The Princess Margaret Hospital based in Windsor is operated by BMI Healthcare Ltd. The service has 66 beds. Facilities include four operating theatres and an endoscopy suite. There is an outpatient department with consulting and treatment rooms, X-ray, and diagnostic facilities including magnetic resonance imaging (MRI), computed tomography (CT) and ultrasound.

The Princess Margaret Hospital provides surgery, medical care, outpatients and diagnostic imaging to people who have private medical insurance, pay for themselves and some NHS funded patients.

This was a focused inspection to follow up on the four serious incidents that had been reported to the Care Quality Commission (CQC) between May 2017 and December 2017. Two serious incidents related to complications during surgery and two for wrong medical device insertion during surgery. In addition, we looked at the areas of improvement identified in the previous surgery inspection report, published December 2016. As the serious incidents occurred in surgery we only inspected surgery. We inspected this service using our focused inspection methodology but for completeness looked at all five key questions, is the service safe, is the service effective, is the service caring, is the service responsive and is the service well-led. We carried out an unannounced inspection on 06 November 2018.

The hospital offers cosmetic procedures such as dermal fillers, ophthalmic treatments and cosmetic dentistry. We did not inspect these services.

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.

Services we rate

Our rating of this service stayed the same. We rated it as Good overall. However, well-led which was previously rated as Requires Improvement improved to Good. We found the service had learnt lessons from when things had gone wrong and put measures in place to prevent reoccurrence.

We found good practice in relation to surgery:

• The service provided mandatory training in key skills to all staff.

• Staff had training on how to recognise and report abuse.

• The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.

• The service had suitable premises and equipment.

• Staff completed and updated risk assessments for each patient. They kept clear records and asked for support when necessary.

• The service had enough staff, with the right mix of qualification and skills, to keep patients safe and provide the right care and treatment. However, there was high usage of bank and agency staff within the service.

• Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date and available to all staff providing care.

• The service followed best practice when prescribing, giving, recording and storing medicines.

• The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service.

• The service provided care and treatment based on national guidance and evidence of its effectiveness.

• Staff gave patients enough food and drink to meet their needs and improve their health.

• Staff assessed and monitored patients regularly to see if they were in pain.

• Managers monitored the effectiveness of care and treatment and used the findings to improve them.

• The service made sure staff were competent for their role.

• Staff of different roles worked together as a team to benefit patients.

• Staff understood how and when to assess whether a patient had the capacity to make decisions about their care.

• Staff cared for patients with compassion.

• Staff provided emotional support to patients to minimise their distress.

• Staff involved patients and those close to them in decisions about their care and treatment.

• The service planned and provided services in a way that met the needs of local people.

• The service took account of patients’ individual needs.

• People could access the service when they needed it.

• The service treated concerns and complaints seriously, investigated them and learned lessons from the results and shared these with staff.

• The service promoted a positive culture, creating a sense of common purpose based on shared values.

• There were effective structures, processes and systems of accountability to support the delivery of the strategy and good quality, and sustainable services.

• The service had good systems to identify risks, plan to eliminate or reduce them, and cope with both the expected and unexpected.

• The service collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards.

• The service engaged well with patients, staff and the public to plan and manage appropriate services.

However,

• Gas cylinders in the theatre area were not stored according to national guidance.

• There was dust in higher to reach parts of the theatre area.

• Level of patient harm was not always recorded when incidents were reported.

• Not all information was cascaded down to agency staff.

• The sepsis screening tool was not embedded by staff.

Dr Nigel Acheson

Deputy Chief Inspector of Hospitals (Acute South)

The focus of this inspection was the experience of patients who use the location for surgical outcomes. This included pre-admission procedures, the medical imaging department, operating theatres and the surgical nursing wards.

Patients we spoke with during the inspection confirmed they had individual treatment and care plans. One person we spoke with commented, “I had detailed discussions about my care with my consultant and I have found this very reassuring”. The second patient we spoke with said, “My doctor explained the operation I was going to have before surgery, came to see me after and we discussed the care I would need after the operation”. Care documentation we reviewed confirmed patients had risk assessments and treatment plans tailored to their individual needs.

Staff we spoke with in the operating theatre and ward were knowledgeable about the fasting procedure and we saw this was adequately explained to patients who underwent surgery on the day of the inspection. Nursing staff on the wards followed the surgeons’ and anaesthetists’ instructions about when patients could recommence oral intake. Sufficient assessment was completed by nursing staff to determine that patients could take food and fluid once again.

The provider responded appropriately to any allegation of abuse. In the surgical wards, we observed there was signage available in staff stations about how to raise safeguarding matters. This included signs and symptoms to be aware of regarding abuse in adults and children, and who to contact both internally and externally in the event that abuse was suspected. The provider had named nurses, midwives and doctors available on site or via bleeper in the event that a safeguarding case needed to be raised.

We spoke to patients about medications in the surgical wards and patients had positive comments. One person told us they had their medications explained to them by the doctor. They said, “My consultant told me about the risk and benefits of taking the medicines”. Another person we spoke with said they understand potential effects that the medication may have had. They told us, “I am aware of the side effects of my medication”.

In the wards, we spoke to the nurses about how the staffing was organised. We spoke to five nurses in the wards, all of whom felt there were sufficient levels of staff at all times. All of the nurses we spoke with told us they were never short staffed and only on rare occasions were agency nurses required. The nurses told us staffing was based on dependency and acuity of patient’s needs.

People spoke very highly of the services and staff at BMI The Princess Margaret Hospital. They told us they were provided with relevant information and felt informed about their care and treatment. People told us their needs and preferences were respected. They felt there were good arrangements to ensure their privacy and dignity. They commented particularly on the positive attitude of staff. One person observed that staff "just smile and put you at ease." People praised the cleanliness of hospital facilities and told us staff used alcohol gel hand rub to minimise infection.

We found that people using the service were provided with appropriate care to meet their needs. Measures were in place to ensure people's privacy and dignity were respected. National clinical guidelines and recommendations were understood and implemented. Infection prevention and control measures were in place. There were systems in place for monitoring the quality and safety of services provided to people. Information security protocols were in place to ensure the confidentiality and security of care records. The hospital monitored how staff completed patients' medical records to ensure the records met professional standards of medical record keeping.

People using the service that we spoke to were all complimentary about the quality of the service that was provided at the hospital. We were told that all the staff were kind and helpful and the rooms were kept very clean.

One person told us “there is nothing to complain about”. Another said to us” the care is brilliant”. Two of the people spoken with had experienced the service before, so knew what to expect.

The Princess Margaret Hospital is one of 59 hospitals and clinics provided by BMI Healthcare Ltd. It is located in Windsor, Berkshire, and on-site facilities include 78 registered beds, four theatres (three laminar flow), and an endoscopy suite. There is an outpatient suite offering consulting and treatment rooms, and an imaging department offering X ray, magnetic resonance imaging (MRI), computed tomography (CT) and ultrasound.

BMI Princess Margaret Hospital provides a range of medical, surgical and diagnostic services to patients, who pay for themselves, are insured, or are NHS-funded patients. Services offered include general surgery, orthopaedics, cosmetic surgery, ophthalmology, general medicine, oncology, dermatology, physiotherapy and diagnostic imaging, ophthalmology, endoscopy and orthopaedic services.

Medical services can be thought of as those services that involve assessment, diagnosis and treatment of adults by means of medical interventions rather than surgery. The medical service consists of two separate components; oncology chemotherapy treatment, and a diagnostic endoscopy service. Endoscopy or chemotherapy services undertaken as a day case are therefore included within medical care in this report.

The announced inspection took place on 13 and 14 September 2016, followed by a routine unannounced visit on 23 September 2016.

This was a comprehensive planned inspection of all core services provided at the hospital: medicine, surgery, outpatient and diagnostic imaging. There are some surgical and outpatient services for patients under 16 years, and these are reported within the surgical report by Specialist Advisers, but the majority of patients are adults.

The Princess Margaret Hospital was selected for a comprehensive inspection as part of our routine inspection programme. The inspection was conducted using the Care Quality Commission’s new inspection methodology.

Our key findings were as follows:

Are services safe at this hospital?

By safe, we mean people are protected from abuse and avoidable harm.

• Patients were protected from the risk of abuse and avoidable harm across all inspected services.
• Staff reported incidents, and openness about safety was encouraged.
• Incidents were monitored and reviewed in most services and staff clearly demonstrated examples of learning from these.
• Clinical areas were visibly clean and tidy. Hospital infection prevention and control practices were followed and these were regularly monitored, to reduce the risk of spread of infections. Where necessary, action was taken to address any identified learning.
• Staff received appropriate training for their role, were supported to keep their skills up-to-date and were further supported in their role through a corporate performance review process. BMI set a target of 90% compliance with mandatory training. Records provided by the hospital showed that the compliance rate for medical care staff was 89%.
• Staff followed national and local guidance when providing care and treatment.
• Equipment was maintained and tested, in line with manufacturer’s guidance. There were appropriate checks and maintenance on the hospital building and plant.
• Medicines were stored securely and chemotherapy was prepared safely. Nursing staff were trained to administer chemotherapy.
• There was regular monitoring of patient records for accuracy and completeness. They were securely stored and available when needed.
• Staffing levels and skills mix were planned, implemented and reviewed to keep patient’s safe at all times. There was sufficient medical cover provided by resident medical officers (RMOs) who covered the hospital 24 hours a day for all specialities. Consultants were also available daily and would provide support and advice out of hours if necessary.
• Plans were in place to respond to emergencies and major situations.

Are services effective at this hospital?

By effective, we mean that people’s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence.

• We found there were arrangements to review guidance from national bodies such as the National Institute for Health and Care Excellence (NICE), and that care was delivered in line with best practice.
• There was a system for reviewing policies and these were discussed at the medical advisory committee (MAC) and other governance groups at the hospital.
• Care was continually monitored to ensure quality and adherence to national guidelines to improve patient outcomes and the hospital participated in relevant national audits.
• We found arrangements that ensured the doctors and nurses were compliant with the revalidation requirements of their professional bodies. All consultants had clear practising privileges agreements, which set out the hospitals expectations of them, and ensured they were competent to carry out the treatments they provided.
• Systems for obtaining consent were compliant with legislation and national guidance, including the Mental Capacity Act (2005) and these were adhered to by staff.

Are services caring at this hospital?

By caring, we mean that staff involve and treat people with compassion, kindness, dignity and respect.

• We observed that patients were treated with dignity and respect and their privacy was maintained.
• Patients who shared their views were very positive about the care they received and spoke of kind and welcoming staff.
• Staff helped patients and those close to them to cope emotionally with their care and treatment
• Staff described how all children were involved in the discussions and decision making processes about their treatment and care, in a way which supported their understanding.

• Patients and relatives commented positively about the care provided and said they were involved in decision making.

• The hospital took part in the Friends and Family Test (FFT). For the reporting period November 2015 to February 2016, 100% of patients said they would recommend the hospital to their friends and families. Between 25% to 50% of patients responded to the FFT.

Are services responsive at this hospital?

By responsive, we mean that services are organised so they meet people’s needs.

• Services were planned and delivered in ways which met the needs of the local population. Patients told us there was good access to appointments, and at times which suited their needs.
• Waiting times, delays, and cancellations were minimal and managed appropriately. Facilities and premises were appropriate for the services being delivered.
• The hospital was a provider of Choose and Book which is an E-Booking software application for the National Health Service (NHS) in England: this allows patients needing an outpatient appointment or surgical procedure to choose which hospital they are referred to by their GP, and to book a convenient date and time for their appointment.

• There was openness and transparency in how complaints were dealt with, and staff could demonstrate where learning and actions had taken place. Patient’s comments and complaints were listened to and acted upon. Information on how to make a complaint was provided on the BMI Princess Margaret Hospital website. However, we did not see any guidance, posters or leaflets instructing patients on how to make a complaint.
• A complaints database enabled the executive director and the director of nursing to track progress and close complaints when the complainant was satisfied.
• For the reporting period March 2015 to April 2016, the hospital consistently met the target of 95% of non-admitted patients beginning their treatment within 18 weeks of referral.
• Patients were able to access services when needed and we found services responsive to meeting individual needs. They were satisfied with the appointments system. Most patients told us it was easy to get an appointment when they needed it.
• Patient Led Assessments of the Care Environment (PLACE) for 2015 showed comparable results to the previous year and above the England average. In the PLACE audit carried out in March 2015, dementia services at the hospital scored 83%. This was above the England average of 81% for independent sector acute hospitals but the hospital was devising a plan to provide more dementia-friendly facilities.

Are services well led at this hospital?

By well led, we mean that the leadership, management and governance of the organisation assures the delivery of high-quality person-centred care, supports learning and innovations and promotes an open and fair culture.

• We found that most staff were conversant with the corporate and local vision and values and strove to demonstrate these in their daily work.
• There was an appropriate system of governance and managers knew the key risks and challenges to the hospital and were taking steps to mitigate the impact of these. Staff attended governance meetings and committees such as infection prevention and control meetings. Staff received feedback from hospital-wide meetings in emails and we saw team meeting minutes were available to all staff.
• Practising privileges were received, authorised and granted in conjunction with the Medical Advisory Committee (MAC) and kept under review. There was effective governance and oversight of the consultant’s performance and behaviours through the MAC and by close working with the local NHS trust, where many of them worked.
• There were effective governance structures, and a hospital- wide risk register, which was updated regularly. Departmental risk registers also identified specific risks in that area which may affect staff, patients and visitors. The risk registers reflected actions to be taken to mitigate any risks. However in Surgery we found, although there were systems for identifying and managing risk, some were rudimentary with limited ability to spot trends. Risks were recorded and mitigations put in place. However, mitigations were not always checked to ensure they were effective.
• There was a culture of collective responsibility between teams and services. Information and analysis was generally used proactively to identify opportunities to drive improvement in care. However, in Surgery we found senior nurses did not always use the quality data generated to drive change and service improvement.
• All policies were approved at local and corporate level. Staff had access to policies in hard copy and on the intranet and signed a declaration to confirm they had read and understood the policy relevant to their area of work.
• There were clearly defined and visible local leadership roles and managers provided visible leadership and motivation to their teams.
• Senior managers were visible and had a thorough understanding of how services were provided at the hospital. They were open and honest about what they did well and where they knew there were areas for improvement. However, some senior staff did not feel empowered to drive positive change and lacked the confidence to challenge poor practice where this was seen. Some staff we interviewed found it difficult to challenge senior staff or consultants due to cultural differences.
• Consultants we spoke with were positive about senior members of the hospital and described good working relationships.

• Patients were encouraged to leave feedback about their experience by the use of a patient satisfaction questionnaire and for NHS patients by the Friends and Family Test
• The executive team knew and understood their main market very well and ensured that services developed to meet the needs of the local community.

We saw one area of outstanding practice including:

• The provider has access via the Consultant users to electronic information held by community services, including GP’s. This meant clinical staff could access up-to-date information about patients, for example, details of their current medicine.

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

Importantly, the provider must:

• Ensure all mitigations to risks identified are put in place and then monitored to ensure compliance. For example, in Surgery we found although a crossover of clean and dirty surgical instruments had been escalated to the risk register, processes to mitigate this were not being followed.

In addition the provider should:

• A suitable system is put in place to screen patients over 75 years of age for dementia, in line with national guidance.
• Pregnancy safety posters to be displayed in the diagnostic and imaging waiting area.
• The complaints procedure is made to be more easily accessible for patients.
• Stocks of medicines need to be checked to ensure they are in date and suitable for use.
• Patients undergoing an endoscopy should have comfort scores recorded.
• Staff should have access to a recognised visual analogue pain assessment tool, for people with a cognitive impairment.

Professor Sir Mike Richards

Chief Inspector of Hospitals