BMI The Shelburne Hospital is operated by BMI Healthcare. The hospital has 26 beds and is a day case facility operating from 8am to 8pm Monday to Friday only. Facilities include three operating theatres, five outpatient consulting rooms, a physiotherapy department and diagnostic facilities.

The hospital is in the grounds of a NHS trust and utilises a number of its services. These include pathology, cardiology, cardiac catheterisation laboratory, nuclear medicine, magnetic resonance imaging (MRI) and computed tomography (CT) scans.

The Shelburne hospital provides surgery, outpatients and diagnostic imaging to adult patients only. We inspected surgery, outpatients and diagnostics, using our comprehensive inspection methodology. We carried out the unannounced part of the inspection on 15 January 2019.

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-refer to the surgery core service.

Services we rate

Our rating of this hospital stayed the same. We rated it as Requires improvement overall.

We found the following issue that the service provider needs to improve:

• The service provided mandatory training in key skills to all staff and processes in place to monitor compliance, but not all staff had completed this training.

• Most equipment was suitable but the paperwork to evidence that equipment had been tested and serviced to ensure it was fit for purpose was not always available, up to date or accurate.

• While staff understood how to protect patients from abuse. However, not all staff had completed the required level of safeguarding training.

• Not all departments had sufficient numbers of nurses with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.

• While staff recognised incidents, they did not always report these appropriately.

• The service provided care and treatment based on national guidance and evidence of its effectiveness. Whilst managers checked to make sure staff followed guidance, this guidance was not always the most up to date.

• Management for the diagnostic department was still in its infancy and was in the process of developing the right skills and abilities to run a service or had just begun to address some of the challenges in their area.

• The provider had a governance framework which was used to improve their clinical, corporate, staff and financial performance. However, these were not always fully embedded into operational practice.

However, we also found the following areas of good practice:

• The service controlled infection risks and kept equipment and the premises clean.

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

• The service had enough medical staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.

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

• Managers monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other BMI services to learn from them.

• Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.

• 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 hospital planned services around the needs and demands of patients, taking into account patients’ individual needs.

• People could access the service when they needed it.

• The service treated concerns and complaints seriously, investigated them and learnt lessons from the results, sharing these both internally and with other BMI hospitals.

• The service had a vision for what it wanted to achieve and workable plans to turn it into action, which it had developed with staff and patients.

• The service engaged well with patients and staff to and manage appropriate services.

  Following this inspection, we told the provider that it should make improvements, even though a regulation had not been breached, to help the service improve. Details are at the end of the report.

Nigel Acheson

Deputy Chief Inspector of Hospitals (London and South Central),

We spoke with two inpatients and one outpatient. They said they had received good, easy to understand information about the treatment options open to them. They said the consultants and nursing staff had taken time to thoroughly explain their medical condition and the procedures they were to undergo. "He explained the whole procedure" one person said.

The three patients we spoke with were positive about the care and support they received. One patient was particulary positive about the proactive management of pain. They also told us that they had been diagnosed with a previously unidentified condition during their stay. This had enabled it to be treated at the same time. This showed care and treatment was delivered in a way that was intended to ensure people's safety and welfare.

We looked at analysis of patient satisfaction questionnaires for December 2013. This showed an average satisfaction level of over 90% for response to nurse call times, pain control and overall satisfaction with nursing care. This meant patients felt the overall level of care they received was good.

Those patients we spoke with said they were confident about the clinical quality and safety of the treatment they had received. We saw comments from patients expressing satisfaction at their treatment, with no concerns about safety identified. We found BMI The Shelburne Hospital had detailed safeguarding policies and procedures in place. These included contact details for the relevant local authority safeguarding team. This meant patients were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.

The commitment of staff and the provision of agency cover without any unreasonable restriction meant there were enough qualified, skilled and experienced staff to meet people’s needs. This had, however, been achieved in the case of the operating theatre by staff working long and in some cases, consecutive long shifts on a regular basis. The potential risks to patients of this had been recognised and action had been taken to address it.

We saw information provided to patients included details of how to make a complaint. The BMI complaints policy included detailed timescales for responses to complaints and how complaints could be escalated. We saw how complaints about what were felt to be 'unexpected' charges for some screening procedures had been addressed. Improved, very clear guidance and information had been made available. This meant patients understood who was responsible for which charges and showed the provider took account of complaints and comments to improve the service for patients.

People told us they were satisfied with the level and quality of the information provided prior to their appointment. They said they were given clear information during the consultation and assessment process. Alternative care options had been explained to them. This meant they had been able to make well informed decisions about the care and treatment options open to them. People told us the staff were friendly and efficient. One person described the support they had received from nursing staff throughout their treatment as "exceptional."

People who had undergone surgical procedures said the clinical care was very good. One person told us their pain relief had been well-managed. Another person told us they had previously had two other surgical procedures carried out at The Shelburne Hospital. They said it was because those experiences had been so positive they had chosen to come back for a third time.

We talked with nursing, administration and physiotherapy staff. They showed they were aware of what constituted abuse and knew what to do if they saw or suspected it.

The people we spoke with confirmed they had been given the opportunity to provide feedback on the care and treatment they received. They told us they knew how to make a complaint if they needed to. Staff told us there were regular forums where they could make suggestions as to how services and procedures could be improved.

People who use the service told us that staff were very good at respecting their privacy and dignity. They told us they had been involved in discussions about their care and treatment. They said they had been given the opportunity to ask questions and had received thorough explanations on such things as consent to their treatment and the risks and benefits involved in their procedures. They said that where possible they had been encouraged to do as much for themselves as they could and they were given choices in relation to their care and treatment.

People told us they had completed a pre-admission assessment and a further assessment on arrival at the Shelburne Hospital. They said they had been asked about their needs as part of the assessment process. People felt that staff were very familiar with their needs and how to meet them. They said that staff responded well to any changes in health they displayed.

People said they felt safe and that their possessions were secure at the Shelburne Hospital. They told us they had no concerns about the way staff treated them. They said that staff appeared competent and knowledgeable in looking after them and were responsive, professional and engaging.

The people we spoke with had not been provided with questionnaires asking for their views on their care and their stay at the Shelburne Hospital. However, we found that questionnaires were being provided to patients on discharge. People said they felt confident in raising any concerns with staff but felt they had no concerns to raise.

One person summarised her time at the Shelburne Hospital by saying: “Everything here is done in a way that you don’t even notice because it’s all so good”. Another person said: “I have had experience of BMI previously and so far the Shelburne Hospital has been consistent with my positive experience”.

BMI The Shelburne Hospital opened in August 2000 and is part of BMI Healthcare. The Shelburne Hospital is part of the BMI South Buckinghamshire Hospitals group. The senior management is shared between this hospital and two other services. We inspected one of these services, The Chiltern Hospital at the same time as The Shelburne Hospital.

There is one ward the Shelburne Ward with 26 beds. The operating department consist of three theatres. In outpatients there are five consulting rooms with the additional supporting services. The hospital has a radiology department providing x-rays and ultrasound and a physiotherapy department.

Additional services are provided by the local NHS trust provides which includes pathology, pharmacy, cardiac catheterisation laboratory, Computerised Tomography (CT) and Magnetic Resonance Imaging (MRI) Scans.

The executive director, had recently moved from another hospital within the group, was applying to become the registered manager. They were supported by a director of clinical services, a director of operations and a team of heads of departments. There was also a hospital manager based at this site.

We inspected the hospital as part of our planned inspection programme. This was a comprehensive inspection and we looked at the two core services provided by the hospital: surgery and outpatient and diagnostic imaging.

The announced inspection took place on 26 and 27 July and an unannounced visit on 1 August 2016.

The hospital was rated good for caring and responsive and requires improvement for safe, effective and well-led services.

Our key findings were as follows:

Are services safe at this hospital?

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

• Staff were clear about their responsibilities to report incidents, however the process for the management of reported incidents was not robust and investigations and the sharing of learning did not always take way in a timely way.

• Processes to protect people from harm, such as infection control, the safe handling of medicines and equipment safety checks were being followed. However staff in theatres did not always follow systems and processes to keep patients safe.

• Patients were assessed and action was taken in response to risk. This included the assessment of patients to ensure only patients who the hospital could safely support received treatment.

• Patient records were stored securely . However, medical staff did not always achieve the required minimum standard of documentation in patient records.

• Staff were aware of safeguarding and were clear about their responsibilities to safeguard people at risk. However training to safeguard children was not currently being provided to the level described in the hospitals policy or safeguarding children and young people: roles and competencies for health care staffIntercollegiate document : March 2014.

• In general staffing levels and skill mix were planned, implemented and reviewed to keep people safe at all times. This was not the case for the operating departmentwhere staffing levels were not always in line with national guidance. Staff in the operating department were also undertaking dual roles without the support of a local hospital policy or risk assessments.

• The hospital compliance target for mandatory training was 85%. Not all staff were up-to-date with the mandatory training and there were delays in accessing practical based courses.

• There was a good understanding of the principles of the duty of candour, and the need to be open and honest.

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.

• Patients’ care and treatment was planned and delivered using evidence based guidance.

• Most staff were qualified and had the skills needed to carry out their roles effectively. Some theatre staff were undertaking the role of surgical first assistant without fully completing a recognised competency based course. There was no assurance that staff were competent to undertake the role.

• There was good multidisciplinary working across all teams in the hospital so patients received co-ordinated care and treatment.

• The hospital provided care to inpatients seven days a week, with access to diagnostic imaging and theatres via an on-call system.

• Staff had access to the information needed to assess, plan and deliver care to people in a timely way.

• Consent to care and treatment was obtained in line with legislation and guidance, and staff had an understanding of the principles of the mental capacity act.

• The hospital had systems in place for granting practicing privileges to consultants and when necessary suspended or removed these. However, the process for the biennial reviews was not being effectively managed.

• The hospital routinely collected and submitted data on patient outcomes. Although senior staff discussed this information at regional level, there was no evidence of how the hospital shared and used the information locally to improve outcomes for patients.

Are services caring at this hospital?

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

• Nursing, theatre and medical staff were caring, kind and treated patients with dignity and respect.

• Patients felt they received sufficient information about their planned treatment and were involved in decisions about their care.

• Patients consistently told us they would recommend the service to friends and family.

Are services responsive at this hospital?

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

• The hospital planned and delivered services in a way that met the needs of the local population. The importance of flexibility and choice was reflected in the service.

• Patients had timely access to initial assessment, diagnosis and urgent treatment at a time to suit them.

• The needs of different people were generally taken into account when planning and delivering services including cultural, language, mental or physical needs. The service had strict selection criteria to ensure only patients whom the hospital had the facilities to care for were referred

• Discharge arrangements were planned but flexible, and care was provided until patients could be discharged safely.

• The hospital dealt with the majority of complaints promptly, and there was evidence that the complaints were discussed amongst staff. Complaints were used to improve the quality of care.

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.

• There was a corporate vision in place, supported by a hospital business plan. Senior managers were aware of the key risks that may affect them achieving the vision.

• Governance processes were not always effective in monitoring the quality and safety of the service at a local level. Practices were taking place in the operating department that were not reflective of corporate polices or current national guidance.

• Managers and staff did not use the hospital risk register effectively to identify and manage risks within the service and there were no risk register at department level.

• The lack of a consistent and experienced theatre manager to lead and manage the operating department had resulted in no-one taking clear accountability and responsibility for the quality and development of the service. Local leadership was being developed with some department managers being new to the organisation.

• Heads of department found the daily senior team meeting an effective way to share key information with them.

• Staff felt they supported each other well in their teams and this had helped during a number of senior staffing changes at the hospital.

• They valued the changes the new executive director had made, particularly improving the appearance of the hospital and listening to their concerns.

After the inspection the provider was issued with a requirement notice letter, as we had identified potential failings to comply with two regulations relating to good governance and staffing; the detail of which is contained within the report and listed in the must actions at the end of the report. We asked the provider to submit an action plan to show how they would address these concerns and demonstrate how they would reduce the associated risks to patients and staff. The provider submitted a detailed action plan within the agreed timeframe which we felt was sufficient to comply with the requirement notice. A responsible person was allocated to each action, with a date for completion. Compliance with the action plan will be monitored through regular engagement meetings with the provider.

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

Importantly, the provider must:

• The provider must ensure that all staff acting as a surgical first assistant have been assessed as competent for the role. In addition, the evidence of completed competencies and log of cases should be available in accordance with the BMI Healthcare Surgical First Assistance policy.

• The provider must ensure it completes regular reviews of compliance with BMI Healthcare policies, with action taken for areas of non-compliance, including the renewal of practising privileges. .

• The provider must ensure that staffing levels in theatres are in line with current national guidance and the BMI Healthcare policy.

• The provider must ensure when staff are undertaking a dual role this is supported by a local policy and risk assessment.

• The provider must ensure all theatre staff receive an annual appraisal.

• The provider must ensure there is robust monitoring of the safety and quality of the surgery service at a local level, with risks identified and timely action taken to manage the risks.

• The provider must ensure all medical records are stored securely at all times, including during transport.

• The provider must ensure the hospital risk register reflects the current risks faced by the hospital and in sufficient detail to show how they are monitoring the risks.

• The provider must ensure staff carry out the six-point safety check prior to any radiological scan.

• The provider must ensure there is robust monitoring of the safety and quality of the outpatients and diagnostic imaging service at a local level, with risks identified and timely action taken to manage risks.

• The provider must ensure all staff in the outpatient department complete appropriate training and competency assessment to carry out their role.

In addition the provider should:

• The provider should ensure a trend analysis of all incident reports is completed, with action plans devised as a result.

• The provider should ensure all patient care records are completed in full, by the multidisciplinary staff providing care and treatment.

• The provider should ensure all staff are up-to-date with all of their mandatory training.

• The provider should ensure all staff complete safeguarding children training appropriate to their role.

• The provider should ensure all intravenous fluids are stored securely.

• The provider should ensure there are clear protocols and guidelines for pain management in the outpatient department.

• The provider must ensure all the key recommendations of the Perioperative Care Collaborative Statement on Surgical First Assistants have been considered, with action taken as indicated.

• The provider should ensure there is local monitoring of national guidelines to ensure patients receive care and treatment that reflects current evidenced based practice.

• The provider should ensure patient surgical outcome data is shared and discussed at relevant departmental meetings so changes can be made to practice where necessary.

• The provider should ensure all theatre staff receive an annual appraisal.

• The provider should ensure for all audits there is a clear action plan, with accountability for completion of any actions, by an agreed date.

• The provider should ensure the outpatient department have knowledge of individual consultant competencies.

• The hospital should ensure all outpatient clinics have sufficient numbers of staff to meet patients’ needs.

• The hospital should ensure there are appropriate arrangements in place for lone working in the outpatient department during evening clinics.

• The provider should consider arranging an external review of its theatre service to seek an independent review of the standards of the service.

• The provider should consider displaying information for patients about how to make a formal complaint.

• The provider should consider improving the signage to the hospital car park.

• The provider should ensure there is a robust risk assessment is carried out to assess the risk of carrying out lumbar punctures in the outpatient treatment room.

Professor Sir Mike RichardsChief Inspector of Hospitals

Professor Sir Mike Richards

Chief Inspector of Hospitals