During our inspection visit we visited the imaging and outpatient departments, Adult Intensive Care Unit (ITU), two adult wards and the operating theatres. We spoke with patients and staff in the wards and imaging departments. We also spoke with the hospital’s Registered Manager, the Director of Nursing, the Medical Director and the infection control specialist nurse. The specialist adviser accompanying us specialised in peri-operative care.

The patients we spoke with were positive about their experiences at the hospital. One person said “it’s like a quality hotel” and another said that there was sufficient time to discuss his treatment. They all said the hospital was clean and they would make a complaint if they needed to. We reviewed the 2013 quarter 3 patient feedback information (404 respondents). 97% of people would recommend the hospital to others.

Patients’ needs were assessed and care and treatment was planned and delivered in line with their individual plans. This included risk assessment, multi-disciplinary team work and patients’ involvement with their care. Surgical processes were safely managed. Before receiving any treatment staff ensured that patients understood and consented to the procedure.

There were effective systems in place to reduce the risk and spread of infection. Staff had received infection control training and there was a team to support and advise staff as well as policies to guide clinical practice. Staff were trained and received appraisal and supervision that was appropriate to their role. This included an induction process for all staff.

There was an effective complaints system which included investigation, response and action planning. We saw that staff were focussed on providing safe and responsive care for their patients.

People we spoke with were satisfied with their care and treatment at the hospital. Many described aspects of their care as “excellent”. They reported that they were treated with respect. People understood the treatment that they or their children were undergoing and had been involved in making decisions about their care. They felt that they could give feedback about the service and ask for more information.

People who did not speak English as their first language told us that they had had a good experience at the hospital. They had had as much information as they needed and could ask for more. They had always been able to use the interpreter service when they needed it, or their doctors spoke Arabic with them.

Bupa Cromwell Hospital is operated by Medical Services International Limited. The hospital has 118 inpatient beds and 19 day case beds. Facilities include five operating theatres, a four-bed level three care unit, endoscopy unit, outpatient and diagnostic facilities.

The hospital provides surgery, critical care, medical care, services for children and young people, and outpatients and diagnostic imaging. We inspected all of these six services.

We inspected this service using our comprehensive inspection methodology. We carried out the unannounced inspection on 18 to 20 September 2018.

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 services provided by this hospital were at the Bupa Cromwell Hospital.

Services we rate

Our rating of this hospital improved. We rated it as good overall.

We found mainly good practice in all the key questions for all the six services we inspected. However, we rated critical care as requires improvement.

The hospital had made significant improvements in the services of medical care and children and young people; both these services had previously been rated as requires improvement. Medical care was rated as outstanding overall.

We found the following areas of good practice across all services:

• The service had improved the systems in place for reporting, investigating and learning from incidents and serious adverse events. There was an open culture of reporting, and learning was shared with staff to make improvements.

• There was sufficient staff with the right skills, training and support to meet the needs of patients and provide effective multidisciplinary care in all the services.

• Staff used a standardised sepsis screening tool and sepsis care pathway. Our review of records showed staff used an early warning score system to monitor patients for signs of deterioration and responded appropriately.

• The service followed best practice when prescribing, giving, recording and storing medicines. Patients received the right medication at the right dose at the right time.

• The hospital used current evidence-based guidance and quality standards to plan the delivery of care and treatment to patients. There were effective processes and systems in place to ensure guidelines and policies were updated and reflected national guidance and improvement in practice.

• We observed staff treated patients and their families with compassion and care to meet their holistic needs.

• The hospital planned, developed and provided services in a way that met and supported the needs of the population that accessed the service, including those with complex or additional needs. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were excellent.

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

• Managers had implemented systems to strengthen governance, performance and risk management arrangements across the hospital since the last inspection.

• Managers across the services promoted a positive culture that supported and valued staff. The majority of staff told us they felt listened to and well supported by managers and colleagues and were confident to raise any concerns they had.

• The hospital engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.

We found areas of outstanding practice

Medical care:

• Staff provided compassionate individualised care. Staff provided extensive support to patients and their relatives and worked hard to meet the holistic needs of their patients through emotional and practical measures.

• The hospital provided extensive emotional support and resources to patients and their families. The oncology and chemotherapy day unit had a qualified Macmillan cancer counsellor and patients really valued the service.

• We saw numerous examples of individualised care and progress made through the involvement of relatives, for example with patients who had suffered a brain injury.

Outpatients:

• The hospital worked with a sight loss charity to provide a braille map for partially sighted and blind patients to enable them to navigate the hospital safely and independently.

• Patients were provided with a single point of contact via a patient care coordinator. This was their point of contact throughout their visit. They were responsible for looking after the patients’ welfare, and checking them in with the consultants’ reception desk. They also kept the patient up to date with any changes or delays.

• The hospital held cultural sessions for both international patients and staff prior to admission to the hospital. This was to ensure both patients and staff understood cultural expectations, enhanced the patient experience and so they did not offend each other.

We found areas of practice that require improvement:

Medical care:

• Clinical equipment was not regularly serviced and sharps bins were not always dated in a timely manner to indicate when they were assembled.

• Some staff from a certain ethnic group had experience bullying from patients within the same ethnic group. Senior managers were aware of this and told us they had addressed the issue with patients and emphasized the organisation had zero tolerance on abuse or victimization.

Surgery:

• Equipment in some patient rooms was covered in dust.

• The service had a high number of unplanned readmissions within 28 days of surgery.

• The service used two different patient pain score measures; one for theatres and one on the wards.

• There was no service level strategy in place.

• Junior nurses felt neglected by the executive team and did not speak highly of the culture.

Critical care

• Not all equipment was safety tested and always cleaned and labelled appropriately.

• Staff did not always adhere to infection prevention and control standards.

• The rate of bank or agency staff did not always comply with recommendations by Core Standards for Intensive Care Units.

• The premises did not comply with Core Standards for Intensive Care Units but the hospital had building plans for a new unit.

• Intensive Care National Audit Research Centre (ICNARC) data showed there were more unit acquired infections in blood compared to similar units.

• ICNARC data showed the risk adjusted acute hospital mortality was above calculated expected acute hospital mortality.

• Not all staff knew about the principles of Deprivation of Liberty Safeguards (DoLS) and how to apply them in a critical care setting.

• The service did not always meet the needs of people. The facilities for patients’ relatives were not appropriate, but there were building plans for a new unit to correct this by 2019.

• Intensive Care National Audit Research Centre (ICNARC) data showed there were more unplanned readmissions within 48 hours from discharge compared to similar units.

• ICNARC data showed there were more out of hours discharges to the ward compared to similar units.

Services for children and young people

• Staff did not receive any specific training on potential needs of people with learning disability and autism. This was not in line with best practice.

• We observed some staff in clinical areas did not adhere to bare below the elbow dress code.

• We found that the clinical audit programme was limited to mainly nurse led audit and the service did not audited their consent practice.

• There was limited monitoring of clinical outcomes.

• Though clinical guidelines were available on the intranet, the process to search correct information was cumbersome.

• There was no learning disability link nurse.

• The children’s service was at an early stage of establishing a formal governance structure and this needed to become well embedded.

Outpatients

• Not all patient records were completed to log patient interactions, assessments, medications prescribed and treatment provided by the consultant.

• Cleaning schedules for consulting rooms were not always completed as required.

• Infection prevention and control (IPC) audits were below the target, and action plans were incomplete.

• The hospital did not audit evidence based care and treatment outcomes, therefore they could not benchmark against other providers.

• Information and assistance posters were only displayed in English.

• Cancellation rates and do not attend (DNA) rates were not monitored due to secretaries booking and cancelling appointments and not working onsite to be able to record this.

• Patients with dementia, learning difficulties and mental health conditions were not able to be flagged via patient records.

• The management and governance team did not always ensure action plans were up to date as a result of audits that had taken place.

Diagnostic imaging

• The service controlled infection risk well. However, some areas did not have documentation to check they were cleaned effectively.

• The service had suitable premises and equipment and looked after them well. However, there were no separate waiting areas for children in the waiting areas for x-ray, CT, PETCT, MRI and ultrasound. This could result in exposure to inappropriate adult conversation.

• There was a lack of health promotion material available across the diagnostic department

• There was a lack of audit to ensure the correct exposures for plain film x-ray were used.

Nigel Acheson

Deputy Chief Inspector of Hospitals