff and how they were treated with respect and dignity. One patient said, "All my consultations were conducted in private." Also, "Every member of staff I came across were so polite."A relative we spoke with said, "All the people here are so thoughtful and polite and treat you with respect."

Staff we spoke with told us they are supported by management. Comments included, "Most of the people working here have been here for a long time that tells you something." Also, "Everybody is so supportive it is a happy atmosphere to come to everyday."

None of the people we spoke with had any issues about the standard of care they were receiving and people told us that they would be comfortable in raising any concerns they may have.

BMI The Lancaster is operated by BMI Healthcare Limited. We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 25 and 26 October 2016 along with an unannounced visit to the hospital on 8 November 2016. This was part of our national programme to inspect and rate all independent hospitals. We inspected the core services of surgical services and outpatients and diagnostic services as these incorporated the activity undertaken by the provider.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

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 – for example, management arrangements – also apply to other services, we do not repeat the information but cross-reference the surgery core service.

We rated this hospital as requires improvement because:

• The hospital had received a Regulation 28 report from the coroner. A Regulation 28 is a report that the coroner has a duty to make where they believe action should be taken to prevent future deaths. The report highlighted areas where failings occurred and improvements were required. We found an action plan had been implemented for this but there had been elements of the action plan that had not been followed through completely.

• We found that some areas of compliance with mandatory training were low.

• The environment had not been suitably adapted to respond to the needs of patients living with dementia. For example signage was not clear, and there were no quiet spaces for patients who may be feeling anxious or confused.

• The hospital had a newly appointed management team who were in the process of identifying gaps in governance and assurance. However, this process had not yet been completed and embedded fully across the hospital.

• There were examples of where the hospital had put controls in place to mitigate the level of certain risks. However, we found that they had not always been implemented in a timely manner. Some actions that had been implemented had not always been monitored to ensure compliance had improved.

• The governance processes did not ensure the correct or most current policies and procedures were being used. This included staff dependency tools to assess nurse staff numbers and assessments of staff competence.

In surgery we also found:

• We observed that the ‘sign out’ phase of the 5 steps of safer surgery including the WHO surgical safety checklist was not always completed fully following a patient undergoing surgery.

• Hand washing facilities in the inpatient ward did not meet current guidance.

• Records indicated that some members of key staff had not been assessed for appropriate competencies before undertaking certain roles within the hospital. This was brought to the attention of the manager following the inspection and assurance was given that action would be taken.

• Records indicated that anaesthetic equipment was not being checked on a daily basis in line with AAGBI guidelines.

• We found that the storage of endoscopes was not compliant with Department of Health guidelines.

• Written patient information was available in English language only.

In diagnostics and outpatients we also found:

• There were patient records which did not have a clinical entry made on the day of consultation and the copy letter to the GP was not signed.This meant that records were not always accurate, complete and contemporaneous. This was brought to the attention of the manager following the inspection and assurance was given that action would be taken.

• There was no separate dirty utility room in the outpatient department which meant staff were disposing of waste, such as urine samples, in the clean treatment room. A formal risk assessment had not been completed to ensure this was being managed effectively.

• Carpeting and seating in the outpatient department did not assist in maintaining good standards of infection control. This was being addressed by the service.

We found areas of good practice including:

• We observed all areas to be visibly clean and uncluttered.

• The hospital had clear safeguarding policies and processes for staff to follow. Staff were able to describe what constituted a safeguarding incident and how this was reported.

• Care and treatment was provided in line with up to date Evidence Based practice.

• Care and treatment was delivered in a caring and compassionate way. Privacy and dignity was maintained for patients when they received care and treatment.

• Complaints and concerns were dealt with in a timely manner and there were examples of the services provided being improved as a result.

• The hospital had a vision and strategy which was underpinned by the overall BMI vision and strategy.

• There was a clear leadership structure in place. Staff informed us that the new management team were visible and approachable.

• Staff throughout the hospital described there being a friendly and open culture.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help it move to a higher rating. We also issued the provider with two requirement notices that affected both surgery and outpatients and diagnostic services. Details are at the end of the report.

Ellen Armistead

Deputy Chief Inspector of Hospitals North.