We spoke with three people who used the service who all told us they were fully consulted and their wishes were respected. They also told us they considered the care and treatment they had received to be good.

We saw that there were processes in place to ensure that staff were suitably recruited and there were sufficient staff available to ensure that continuity of care was delivered.

We saw that there were quality assurance procedures in place to monitor the service that people received.

When we carried out our inspection we spoke to three patients who were all waiting for day surgery. One patient told us they had “no worries whatsoever” about their treatment.

All the patients expressed satisfaction with their treatment so far and were complimentary about the hospital.

BMI The South Cheshire Private Hospital, Crewe is an independent hospital, based in a semi-rural location on the site of a large NHS Hospital in Crewe, is easily accessible, with free on site car parking and is part of BMI Healthcare. The hospital is registered to provide the following regulated activities:

• Diagnostic and screening procedures

• Family planning services

• Surgical procedures

• Treatment of disease, disorder or injury.

The hospital director is the registered manager, supported by a senior management team. The hospital director also managed another BMI Healthcare hospital at the time of the inspection.

This inspection was carried out as part of our on going programme of comprehensive independent health care inspections. We inspected the hospital on 6 and 7 September 2016 as an announced visit. During the inspection there were scheduled surgical procedures and outpatient clinics taking place and also radiological investigations. On 21 September 2016 we also carried out an unannounced inspection when there were surgical procedures, radiological investigations and outpatient clinics taking place.

We inspected the core services of surgery and outpatients and diagnostics (OPD) at the hospital.

Are services safe at this hospital

• Never events’ are serious incidents that are wholly preventable as guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers. There was one ‘never event’ in 12 months prior to the inspection, which occurred in theatres. Improvement actions were identified during the root cause analysis (RCA) investigation; however, staff told us that the details of this never event were not circulated effectively to staff to enable learning and prevent recurrence.

• There were 250 clinical incidents in the reporting period April 2015 to March 2016.

• Out of 250 clinical incidents, 95% occurred in surgery or inpatients and 1% in other services. The remaining 4% of all clinical incidents occurred in outpatients and diagnostic services.

• The hospital followed a reporting policy where incidents were categorised into clinical or non-clinical and were reported on colour coded incident forms, pink for clinical and blue for non-clinical, however, not all staff were aware of how to report an incident. Some told us that it was quite difficult to do. A list of what could be reported as an incident was available on the ward. This could be quite limiting as the codes were mandated per area, however, we were told that free text was allowed. Incidents were recorded in a paper format, and then submitted to the Quality and Risk Manager for inputting into the electronic system. We did not see any formal action tracking following incidents during the inspection. We were told that a new system that would enable staff to report incidents electronically was to be introduced this year.

• We found limited evidence of analysis and learning from incident reporting. All incidents reported were presented to the Medical Advisory Committee along with a brief description of some incidents (2-3 sentences).The main types of incidents that were discussed were ‘day case to inpatients’ and ‘cancelled operations’.No examples of learning or actions could be found within the minutes.We were told that there was discussion and challenge at the meetings but it was acknowledged that the minutes did not reflect this.

• The hospital had a system to identify and safeguard the needs of vulnerable adults, children and young people. Staff were aware of their responsibilities and the correct procedures to follow if a patient was at risk.

• Systems were in place to protect people from the risk of healthcare related infections. There were no reported healthcare related infections at the hospital in the period April 2015 to March 2016 and there were no reported incidents of acquired venous thromboembolism or pulmonary embolism in the same period.

• The environment was generally visibly clean and tidy; we saw that cleaning rotas were in place and that these were audited regularly. Action plans were in place, if necessary and were reviewed regularly.

• The hospital generally performed similar to the England average in the person-led assessment of the care environment (PLACE) audits for 2016 for questions related to the safe domain.

• Records were stored securely and generally contained relevant information; however Nursing staff in outpatients had very limited or no information regarding patient’s requirements who attended the outpatient department for follow up nursing care. Patient records were sent to medical records following a procedure performed in the outpatients department or discharge from the wards. In addition there were no individual patient records for patients attending for follow up review and treatment. We observed an A4 book which staff had documented care given for each patient at every visit. The information was limited with no evaluation, plan of care or reasons for treatment. On our return to the hospital for the unannounced inspection, the hospital had implemented a new process, in place of the ‘A4 book’, but it was too soon to judge its impact and effectiveness.

• Medicines were stored securely and there were processes in place to ensure they remained suitable for use. There were pharmacy audits and controlled drugs audits completed.

• Staffing levels were planned and implemented to ensure that there was sufficient staff on duty to provide safe care. This included the resident medical officer (RMO) cover.

• The use of agency staff and bank nurses working in inpatient departments was below the average when compared with independent hospitals we hold this type of data for in the reporting period of April 2015 to March 2016.

Are services effective at this hospital

• The hospital had a ‘Corporate Audit’ document which listed the monthly audits undertaken. These were the same audits each month and enabled comparison of compliance. Compliance was generally high, with the exception of falls, which was at 52% in January 2016. We requested the action plan for the fall audit. On discussion we were told that there wasn’t an action plan in place but were shown the data collection pro-forma and where the hospital believes errors had occurred in the data collection process. The Quality and Risk Manager explained that there were a few areas where improvements could be made in practice but that the main improvements required were in accurate initial data collection.

• During our visit we spoke with two consultant surgeons about clinical audits and we were told that there would be limited evidence of clinical audits on this site. It was explained that as the majority of the doctors at this hospital also work at the NHS Trust co-located on the same site, the NHS cases were all included in the audits conducted at the NHS Trust. This was discussed with hospital management team who confirmed that this is an area for improvement within the audit programme.

• The service bench marked themselves corporately with other BMI services. The service planned to participate in the Private Healthcare Information Network (PHIN) which at the time of our inspection had not yet started.

• There were poor appraisal rates across surgical wards, theatres and outpatients. Staff we spoke with felt that appraisals were beneficial and wanted regular appraisals. Some staff said they had not had an appraisal for at least two years. They were happy that these had been started up again and those whom had had an appraisal recently stated this was a positive move. Organisational data showed that 33% of theatre staff and 40% of ward staff had received an annual appraisal in the 12 months, up to September 2016. In outpatients Information provided by the hospital showed that 66% of of health care assistants (HCA) had received their appraisal at the time of inspection. The nursing sister told us since the Director of Clinical Services had been employed there was a focus on performing appraisals. At the time of the inspection we asked for the most up to date appraisal rates, but were not provided with them. At a later date we were shown appraisal rates for the time period requested.

• There were local policies and procedures in place and we saw evidence that departments followed relevant guidelines. The hospital kept their practices up to date and current by ensuring they were consistent with latest guidance such as those from the National Institute of Health and Care Excellence (NICE) and the relevant Royal Colleges’.

• Nutrition and hydration was assessed, information on fasting for surgery was provided; however, the letters we checked did not reflect the latest guidance which resulted in some patients fasting for longer periods than necessary.

• There was a comprehensive induction programme in place for new staff.

• The hospital was generally performing similar to, or better than the England average, for outcomes in relation to knee and hip replacements for the period of April 2014 to March 2016.

• Staff were observed working in partnership with a range of staff from other teams and disciplines including allied health professional, consultants and administration staff.

• The hospital had policies and procedures in place for consent, mental capacity and deprivation of liberty safeguards. Consent was sought prior to any treatment and patients were required to sign consent forms, which were then confirmed on the day that patients attended the hospital. We saw evidence that where a patient lacked capacity to make a decision, decisions about care and treatment were made by relevant professionals within a multidisciplinary team setting. Input was sought from the patient, their family and their representatives. Such decisions were made in the best interests of the patient and were documented and recorded appropriately

Are services caring at this hospital

• Patients we spoke to were positive about staff and said they were kind, considerate and treated them with dignity and respect.

• Without exception, every patient we asked spoke very highly of staff and were very positive about the way they had been treated by the service. They felt very strongly that staff were exceptionally caring and considerate of their needs.

• We observed staff being attentive and caring to patients during the inspection.

• The NHS friends and family test (FFT) is a survey, which asks NHS patients whether they would recommend the service they have used to their friends and family. From April 2015 to March 2016, hospital wide, 100% of NHS patients would recommend the service to their family or friends, the response rates were above the England average of 49.9%.

• The hospital performed well in the Person-Led Assessment of the Care Environment (PLACE) audits. The results for privacy and dignity at the hospital were 86% in June 2016 which was better than the England average of 83%.

Are services responsive at this hospital

• Information provided regarding waiting times for treatment for NHS patients, also known as referral to treatment times (RTT) showed that from April 2015 to March 2016, on average 92% of patients referred to the BMI South Cheshire private hospital were admitted for treatment within 18 weeks of referral.

• The hospitals performance in the Person-Led Assessment of the Care Environment (PLACE) audits for 2016 in relation to responsiveness was mixed. The hospital performed better than the England average for privacy, dignity and wellbeing. However, they performed significantly below the England average for dementia.

• Signage around the inpatients ward was not dementia friendly, in that signage was not in both written and pictorial form. However, the inpatient ward had done a lot of work on trying to improve the environment for people living with dementia and had established a designated dementia friendly room.

• There was no cosmetic surgery specialist nurse in post therefore there was a lack of formal assurance that issues such as psychological assessment of patients seeking cosmetic surgery and enforcement of the two week ‘cooling off period’ were being achieved.

• The hospital received very few complaints. We were provided with a tracker detailing ten complaints to date this financial year (at the time of the inspection). All of the complaints had been acknowledged on the day of receipt. Only 50% of the complaints on the tracker had been closed. The oldest open complaint was from 3.5 months ago; a holding letter had been sent one month after receipt. The hospital followed the corporate complaints policy which was a three stage process; if the complainant was not satisfied at stage one, which was at hospital level, the complainant had the right to escalate as per policy, to stage two, which was investigated by a senior director within BMI Healthcare. These complaints tended to be around financial issues as opposed to patient safety or experience issues.

• Meeting minutes we reviewed indicated that complaints were discussed at the Senior Management Team (SMT) meeting. They were also discussed through the clinical governance and medical advisory committee (MAC) meetings.

Are services well led at this hospital

• Staff were aware of the BMI Health vision, values, and strategy.

• The Risk Management Policy and Procedure was a new document issued in August 2016.

• There was a risk register in place at the time of the inspection. The risk register was a generic document provided by the corporate team and risk was rated by the hospital staff. Additional information, such as ‘actions to be taken’, could be added to the document to localise some of the risks. We reviewed the risk register and found that local risks were added by inserting a sentence in bold, for example ‘Use of aged Diathermy Machines’. We saw five local risks had been added all relating to equipment.  The risk descriptions were poor and did not clearly articulate the condition, cause and consequence of the risk. Staff were not aware of the risk register, key risks included or how to have a risk included on the risk register. Actions were listed for each risk.  However, there was no timescale or lead for each action (an overall lead for each risk was allocated). This did not appear to be a live document identifying and managing risks proactively. The Quality and Risk Manager did tell us that a new online system, which would capture incidents and have a comprehensive risk register module, was due to be implemented in October 2016.

• The hospital had a Clinical Governance Committee. We looked at the minutes from January, April & June 2016. They did not demonstrate any robust challenge or discussion around key clinical governance issues.  The minutes read as being very process rather than outcome driven.  For example, evidence was recorded that a root cause analysis (RCA) was being undertaken or had been completed but there was no record of the findings or improvement actions. Actions within the minutes were given a status of ‘New,’ ‘Ongoing’ or ‘Closed’.  There were no timescales allocated and no monitoring system to ensure that actions were responded to on a risk basis and in a timely way. The Clinical Governance Committee minutes referred to the risk register, as in stating that the first draft had been completed, but there was no discussion of any actual risks, no debates about risk ratings and no updates on actions taken to mitigate any risks.We discussed this with the hospital management team who acknowledged that an area for improvement is bringing to life the governance systems as opposed to managing processes.

• The management team included the Medical Advisory Committee (MAC) Chair.

• There was a formal process for when new procedures or techniques were introduced / approved. The hospital dealt with this through practicing privileges interviews and new procedures were then escalated to the MAC for approval but BMI were planning introduce a new formalised system and flowchart to indicated the process for considering and approving new procedures.

• We observed some non-adherence to the sign in stage within the World Health organization (WHO) checklist and National Patient Safety Agency (NPSA) five steps to safer surgery process, yet the management audit had been recorded as compliant. After the inspection we wrote to the hospital concerning this matter and received assurance that all theatre staff had been briefed with our findings and saw evidence of communication to consultant surgeons and anaesthetists, highlighting the importance of the WHO checklist process. We were informed that the hospital would be reviewing their processes to ensure that compliance and completion of the ‘WHO‘ checklist is adhered to for all surgical procedures.

• The hospital undertook a BMI  staff survey on an annual basis. We were provided with the hospitals results from the 2016 survey, comparing results to the 2014 survey. There were a number of areas that staff experience deteriorated. Only 51% of staff were ‘likely’ or ‘extremely likely’ to recommend BMI Healthcare to friends and family as a place to work. This was a 13.9% reduction from 2014.All areas of the survey under ‘Our Purpose’ (vision, goals, communication of these, objectives etc.) had deteriorated since 2014, as had all areas under ‘My views of BMI Healthcare’ (proud to work for, recommend as an employer, valued etc.).Of those surveyed, 68% said that they were likely to be working for BMI Healthcare in 12 months’ time. In terms of the way changes are made, only 27% reported that changes were introduced effectively. Staff told us that morale was low and this was also reported in the survey with only 28% reporting that morale was good.

• The leadership team were making efforts to improve the engagement with staff to improve morale. Various initiatives such as the staff forum and newsletter was in place to encourage place to improve engagement with staff both locally and nationally. The recently recruited Director of Clinical services had focused on improving governance, quality and leadership within the outpatient department with addressing training and appraisals, which staff agreed had improved.

We identified some areas of poor practice where the provider must make improvements;

Hospital-wide

• The hospital must improve its clinical governance and risk management processes to provide greater assurance that actions are being monitored to ensure timely attention to matters.

• The hospital must improve the incident reporting process to enable all staff to submit reports and enable all manner of incidents to be reported. There should be an effective system of circulating information and learning about incidents so that all staff remain aware of issues.

• The hospital must improve communication to ensure people who use the services, those who need to know within the service and, where appropriate, those external to the service, know the results of reviews about the quality and safety of the service. In particular, meetings need to be better attended with important information shared and distributed accordingly.

• The hospital must ensure staff are appropriately supported and have access to an annual appraisal.

• The hospital must ensure that there is an effective process for clinical staff to receive supervision.

• The hospital must address issues with patient records to ensure that there are contemporaneous medical records for each service user, which include all relevant pre and post-operative information.

In surgery

• The hospital must ensure that clinical waste from theatres is labelled in line with guidance issued by Association for Perioperative Practice (AFPP) in 2015 ‘Standards and Recommendations for Safe Perioperative Practice’.

There were also areas we feel the provider should make improvements;

In surgery

• The service should ensure they demonstrate progress towards implementation of the National Safety Standards for Invasive Procedures (NatSSIPs) and Local safety standards for invasive procedures (LocSSIPs).

• The hospital should take step to improve signage to make it more dementia friendly.

• The service should optimise the fasting periods for patients prior to surgery in keeping with best practice guidance.

• The ward should consider removal of carpets in all clinical areas for infection prevention purposes.

• Managers should become familiar with contingency and business continuity plans for their departments.

In outpatients and diagnostic imaging

• The hospital should ensure staff are trained appropriately in relation to record keeping.

• The hospital should consider implementing a pain tool for use within the outpatient department.

• The hospital should consider ways to measure patient outcomes to identify areas for improvement.

• The hospital should store sharps equipment for example cannulas and needles within a locked cupboard/drawer.

• The hospital should increase patient engagement.

• The hospital should improve the environment to make it dementia friendly.

• The hospital should consider ways to improve support to those patients with learning difficulties or additional needs.

Professor Sir Mike Richards

Chief Inspector of Hospitals