At The time of the inspection on 16 December 2013, BMI Fawkham Manor Hospital was closed to elective inpatients because major refurbishment work was underway in the main theatre department. We found that there were no inpatients as they had all been discharged on Sunday 15th December. We therefore spent time talking with people who were attending for outpatient appointments, physiotherapy sessions and ambulatory care treatment.

We approached 15 patients to seek their views on the service. 6 people were new to the service and were attending for their first appointment; they were not able to comment about any treatment as they had yet to receive inpatient care. 8 patients were attending outpatient appointments as a follow-up, having received inpatient care previously at the hospital.

Patients spoke positively about the care and treatment they received at BMI Fawkham Manor. Comments included "The staff could not have done enough...They were so kind", Couldn't top it, fortunate to come here as an NHS patient" and "I cannot fault anything... they have been brilliant."

We found that people's care needs were assessed and care and treatment was planned and delivered in line with their individual treatment plan.

Signs with information about infection control were displayed for staff and visitors. There were adequate hand washing facilities and alcohol hand rubs for use by staff and visitors. The areas we visited were clean and well maintained.

We found that patients were surveyed about the care they received. This meant the Provider was seeking the views of people to help improve the quality of the service they provided.

There was evidence that learning from incidents / investigations took place and appropriate changes were implemented.

Everyone told us that they had signed the relevant consent form and that their treatment plan had been discussed. This showed us that before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes.

The care pathways seen were linked to the specific procedure carried out and demonstrated a holistic approach to care. This meant that people experienced care, treatment and support that met their needs and protected their rights.

The training records seen showed us that staff had received their safeguarding training and those staff spoken with demonstrated a clear understanding of their role in identifying abuse. This showed us that people who used the service 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.

Staff reported that they received additional training to assist them in meeting the health care needs of the people who used this service. This showed us that people were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard.

We noted that monthly integrated clinical effectiveness meetings were held and that actions had been taken to address any variations in the care provided to people. This demonstrated to us that the provider had an effective system to regularly assess and monitor the quality of service that people received.

Fawkham Manor Hospital is operated by BMI Healthcare Limited. The hospital has 30 beds. Facilities include two operating theatres, one of which has laminar flow, seven consulting rooms, X-ray, outpatient and diagnostic facilities.

Fawkham Manor Hospital provides surgery, medical care and outpatients and diagnostic imaging core services. This inspection was a focused, follow-up visit, and we inspected the surgical core service.

We previously inspected the hospital in August and November 2016 as part of our national programme to inspect and rate all independent hospitals. The 2016 inspection was brought forward because of information received, which raised concerns about the standard of governance at the location. Following our 2016 inspection, we rated the surgery core service as inadequate and outpatients and diagnostic imaging as requiring improvement. This gave the hospital an overall rating of inadequate, and we issued four requirement notices where the provider was not meeting the legal requirements of the Health and Social Care Act (Regulated Activities) Regulations 2014.

A serious incident occurred on 8 February 2017 that demonstrated to us that the safety monitoring systems in place at BMI Fawkham Manor Hospital were not effective. In March 2017 we issued a warning notice because the provider was not compliant with Regulation 12, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. There was a time scale of one week with a date set for the provider to be compliant by 20 March 2017. The provider demonstrated compliance with the warning notice, although not within the required timeframe.

During this inspection, we reviewed surgical services only. We carried out the announced part of the inspection on 10 and 11 April 2017, along with an unannounced visit to the hospital on 5 April 2017. To give the hospital’s overall rating, we have included the rating for outpatients and diagnostic imaging services in the ratings grid, which was taken from our previous inspection in 2016.

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. On this inspection, we did not inspect the caring domain as we found this to be good on our 2016 inspection and we had no information to suggest that this position had changed.

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

We rated surgery as requires improvement. This was because:

• Medical Advisory Committee (MAC) meeting minutes showed that not all the findings and learning from root cause analysis (RCA) investigations following serious incidents were shared and discussed at MAC meetings. This meant that not all consultants might have learnt lessons from serious incidents to help prevent recurrences.

• There was a hospital risk register, which staff reviewed at monthly clinical governance committee meetings as a standard item. However, the MAC chair was not aware of any items on the risk register. When asked, the MAC chair said they felt there “were risks to the hospital, but none now”. This meant the MAC was not aware of key risks to the service and demonstrated weaknesses in governance.

• Medicine fridge temperatures in theatres were not consistently recorded daily to ensure medicines remained safe to use.

• Not all waste bins were labelled indicating the type of waste to be disposed. Bulk storage bins for clinical waste were adjacent to the patient car park and unsecured. This was not in line with Health Technical Memorandum 07-01, which states bulk storage areas should be away from routes used by the public, be totally enclosed and secure, and kept locked when not in use.

• Three out of seven patient records we reviewed did not always show evidence of consultant or medical review when this was required. For example, we did not find evidence of a pre or post operation review by a consultant. This is not in line with the Royal College of Surgeons (RCS) (2014); good surgical practice, which recommends “surgeons must ensure that accurate, comprehensive, legible and contemporaneous records are maintained of all interactions with patients”.

• Following concerns around poor staff compliance with the World Health Organisation (WHO) “Five Steps to Safer Surgery” checklist identified at our 2016 inspection, we found staff engagement with the WHO checklist remained inconsistent on our unannounced visit on 5 April 2017. However, we saw improvements in the way staff carried out the WHO checklist during our announced visit on 11 April 2017.

• The hospital provided subsequent assurances that improvements with the WHO checklist were being maintained. We saw an observational audit carried out by an external theatre manager following our inspection. This showed 100% compliance with all areas of the WHO checklist. The auditor commented that the WHO checklist flowed much more routinely and that it was “well ingrained”. The executive team encouraged staff to report any non-compliance with the WHO checklist on the hospital’s incident reporting system. The interim director of clinical services told us staff had reported two incidents of consultant non-compliance.

• We also saw a letter drafted by the MAC chair to the consultant body on 4 May 2017. This made explicit the requirement for staff to report breaches of the WHO checklist process as incidents on the electronic reporting system. We also saw an addendum to the hospital’s action plan, which provided details of the action being taken in respect of consultants who failed to engage with the WHO checklist process and best theatre practice. This included a meeting with the hospital director and the MAC chair that would be recorded in consultant files. Further or persistent failure to follow policy might result in loss of practicing privileges. This demonstrated the hospital was taking action to ensure continuing compliance with the WHO checklist and the requirements of Regulation 12 (1) (2) (b), Safe care and treatment, of the Health and Social Care Act (Regulated Activities) Regulations 2014.

• However, internal hospital staff carrying out WHO checklist audits did not always have audit training. This meant the hospital might not have had assurances staff carried out WHO checklist audits correctly.

• Patients had signed four out of six consent forms we reviewed on the day of surgery. This was not in line with guidance from the RCS Good Surgical Practice 2014, which states staff should “obtain the patient’s consent prior to surgery and ensure that the patient has sufficient time and information to make an informed decision”.

• Patient reportable outcome measures (PROMs) data showed the hospital’s patient outcomes following groin hernia repair and primary knee replacement were worse than the England averages between April 2015 and March 2016.

• The hospital did not have a robust system in place to assess the competence and record the use of external staff as surgical first assistants.

• The service cancelled 30 operations on the day of surgery, for a non-clinical reason within the last 12 months. The hospital offered only a third of these patients with another appointment within 28 days of their cancelled appointment. This was in not in line with the NHS Constitution pledge.

• The service did not always use complaints as an opportunity to learn lessons and improve.

• Staff demonstrated limited knowledge around the additional support required for patients with learning disabilities.

• There was no step-free wheelchair access to baths or showers in the ward.

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 five requirement notices that affected the surgical core service. Details are at the end of the report.

Professor Edward Baker

Deputy Chief Inspector of Hospitals (South)