Patients’ needs were assessed and care and treatment provided compassionately and safely. Typical comments we received from patients included: “the staff make clear they are working with you to make sure you are happy” and “I have received exceptional care.” Patients were satisfied with the meals provided. For example, one patient said, “the meals are very tasty and very nutritional with lots of vegetables.” Another patient told us, “it always arrives hot, it’s well-presented and there are good-sized portions.” There was a wide choice of meals and special diets were catered for. Patients’ nutritional needs were assessed to ensure they were protected against the risks of inadequate nutrition and hydration.

The hospital was well-led and there were systems in place to assess and monitor the quality of service that patients received and ensure care was provided safely and effectively. Patients told us they felt able to raise any concerns or worries they had and were confident they would be listened to by staff. Complaints were responded to effectively. Most equipment used on the ward and in theatres was checked and serviced regularly to ensure that it was functioning effectively and fit for purpose.

We spoke with three patients about the care and treatment they had received in the hospital. Everyone was positive about their experience. For example, one patient told us their admission had been “fantastic, from start to finish.” Another said, “it has been a delight to be here.” Staff were described as “very attentive”. Everyone confirmed that consent had been discussed with them before they underwent a surgical procedure. Treatment was discussed in detail and the risks and benefits of the procedure explained in detail.

There were effective systems in place to reduce the risk and spread of infection. A patient told us, “the cleanliness is very good. The nurses always use soap, the cleaners are very good and I can’t fault the place.” Equipment used in the care and treatment of patients was regularly serviced and maintained.

Staff were suitably qualified and received appropriate training to enable them to provide safe care and treatment. Patients had confidence in the knowledge and skills of staff. One patient told us, “the staff are absolutely fantastic.” Another said, “the instant I arrived it was good and welcoming”. Appropriate and accurate records were kept by the service and they were promptly located when requested.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

We spoke to a number of patients in the hospital and they told us they were happy with the care they received. Staff were described as ‘lovely’, ‘friendly’ and ‘warm’. Patients were given enough information to help them make decisions about their treatment. The privacy and dignity of patients was respected by staff, particularly whilst providing personal care. The overall service was described as ‘excellent’ by one patient, which was typical of the comments we received.

BMI The Cavell Hospital is an acute independent hospital in Enfield that provides outpatient, day care and inpatient services. It has 27 registered beds. The hospital is owned and managed by BMI Healthcare Limited.

The hospital comprises two main buildings; the original hospital (Cavell building) dates from 1976 and accommodates the consulting rooms, physiotherapy department and endoscopy suite. The newer main building (Trent building) dates from 1994 and houses the imaging suite, ward and theatres.

The hospital provides a range of services including surgical procedures, outpatient consultations and diagnostic imaging services. Services are provided to both insured and self-pay private patients and to NHS patients.

We inspected the hospital on 21-23 June 2016 as part of our independent hospital inspection programme. The inspection was conducted using the CQC’s comprehensive inspection methodology. It was a routine planned inspection. We inspected the following three core services at the hospital: medicine, surgery and outpatients and diagnostic imaging.

Prior to the inspection, the hospital's senior management team took the decision to stop treating children, with the exception of over 16s who were on an adult care pathway.

Facts and Data

The hospital had 27 beds which were used for inpatients and day-case patients. All rooms had en suite facilities. Twenty-six percent of the patients seen at the hospital in 2015 were NHS funded, and the remaining 74% were insured and self-pay patients.

BMI The Cavell provided an outpatient service for various specialties. This included, but was not limited to, gynaecology, cardiology, dermatology, oncology, ophthalmology and orthopaedics. Outpatient services were provided from 13 consulting rooms, in addition to a nurse treatment room, an imaging suite and a physiotherapy department which also provided post-operative treatments and rehabilitation. There were over 27,500 first (46%) and follow-up (54%) outpatient appointments booked at the hospital from January to December 2015.

The hospital had two operating theatres, one with laminar flow. There were 5,070 visits to the theatre between January 2015 and December 2015. The five most common surgical procedures performed were:

• Hysteroscopy including biopsy, dilatation, curettage and polypectomy (495)

• Image-guided injection(s) into joint(s) (311)

• Phacoemulsification of lens with implant -unilateral (212)

• Therapeutic endoscopic operations on uterus (208)

• Multiple arthroscopic op on knee (inc meniscectomy) (179).

Medical care included chemotherapy and endoscopy. The chemotherapy service was situated on the Trent Ward, in four designated single accommodation rooms. The endoscopy services included gastroscopy, colonoscopy, oesophageal dilatation and flexible cystoscopy. The dedicated endoscopy unit was situated in the Cavell building separate to the main theatre located within the Trent building.

There were 153 doctors with practising privileges at the hospital and 79.6 whole time equivalent employed staff.

Patients were admitted and treated under the direct care of a consultant and medical care was supported 24 hours a day by an onsite resident medical officer (RMO) Patients were cared for and supported by registered nurses, health care assistants and allied health professionals such as physiotherapists and pharmacists who were employed by the hospital.

The hospital Accountable Officer for Controlled Drugs is the Executive Director.

BMI The Cavell Hospital was last inspected by the CQC in February 2014.

We inspected and reported on the following three core services:

• Medical care

• Surgery

• Outpatients and diagnostic imaging

We rated the hospital as Requires Improvement overall.

Our key findings were as follows:

Are services safe at this hospital?

We rated safe as requires improvement for all three core services because:

The environment did not always comply with national guidelines relating to infection prevention and control. Rooms used for chemotherapy were used by other patients on occasions increasing the risk of immuno-compromised patients getting an infection. There was a known issue with the temperature control system for theatres, however, the hospital had plans to resolve this. Funding was approved for replacement of the DX units, and temporary chiller units were being installed in the interim to ensure the temperature of the theatre environment was controlled, as there was a minimum 12 week order time for the replacement units.

Patient records were not always complete. For example, some outpatient records did not include care plans. Staff were unable to access records for chemotherapy patients outside of daytime hospital hours. Some records had poor legibility.

There were systems for reporting incidents, however, these were not always implemented.

The hospital pharmacy did not hold an up to date list of authorised signatories for staff working in theatres and on the ward.

There was no formal anaesthetic on-call rota, the hospital relied on an informal agreement that anaesthetists in charge of the list were responsible for patient up to 48 hours post-operatively.

However,

Patients were appropriately monitored for signs of deterioration and patient records we reviewed had evidence of National Early Warning Scores (NEWS) being completed. Staff knew what actions to take if NEWS was elevated.

The hospital monitored and reported hospital acquired infections. In the year prior to inspection there had been no incidents reported of hospital acquired infections such as MRSA or C Difficile and the rate of surgical site infection was within the expected range.

Staffing levels and skill mix were planned using an acuity tool and there were enough staff on duty on every shift to ensure patients received safe care.

Medicines were managed safely and stored appropriately. Clinical waste including medicines, sharps objects and chemotherapy waste, was disposed of safely.

Staff demonstrated an understanding of their responsibilities in relation to safeguarding and knew how to raise concerns.

Are services effective at this hospital?

We rated effective as requires improvement overall because:

For medical care, there was limited evidence of how practice was audited against current evidence-based guidance, standards and best practice. There was no regular physician representative on the medical advisory committee (MAC) or at the clinical governance committee. The hospital did not audit use of National Institutes for Care Excellence (NICE) guidelines and other evidence based practice in the outpatient department. However, the hospital participated in national audits in endoscopy, which showed good outcomes within an expected range.

Staff appraisal rates did not meet the hospital target for some staff groups. There were gaps in clinical supervision of the Resident Medical Officers (RMO).

There were limited opportunities for multidisciplinary team (MDT) working in the outpatient department and there were no formal arrangements to ensure MDT discussion of medical patients except oncology patients.

Staff in outpatients did not always have the complete information they needed before providing care and treatment. Systems to manage and share care records were uncoordinated.

Documentation around 'do not attempt resuscitation' (DNACPR) was not in line with the organisation’s policy and discussions with family members were not always recorded.

However,

The MAC chair worked closely with the senior management team and the clinical governance committee to ensure that the hospital was completing and acting on audits.

Surgical care and treatment was provided in line with national guidelines and most outcomes for patients were within the expected range.

We found evidence of good MDT working in surgery, and for oncology patients.

There was evidence of good pain management. Consent to care and treatment was obtained in line with legislation and guidance. Staff showed a good understanding of the consent process including assessing capacity for consent.

Staff were competent and had the necessary skills and knowledge to provide safe care and treatment.

Are services caring at this hospital?

We rated caring as good for all three core services because:

Nursing, medical and other healthcare professionals were caring and patients were positive about their care and experiences.

Patients were treated with dignity and respect. They were kept informed about their care and treatment and felt supported by staff.

Staff encouraged patients to complete the NHS Friends and Family Test (FFT) and we saw the FFT scores for the period of July to December 2015 were consistently between 98% and 100% which was better than the national average.

Are services responsive at this hospital?

We rated responsive as good overall because:

The hospital consistently performed better than the England average for independent acute hospitals for referral to treatment (RTT) pathways in 2015.

The hospital had an admission policy to ensure only patients whose needs could be met were admitted. Senior nurses worked closely with consultants to ensure the policy was being adhered to.

Staff completed dementia awareness training and ensured patients who lived with dementia or who had learning disability were seen quickly to minimise the possibility of distress to them.

Complaints were acknowledged, investigated and responded to in a timely manner, and were discussed at the complaints review forum.

However,

The hospital did not monitor diagnostic imaging and procedures waiting times.

Information on how to make a complaint was not always clearly displayed.

Are services well led at this hospital?

We rated well led as requires improvement overall because:

Within the year prior to inspection there had been senior management vacancies which meant managers had not been able to effectively implement the arrangements for governance and performance management. For example, there had been no permanent Head of Clinical Services for 16 months.

There was a lack of effective medical leadership and medical care was not regularly represented at the MAC.

Although there was an audit calendar in place, some audits were not regularly completed.

However,

Staff were aware of the vision and strategy of the hospital. For example, they told us of plans for a new high dependency unit.

There was a team of suitably qualified heads of department with managerial responsibilities.

The MAC reviewed all new consultants before practising privileges were approved; this included their scope of practice. The hospital had an effective system in place to ensure that practising privileges were updated with the relevant information.

Staff told us the senior management team were visible, approachable and supportive. We observed that staff worked well as a team.

There were also areas of poor practice where the provider needs to make improvements.

Importantly, the provider must:

Review the governance arrangements to ensure structures, processes and systems of accountability for the medical service are clearly set out, understood and effective.

Ensure the chemotherapy service is complying with national guidance for monitoring and reporting neutropenic sepsis and other patient outcomes.

Keep an up to date list of authorised signatories of staff that can order medicines in the hospital pharmacy, so that staff who undertake this responsibility can be identified.

Ensure that when risks are identified that they are recorded, reviewed regularly and timely action is taken to mitigate them.

Ensure patient records are complete and up to date, including care plans, nursing assessments and do not attempt cardiopulmonary resuscitation orders.

Ensure all consultants who are transporting and storing medical records are registered with the Information Commissioners Office.

Improve staff attendance at mandatory training.

Ensure all relevant staff can access records in the chemotherapy service out of hours.

Ensure all staff have an annual appraisal.

In addition the provider should:

Ensure the medical service benchmarks its performance so it can monitor and improve its service. This includes ensuring the audit schedule and calendar are followed.

Review the multidisciplinary arrangements for all medical patients and ensure they meet national requirements.

Establish a formal service level agreement for the emergency transfer of unwell patients for treatment in local NHS facilities.

Ensure all staff comply with infection prevention and control practices such as being bare below the elbow and decontaminating hands between patient contacts.

Ensure all clinical areas comply with the requirements of Health Building Notice (HBN) 00-09: Infection control in the built environment.

Ensure patients have access to information on how to make a complaint as well as information on how to access external support.

Ensure all staff involved in care and treatment have access to full information related to patients' treatment to support decision-making.

Audit the use of National Institutes for Care Excellence (NICE) guidelines to ensure these are followed when providing treatment.

Enable multidisciplinary involvement in outpatients to ensure treatment options are considered in full and knowledge is shared.

Monitor key performance indicators, such as whether patients with suspected cancer were seen promptly, diagnostic imaging and procedures waiting times, and the time it took to issue an appointment letter from receipt of referral, to ensure quality monitoring and continuous improvement.

Professor Sir Mike Richards

Chief Inspector of Hospitals