This was the first comprehensive inspection of BMI The Lincoln Hospital, which was part of the CQC’s ongoing programme of comprehensive, independent healthcare acute hospital inspections. We carried out an announced inspection of BMI The Lincoln Hospital on 9 February 2016. Following this inspection an unannounced inspection took place on 12 February 2016.

The inspection team inspected the core services of surgery and outpatients and diagnostic imaging services.

Complex diagnostic investigations such as magnetic resonance imaging (MRI) and computerised tomography (CT) scans were provided by an external provider. There was a service level agreement (SLA) in place for these complex diagnostic imaging services. We did not inspect these services as part of our inspection.

Overall, we have rated BMI The Lincoln Hospital as good. We found surgery services were good in all five of the key questions we always ask of every service and provider relating to safe, effective, caring, responsive and well led. Outpatients and diagnostic imaging services were good in the four key questions relating to safe, caring, responsive and well led. We inspected but did not rate the key question of effective in outpatient and diagnostic services.

Are services safe at this hospital

We found services provided at BMI The Lincoln Hospital were safe.

• Patients were protected from avoidable harm and abuse.

• There was a good incident reporting culture throughout the hospital.

• Staff were supported to be open and transparent and they understood and fulfilled their responsibilities to raise concerns and report incidents and near misses.

• There was an open and honest culture at all levels within the hospital. Staff were aware of the duty of candour regulation. [This regulation requires providers to be open and transparent with people about the care they receive in particular circumstances and especially where things go wrong].

• Incidents were investigated and learning from incidents was shared throughout the hospital and where appropriate at a corporate level.

• Safeguarding of patients was given sufficient priority. The hospital had a safeguarding lead and staff were supported to take a proactive approach to safeguarding. All staff knew who the safeguarding lead was and told us they would always approach them for guidance. The safeguarding lead at the hospital had good links with the safeguarding lead at the local authority.

• Risks to patients and people using the service were assessed, monitored and managed on a day-to-day basis. These included signs of deteriorating health and medical emergencies. The hospital had appropriate processes and agreements in place to transfer patients to a nearby acute hospital if their condition deteriorated.

• Staffing levels and skill mix were planned, put in place and reviewed to keep people using the service safe at all times. Nursing and medical staffing was managed effectively to deliver appropriate care to patients.

• A resident medical officer (RMO) provided 24 hour cover seven days a week for all patients. 99 consultants had been granted practising privileges at the hospital, 87 of whom had been undertaking work at the hospital for over 12 months.

• There were effective arrangements and processes in place to support the handover of appropriate patient information between the RMOs, consultants and other clinical staff such as nurses and allied healthcare professionals at the hospital.

Are services effective at this hospital

We found services provided at BMI The Lincoln Hospital were effective.

• Care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and legislation.

• Local policies and procedures, alongside National Institute for Health and Care Excellence (NICE) guidelines were discussed the Medical Advisory Committee (MAC) meetings.

• Patients received care and treatment in line with national guidelines such as National Institute for Health and Clinical Excellence (NICE) and the Royal Colleges.

• The rate of unplanned readmissions and unplanned patient transfers to other hospitals was within expected levels when compared to national averages and other independent hospitals.

• The hospital participated in national audit programmes such as performance reported outcomes measures (PROMs) and the National Joint Registry. Results showed patient outcomes were in line with the national average. Audit findings were reviewed and monitored at routine clinical governance and MAC meetings.

• Consultants working at the hospital were employed under practising privileges (authority granted to a physician by a hospital governing board to provide patient care in the hospital) that were monitored by the Medical Advisory Committee (MAC). Any changes to policies were reviewed by a consultant with the relevant expertise and discussed and ratified during MAC meetings.

• The location had appropriate arrangements in place for checking qualified doctors, nurses and allied health professionals had renewed their registration on an annual basis.

• Consent to care and treatment was undertaken in line with guidance. Staff were aware of the legal requirements of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards.

Are services caring at this hospital

We found services provided at BMI The Lincoln Hospital were caring.

• All staff we observed, without exception, treated patients with compassion, dignity and respect.

• Patients were kept informed and were involved in every stage of their care and treatment.

• Staff demonstrated pride in the care they delivered and spoke about patients in a respectful manner. Patients we spoke with confirmed that staff were kind, considerate and treated them with dignity and respect.

• Emotional support was provided by staff at the hospital. We saw staff providing reassurance for patients throughout their treatment and care.

• Patient experience was reported through local patient surveys and the NHS Friends and Family Test (FFT). Patient satisfaction was high. Between September 2014 and November 2015 between 98% and 100% of patients being treated at BMI The Lincoln Hospital would recommend the hospital to their family and friends as a place to receive treatment and care.

Are services responsive at this hospital

We found services provided at BMI The Lincoln Hospital were responsive.

• People’s needs were met through the way services were organised and delivered. Patients accessed services provided by the hospital via an NHS referral, via self-referral and self-funding or via their health care insurer.

• Services were flexible and choice and continuity of care was reflected throughout the service. For example weekend appointments could be made for some outpatient clinics. The needs of all patients were taken into account throughout the planning and delivery of services.

• Waiting times, delays and cancellations were managed appropriately. Referral to treatment times (RTT) for both admitted and non-admitted patients were consistently above the national average of 90%.

• Occupancy rates on the ward meant that any day case patients who needed to stay overnight because they were not fit to go home could do so.

• The hospital had a policy, which outlined the inclusion and exclusion criteria for patients. Patients with an American Society of Anaesthesiologists (ASA) physical status score of three or greater were excluded.

• All patients were screened pre-operatively to determine whether the hospital could meet their needs. Where a patient was identified as living with dementia or a learning disability, a person-centred approach was adopted to ensure the person received the right care in the right place at the right time.

• There was sufficient capacity to provide care and treatment for patients undergoing surgery at the hospital.

• In line with the provider’s policy, all complaints were responded to in a timely manner.

Are services well led at this hospital

We found services provided at BMI The Lincoln Hospital were well led.

• The leadership, governance and culture promoted the delivery of high quality person-centred care.

• There was a clear corporate vision and strategy in place which was driven by quality and safety. The vision and values were visible throughout the hospital. The mission statement for the hospital was ‘passionate about care.’ Staff were aware of this and they demonstrated this mission statement through the care they provided to people who used the service.

• There was a clear governance structure in place which enabled heads of department to feed into the medical advisory committee (MAC) and the hospital executive management team.

• There were effective systems and processes in place to check that all new and existing executive and senior team leaders were and continued to be of good character and had the necessary qualifications, skills and experience for their role. The Executive Director and the Director of Clinical Services had supplied specific information such as a disclosure and barring service (DBS) check and a full employment history to demonstrate their ability to be a fit and proper person [The fit and persons requirement (FPPR) for directors was introduced in November 2014. The FPPR intends to make sure senior directors are of good character and have the right qualifications and experience].

Our key findings were as follows:

• Although the hospital had a relatively new senior leadership team, they all displayed the skills, knowledge and experience required to lead. This was demonstrated through their attitude, values and commitment to ensure staff felt valued and involved in decision making throughout the hospital.

• There were clearly defined and visible local leadership roles at hospital wide and local levels. Senior staff provided clear leadership and motivation to their teams. The leadership team were known to staff and were visible throughout the hospital on a daily basis talking with patients and observing clinical practice including attendance during theatre lists.

• Staff morale and motivation were good and staff enjoyed working at BMI The Lincoln Hospital. There was supportive management at all levels, effective team-working and an open culture in which staff were able to raise concerns and make suggestions.

• All clinical areas were clean. The hospital had reported no incidence of MRSA, clostridium difficile (C.diff.) or methicillin-sensitive staphylococcus aureus (MSSA) in the reporting period between October 2014 and September 2015.

• Patient-led assessments of the care environment (PLACE) audits for 2015 showed the hospital had achieved 100% for cleanliness. This was above the national average of 98%.

• All the areas we visited were visibly clean and tidy. Staff were aware of current infection prevention and control guidelines. Cleaning schedules were in place with clearly defined roles and responsibilities for cleaning the environment and cleaning and decontaminating equipment.

• The hospital had employed an infection control link nurses to provide training and to liaise with staff so patients who acquired infections could be identified and treated promptly.

• A Resident Medical Officer (RMO) provided 24-hour medical and surgical cover for all patients. Consultants and anaesthetists could be contacted 24 hours a day.

• There had been no unexpected inpatient deaths in the hospital in the 12 months preceding our inspection. If deaths did occur then these would be reviewed and discussed at the clinical governance and Medical Advisory Committee (MAC) meetings.

• Patient records included an assessment of patients’ nutritional requirements.

• Staff followed guidance on fasting prior to surgery which was based on best practice. For healthy patients requiring a general anaesthetic this allowed them to eat up to six hours prior to surgery and to drink water up to two hours before.

• The areas we inspected had a sufficient number of trained nursing and support staff with an appropriate skills mix to meet patients’ needs.

• Staffing levels were monitored using the BMI Healthcare nursing dependency and skill mix tool. The theatres did not have a full establishment of permanent staff. However, staffing levels had been calculated on the basis that the two operating theatres would be supporting patients with general anaesthetic. Gaps were maintained through the use of regular long-term agency staff.

• Patients were screened at the pre-assessment stage using a screening tool to identify any risks prior to admission. Where appropriate actions were taken to ensure patients were given every opportunity to have their treatment at the hospital.

• Vulnerable adults, such as patients with a learning disability and those living with dementia were identified at the referral stage; steps were taken to ensure they were appropriately cared for. This included an appointment time during less busy periods, continuity of staff and informing carers or representatives of the plan of care.

• The Director of Clinical Services had taken the lead on environmental changes to ensure people with dementia were fully supported. In 2015 a patient-led assessment of the care environment (PLACE) audit highlighted carpets as being a risk for patients living with dementia. This was identified as a risk on the hospital’s risk register and this was addressed as part of a refurbishment programme where carpets were replaced with laminate floors. There were also plans to discuss appropriate dementia friendly signage throughout the hospital.

• Local patient questionnaires were available and themes were collated and used for patient experience planning. Patients received follow up calls within 48 hours following discharge which provided patients with an opportunity to feed back on their experience.

There were areas of practice where the provider should make improvements.

The provider should:

• Ensure seating is washable in patient areas.

• Audit the imaging reporting turnaround times.

• Continue to prioritise the recruitment of staff to theatres.

• Ensure references are obtained for all doctors working at the hospital under practising privileges.

• Ensure training for all staff in relation to caring for patients living with dementia is completed as soon as possible.

• Consider purchasing a ventilator to mitigate risks to staff when using paracetic acid for endoscopic processes.

Professor Sir Mike Richards

Chief Inspector of Hospitals

During our inspection we focused on one key question

Is the service safe?

We found through speaking with staff, observation, reviewing care records and talking to patients' that their safety was ensured and their individual needs were met.

We spoke to four patients, one of whom was visiting as an out-patient. We also looked at the care records of three patients. We also spoke with the registered manager, clinical director and a sample of ward and theatre staff.

We saw that patients were given choices and they told us they felt able to make their own decisions. Their comments were positive about how they felt their privacy and dignity was respected. Staff were described as “polite” and patients said that they felt “comfortable” with the way in which their dignity was respected.

Patients were also complimentary about the cleanliness of the hospital. We saw that there was a programme of refurbishment and redecoration in place which took account of infection control issues.

The quality assurance systems encouraged patients to express their views about the service. Patient’s commented they would raise any issues they had with staff as they were approachable, and they were encouraged to complete questionnaires.

In general we saw that patients were supported by knowledgeable staff and received the care and support they wanted and needed. We saw and were told by patients that there was sufficient staff to meet their needs and that call bells were always answered promptly. Patients made comments such as, "I feel safe here”, “All the staff are very good” and “10 out of 10 for all aspects of care.”

During our inspection we spoke with six people that used the service and four people’s relatives. One person we spoke with told us. “I think it’s absolutely outstanding. The staff are really friendly.” Another person said, “There’s not a single thing I could criticise. I’ve been consulted about everything.”

We found that before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. We saw people’s care and treatment reflected relevant research and guidance.

When we examined care records we found care and treatment was not always planned in a way that was intended to ensure people’s safety because assessments of risk were not always completed fully or correctly.

We found there were arrangements in place to deal with foreseeable emergencies. We also found appropriate arrangements were in place in relation to obtaining, recording, storing and administering medicines.

We spoke with seven members of staff and found they received appropriate professional development and were able, from time to time, to obtain further relevant qualifications.

We found people were made aware of the complaints system and this was provided in a way they could understand.