Alexandra Private Hospital is operated by Alexandra Healthcare Limited. The hospital facilities include 21 individual rooms located over two floors, and two operating theatres. The hospital does not perform surgery every day; on average, there are four to five days per month when surgery takes place.

The hospital provides cosmetic surgery for self-funding patients. The hospital also offers cosmetic procedures such as dermal fillers and laser hair removal, ophthalmic treatments and cosmetic dentistry. We did not inspect these services.

We inspected cosmetic surgery using our comprehensive inspection methodology, on the 14 and 16 June 2016. This identified the provider was in breach of five regulations of the Health and Social Care Act 2008 (Regulated Activity) Regulations 2014. These were:

• Regulation 12: Safe care and treatment
• Regulation 17 Good governance
• Regulation 13 Safeguarding service users from abuse and improper treatment
• Regulation 19 Fit and proper persons employed
• Regulation 15 Premises and equipment

The full report of this inspection can be found on the CQC website: https://www.cqc.org.uk/location/1-114136771

We carried out a focused inspection again on the 23 January 2017, to follow up our concerns.

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.

At this inspection we looked at the safe, effective and well led domains only.

We regulate cosmetic surgery services but we do not currently have a legal duty to rate them. We highlight good practice and issues that service providers need to improve and take regulatory action as necessary.

We found the following areas of good practice:

• The hospital was visibly clean and tidy and processes were in place to ensure equipment was cleaned appropriately between use.
• The provider had introduced a new policy relating to the use of using aseptic non-touch technique (ANTT), which is a standardised approach to performing procedures in order to reduce the risk of a healthcare associated infection (HCAI). Staff confirmed their knowledge and understanding of this.
• The provider had introduced monitoring processes to ensure that consumables were in date.
• Medicines were stored securely and in date, and the provider had introduced a new policy for the prescribing of antibiotics, which was in line with national guidance.
• Records were kept securely.
• The provider was working with the local acute NHS trust to formalise the existing agreement for a patient to be transferred to the local acute NHS hospital if their condition deteriorated, as required by the Independent Healthcare Advisory Services.
• Staff used an early warning score (EWS) to identify a deteriorating patient. Early warning scores have been developed to enable early recognition of a patient’s worsening condition by prompting nursing staff to get a medical review at specific trigger points.
• The provider was actively working to meet the requirements of the Review of the Regulation of Cosmetic Interventions (2013).

However, we also found the following issues that the service provider needs to improve:

• Governance, risk management and quality measurement were not robust and we were not assured the provider was taking a proactive approach to continuous learning and improvement.
• We did not see sufficient evidence to ensure us that all incidents were reported and lessons learnt and shared.
• Not all policies reflected up to date guidance or reflected the needs of the organisation.
• Disclosure and barring service (DBS) checks had not been completed for the staff member we identified at the inspection on the 14 and 16 June 2016.
• Information advising patient about cosmetic surgery and having an anaesthetic was out of date.
• There was no system to electronically record details of any implants used, which could be easily accessible in the case of a product recall.
• Whilst the provider had incorporated the World Health Organisation (WHO) Surgical Safety Checklist into existing documentation that staff used in theatres not all elements of the WHO had been included. The WHO checklist is a set of safety checks, identified for improving performance at safety critical time points within the patient’s intraoperative care pathway. Staff did not undertake child safeguarding training. Whilst the hospital did not care for children, this did not mean that children did not visit the hospital. Therefore, staff should have children safeguarding training as outlined in the Royal College of Paediatric Health intercollegiate document: safeguarding children and young people (2014).
• There was no clear guidance as to which risk assessments and screening were required preoperatively for patients. Staff did not assess patients for their risk of venous thromboembolism (VTE) or consider their psychological well-being preoperatively. Preoperative checks, such as MRSA risk and blood pressure recording undertaken by the registered nurse as part of the pre-operative screening process had not been recorded.
• Fasting guidance for patients undergoing a general anaesthetic did not reflect current best practice.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with one requirement notice that affected the cosmetic surgery service. Details are at the end of the report.

Professor Sir Mike Richards

Chief Inspector of Hospitals

The Alexandra Private Hospital is an independent cosmetic hospital, based in Chesterfield and is part of Alexandra Health Care Limited.

The Alexandra Private Hospital is registered to provide the following Regulated Activities:

• Diagnostic and screening procedures.
• Surgical procedures.
• Treatment of disease, disorder or injury.

The hospital’s senior management team consists of the owner who is also the registered provider and a theatre manager.

Our inspection was part of our ongoing programme of comprehensive Independent Health Care inspections. We inspected the hospital on 14 June 2016 on an announced visit. During this visit, there were no patients and no surgery planned for the day. On 16 June 2016, we carried out an unannounced inspection of the hospital, when there were patients undergoing surgical procedures.

We inspected the core service of surgery, at the Alexandra Private Hospital, which also incorporated the consultations patients had with their surgeon prior to and after their operations.

Are services safe at this hospital/service

Systems in place were not consistently reliable in protecting people from the risk of healthcare associated infections. We found some out of date consumable items on the resuscitation trolley and within theatres. The arrangement for managing medicines was not robust. Some medicines were out of date and some medicines were left unattended. There was no process in place for monitoring the use of prescriptions and no protocols for antibiotics prescribing. Temperatures of the medicine fridge were above the recommended range. Records were not kept securely. The safeguarding policy lacked detail, did not reflect current best practice and the service was unsure as to what level of safeguarding training staff received. There were no robust processes in place to respond to and reduce patients’ risk. The use of an early warning score (EWS) to identify a deteriorating patient was inconsistent; however patients did receive regular monitoring following surgery. Although there was a procedure in place for a patient to be transferred to the local acute NHS hospital if their condition deteriorated there was no formal written agreement between the local NHS acute trust to admit patients as required by the Independent Healthcare Advisory Services (2015). There were no clear processes for assessing patients’ risk of developing venous thromboembolism (VTE), for identifying those patients who should be screened for MRSA, or for assessing the psychological well-being of patients prior to theatre.

However, all staff had attended mandatory training. Staffing levels, including resident medical officer cover (RMO) were planned, implemented and reviewed to ensure there were sufficient staff to provide safe care. There was clear patient exclusion criteria to identify those patients who would not be suitable for surgery, which meant patients who were potentially high risk were not admitted. The service reported no never events, no wound infections and no VTE incidents. During our inspection we observed an anaesthetist respond appropriately and efficiently to a potential risk to a patient.

Are services effective at this hospital/service

Policies referred to out of date material, or did not reflect current best practice. The service had not started to collect data for the submission to the Private Healthcare Information Network (PHIN); PHIN requires every private healthcare facility to collect a defined set of performance measures and to supply that data to PHIN. The service did not collect and report Q-PROMs from patients. Q-PROMS are patient report outcome measures, which describe the level of patient satisfaction with certain operations and is a recommendation from the Royal College of Surgeons (RCS). The service did not keep electronically the details of implants used. This is required to ensure information is easily accessible in the case of a product recall. However, the service did use a paper-based system that recorded details of all the equipment used during a patient’s operation. There was no robust system in place to ensure information was communicated with the patient’s GP.

However, patient pain was managed effectively. Staff worked well together with effective communication and partnership working between the different professional groups. There was a robust procedure in place to ensure patients were able to give an informed consent. The service had an audit programme in place.

Are services caring at this hospital/service

Without exception, patients told us they were treated with kindness and compassion by all staff. Patients spoke positively about the service and the care they had received. Patients were fully involved in their care and staff explained procedures to them, and provided emotional support.

Are services responsive at this hospital/service

The service arranged appointments and surgery times to meet the needs of individual patients. Patients were able to self-refer to the hospital or were referred from other independent cosmetic surgery services. There was a clear complaints policy, although patient information displayed regarding this was inaccurate. Written information for patients was out-of-date.

Are services well led at this hospital/service

There was no documented vision or strategy for the hospital, which had been shared with staff. Governance arrangements were not robust. Quality assurance systems and audits completed had not identified the issues found on our inspection. Whilst the service reported no incidents, we could not be assured whether this was because there were no incidents or there was a failure to report. Many policies and risk assessments did not reflect up-to-date practice or current guidance. Disclosure and barring service (DBS) checks had not been completed for one staff member and one doctor did not have evidence of indemnity insurance in their file. The hospital had not made arrangements to ensure they were meeting the recommendations from the Review of Regulation of Cosmetic Interventions (2013).

However, staff spoke very positively about the leadership of the service; staff felt engaged and enjoyed working at the hospital. The service sought feedback from all patients regarding the care they had received.

Our key findings were as follows:

• Systems in place were not consistently reliable in protecting people from healthcare associated infections. We saw dust on equipment such as fans and dust in the corners of patients’ rooms. We saw debris had collected in the light fitting of theatre. There was inappropriate storage of items such as mop heads and linen. Decontamination procedures for equipment were ineffective and staff did not always adhere to recognised good practice procedures, such as using aseptic non-touch technique (ANTT), which is a standardised approach to performing procedures in order to reduce the risk of a healthcare acquired infection (HCAI).
• Whilst the service reported no incidents, we could not be assured whether this was because there were no incidents or there was a failure to report.
• The policy for reporting notifiable incidents to the CQC, referred to out of date legal regulations.
• We found some out of date consumable items, some of these were on the resuscitation trolley.
• The arrangement for managing medicines was not robust; some medicines were out of date and some medicines were left unattended. There was no process in place for monitoring the use of prescriptions and no protocols for antibiotics prescribing. Temperatures of the medicine fridge were above the recommended range.
• Records were not kept securely and poor quality photocopied documentation was used.
• The safeguarding policy lacked detail, did not reflect current best practice and the service was unsure as to what level of mandatory safeguarding training was provided.
• There were no robust processes in place to respond to and reduce patients’ risk. The use of an early warning score (EWS) to identify a deteriorating patient was inconsistent, although patients were monitored regularly following surgery.
• Although there was as procedure in place for a patient to be transferred to the local acute NHS hospital if their condition deteriorated there was no formal written agreement between the local NHS acute trust to admit patients, as required by the Independent Healthcare Advisory Services (2015).
• Documentation that reflected The World Health Organisation (WHO) Surgical Safety checklist (2008) was under development, but this had not yet been implemented.
• There was no clear guidance as to which risk assessments and screening were required preoperatively for patients. There was no clear guidance for assessing patients for their risk of developing venous thromboembolism (VTE), or identifying those patients who required screening for MRSA. There was no consistent assessment of the psychological well-being of patients prior to theatre.
• There was no robust system in place to ensure information was communicated with the patient’s GP.
• The service had not started to collect data for the submission to the Private Healthcare Information Network (PHIN), nor did it collect and report on Q-PROMs for all patients. Q-PROMS are patient report outcome measures, which describe the level of patient satisfaction with certain operations and is a recommendation from the Royal College of Surgeons (RCS)
• The hospital had not made any arrangements to ensure that surgical cosmetic procedures were coded in accordance with SNOMED_CT. SNOMED_CT uses standardised codes to describe cosmetic surgical procedures, which can be used across electronic patient record systems.
• There was no system to electronically record details of implants, which could be easily accessible in the case of a product recall.
• Many policies and risk assessments did not reflect up-to-date practice or current guidance.
• Disclosure and barring service (DBS) checks had not been completed for one staff member and one doctor did not have evidence of indemnity insurance in their file.
• Written information for patients relating to having an anaesthetic was not current.
• All staff had attended mandatory training.
• Staffing levels and skill mix were planned, implemented and reviewed to ensure there were sufficient numbers of staff.
• Staff spoke very positively about the leadership of the service; staff felt engaged and enjoyed working at the hospital.
• We saw effective communication and partnership working between the different professional groups.
• There was a clear patient exclusion criteria to identify those patients who would not be suitable for surgery.
• The service reported no never events, no incidents, no wound infections and no VTE incidents.
• We observed an operation, where the anaesthetist responded appropriately and efficiently to a potential risk
• Without exception, patients told us they were treated with kindness and compassion by all staff. Patients spoke positively about the service and the care they had received. Patients were fully involved in their care and staff explained procedures to them.
• Patient’s pain was managed effectively and staff provided emotional support.
• Patients were able to self-refer to the hospital and the service arranged appointment and surgery times to meet the needs of the individual patient.
• There was a robust procedure in place to ensure patients were able to give a fully informed consent.
• The service had a clear complaints policy, and the service continually sought feedback from all patients regarding the care they had received.

There were areas where the provider needs to make improvements.

Importantly, the provider must:

• Ensure systems and processes are in place to ensure people are protected from healthcare associated infections.
• Ensure policy for reporting notifiable incidents in line with the CQC (Registration) Regulations 2009.
• Ensure systems and processes are in place so that all incidents are reported and investigated.
• Ensure learning from incidents is used to evaluate and improve practice.
• Ensure processes are in place to guarantee that consumables are in date.
• Ensure there is a safe process for the management of medicines.
• Ensure safe storage of patients’ records.
• Ensure that safeguarding policy is in line with current legislation and that staff receive mandatory safeguarding training at the correct level.
• Finalise and implement new documentation that reflects the World Health Organisation (WHO) Surgical Safety Checklist.
• Ensure there is a formal written agreement with the local NHS acute trust for the transfer of a deteriorating patient.
• Improve compliance with the use of the early warning system (EWS).
• Ensure there is clear guidance for which risk assessments and screening are required preoperatively for patients.
• Ensure all policies reflect up-to-date guidance and that care provided reflects best practice.
• Ensure the recommendations from the Review of the Regulation of Cosmetic Interventions (2013) are being met.
• Ensure there are robust governance arrangements in place that include ensuring risk assessments reflect best practice and that there is a robust system for staff checks.
• Ensure patient information is up-to-date and patients are signposted to information resources to help make an informed decision about their procedure as recommended by the Royal College of Surgeons Standards (2016).

In addition the provider should:

• Consider providing clear guidance describing which operations need to be performed in the theatre with specialist ventilation.
• Consider improving the quality of the documents used for patients’ records.
• Consider the procedure for the nurse lead pre-operative clinic.
• Consider developing a training needs analysis for all staff.
• Consider how they meet the requirements of the Duty of Candour regulation.

Professor Sir Mike Richards

Chief Inspector of Hospitals

During our visit to Alexandra Private Hospital we spoke with two patients who had recently had cosmetic surgery at the hospital. Both of the patients spoke very highly of the care and treatment they had received, commenting that the nursing staff were very attentive to their needs. We also saw positive feedback from patients who had received dental treatment at the hospital.

Care and treatment was planned and delivered in a way that ensured people’s safety and welfare and there were arrangements in place to deal with foreseeable emergencies. Patients were being cared for in a clean, hygienic environment.

The provider worked in co-operation with others to ensure the safety and welfare of patients.

The provider had an effective system in place to regularly assess and monitor the quality of service that people receive. This included a number of quarterly audits used to monitor infection control, patient records and the results of patient questionnaires.

Alexandra Private Hospital's dental surgery had recently begun to take enquiries and hold consultations with patients about proposed treatments. The provider planned to begin providing dental treatment for people in April 2013.

We saw that consent was sought before any procedure was undertaken and that people were given appropriate information and support before giving their agreement to proceed with treatment. One person told us, "I was fully informed about every aspect of my treatment. I was told that I will need to give my consent when I'm sure, and before anything is done."

We looked at records, policies and procedures and found that appropriate arrangements were in place for the planning and delivering people's treatment and care. We spoke with people who had attended a consultation and found that they were happy with the information and care they had received. One person we spoke with said, "I found everyone very professional indeed. Certainly the best dentist I have been to."

We saw that a complaints procedure was made available to anyone who received care

We looked at equipment found that it was appropriate for the treatments being planned. We also found that systems were in place to ensure that equipment and medical devices were safe for use.

We saw that procedures ensured that appropriately qualified and experienced staff were employed to provide people's treatment and care at the dental surgery.