We spoke with 21 patients, six friends and relatives and 30 members of staff including members of the Executive team, department managers/directors, consultants, surgeons, nurses, health care assistants, porters, administrative, human resource and clinical governance staff.

Although most of the patients we spoke with were happy with their care and treatment and had their consent obtained, there were not adequate arrangements for foreseeable emergencies, and patient safety and welfare were not always ensured.

A few patients were concerned about the way they were treated by staff and we found that the provider had not taken sufficient steps to ensure patients were safeguarded from abuse.

Although most of the patients we spoke with were happy with the environment and found it clean and tidy, the provider had not put in place appropriate measures to ensure patients were protected against the risk of infection and parts of the premises were not fit for purpose.

Patients were not protected against the risks of the unsafe use or management of medicines.

The provider did not always have sufficient or maintained equipment.

Most patients were happy with the numbers and the quality of staff that cared for them, however we found there were not always sufficient, trained or professionally developed staff.

There were not appropriate arrangements in place to monitor the quality of the service.

The inspection team included a hospital theatre specialist. We inspected the emergency care centre, orthopaedic unit, critical care unit, oncology and the operating theatre suite. We spoke with people who use the service, staff and managers.

People using the service told us that, "the service is fantastic", "I'm always treated with dignity and respect" and "Everything is clearly explained". The staff told us how they meet people's individual needs by carrying out risk assessment and having personalised care plans for each person. This was confirmed by the records we viewed.

We saw evidence that people were protected from the risks of abuse because the provider had up to date policies in place and staff had attended relevant training. The staff were able to identify different types of abuse and explain how they would deal with any issues.

The provider had regular audits to ensure that infection control procedures were being followed by staff. People using the service told us, "Staff always wash their hand when they come into my room".

There were daily and weekly checks of the equipment that was being used in the hospital. The maintenance and servicing of this equipment was carried out according to the guidelines issued by the manufacturer.

A recent patient satisfaction survey had been carried out in which 95.5% of respondents stated that they were satisfied with the overall service they received.

Patients told us they were able to discuss treatment options in detail with their consultant and their views were taken account of. They told us they received information packs about the hospital and the services provided prior to their admission.

They described staff as “wonderful and willing to help”.

Patient responses in the hospital satisfaction survey showed a high level of satisfaction with facilities, staff, treatment and care.

BMI The Clementine Churchill hospital is an acute independent hospital that provides outpatient, day care and inpatient services. The hospital is owned and managed by BMI Healthcare Limited.

A range of services such as physiotherapy and medical imaging are available on site. The hospital offers a range of surgical procedures and as well as rapid access to assessment and investigation. The hospital also provides level three critical care facilities.

Services are available to people with private or corporate health insurance or to those paying for one off treatment. Fixed prices, agreed in advance are available. The hospital also offers services to NHS patients on behalf of the NHS through local contractual arrangements.

We carried out a comprehensive inspection of BMI The Clementine Churchill Hospital on 29 - 31 July 2015 (announced) and 11 August 2015 (unannounced). The inspection reviewed how the hospital provided outpatient services (including to children), medical care, surgical services, critical care and minor injuries service as these were the five core services provided by the hospital from the eight that that are usually inspected by the Care Quality Commission (CQC) as part of its approach to hospital inspection.

Prior to the inspection, the hospital's senior management team took the decision to stop treating and admitting children under the age of 16 other than in an outpatient setting.

At a previous CQC inspection, in January 2014, we found concerns with a number of areas including governance, safeguarding, medicines management, the physical environment, equipment, staffing levels, infection control, staff support, auditing, and records.

Our key findings in July and August 2015 were as follows:

Are services safe?

• There was an appropriate system for reporting and learning from incidents with a paper based reporting system that was logged electronically. Although staff were able to demonstrate that there was a robust investigation of incidents, this was not always fully evidenced due to the template that BMI used. Risks were mostly recorded but some had been fully mitigated but not archived.

• The hospital performed well in relation to preventing patients coming to harm with a low rate of falls and pressure ulcers in particular.

• Medicines were well managed. Regular audits were carried out although they did not include medicine reconciliation. However, there were some concerns with legibility of medicine administration records. 

• There were some concerns with equipment checks, particularly in outpatients, the intensive care unit (ITU) and surgical wards where mostly portable appliance tests were not up to date.

• The environment in phlebotomy was not fit for purpose with a lack of space meaning there was a risk of safety related incidents.

• A new endoscopy unit had been opened in recent weeks that had been built with the assistant of a JAG accreditor.

• Infection prevention and control (IPC) was poor in the medicine ward and ITU. There was poor compliance of hand hygiene and wearing personal protective equipment on the medical ward and poor cleanliness in the ITU on our announced visit although this had improved on our unannounced visit. The hospital currently had a temporary lead IPC nurse and was due to appoint a permanent one. Many areas of the hospital were still carpeted.

• Staff were aware of their responsibilities regarding safeguarding vulnerable adults and children and knew who to contact if they had any concerns.

• Mandatory training was up to date in most areas although we received a lack of detail as to whether some subjects had better compliance rates than others.

• Patients who deteriorated were appropriately monitored and responded to.

• There were insufficient permanent nurses employed although staffing levels mostly met the acuity and dependency of patients. There was a high reliance on agency staff in some areas although recruitment drives were taking place that had some recent success and there was a robust checking and induction of agency nurses.

• The hospital contracted four resident medical officers (RMO)s who rotated mostly two at a time on a weekly basis 24/7. to cover the wards. Additionally there is 24 hour RMO cover in ITU, and a further RMO to cover ECC while it is open. However there were concerns that one RMO covered the ITU and crash calls at the same time.

• Although there were 462 consultants who had practising privileges and either were in attendance for their patients or had cover if there was a deterioration, the emergency care centre was not meeting national guidance for seniority of doctors on shift.

• The hospital used paper records for patient care, however there was varying quality of completion of medical records with poor completion on the medical and surgical wards but satisfactory records in the emergency care centre, ITU and theatres.

Are services effective?

• National guidance was mostly followed. However some of both BMI and hospital policies and procedures required updating, particularly with regard to the removal of children's inpatient and emergency services.

• Where we could benchmark the hospital nationally for patient outcomes, the hospital either met or was better than the national average. However, we were provided with little information to benchmark the hospital either to other BMIs or independent hospitals.

• There was a robust induction and orientation process for bank and agency staff with checklists they had to complete before they started a shift. These staff also had to evidence their competencies such as giving intravenous therapy (IV). Staff were also developed including support for external courses. However there was a lack of ITU nurses that were critical care trained.
• Medical and surgical staff were required to have practising privileges to work at the hospital and these were appropriately checked and maintained by the Medical Advisory Committee as necessary. We saw evidence of consultants being removed or suspended if they did not meet the practising privileges criteria. However there were a number of consultants that had practising privileges that had not conducted a clinical activity at the hospital in the last year.
• Although there was mostly an understanding of the Mental Capacity Act and Deprivation of Liberty Safeguards, some of the patient records for these were not complete.   
• Internal multidisciplinary working was in place in most departments. Although there was a lack of formal external working, when working with other organisations was required, there were no concerns with how this operated.
• Some of the records regarding nutrition were not complete. Most patients were happy with the food they received but there had been a high amount of complaints regarding food quality in recent months. The hospital had started taking action to address this.

Are services caring

• Mostly all the patients we spoke with gave a positive experience about their care. They reported staff were caring and maintained their privacy and dignity.

• Patients and their families reported being involved in their care including being informed about potential costs in most departments.
• Staff offered support to patients and families who wanted or required it including having difficult conversations.

Are services responsive?

• Flow through the hospital was well managed including discharge although targets for discharging were not always in place and there was some improvement still to make with pre-operative assessment.

• There was some specific support given for individual patient needs such as those living with dementia or those that required translation services but support for other patient groups, including children, was limited.

• The hospital met and exceeded targets responding to patient needs such as referral to treatment and waiting time in the emergency care centre.

• Complaints were mainly well-managed and learnt from across the hospital.

Are services well-led?

• Most services were well-led with visible leaders and local visions and strategies. However ITU leaders had limited visibility and forward planning.

• Governance and performance monitoring was in place across most services. All services were involved in briefing sessions, called Comm Cells which were effective in all areas other than ITU. ITU also lacked auditing and improvements were not made from audits undertaken.

• Although the senior management team were risk aware and actions were in place to address areas of risk, there were some areas that had not been actioned or identified such as the phlebotomy environment.

• The culture of the services was mostly positive and staff felt engaged in how the hospital was to improve. However some local staff survey results were not very positive and there was some discontent with some consultants due to recent management decisions on practising privileges when incidents had occurred.

Was the hospital well-led?

• The Executive Director (and registered manager) had been in post around 18 months and most of the senior management team (SMT) had been in post a year or less. However staff described that they had mostly been a positive effect on the hospital.

• The SMT had brought in 'Comm Cells' which were briefing sessions that occurred at all levels, from SMT, to ward and department levels with a heads of department meeting, which all staff were invited to. These went through a number of aspects including activity, performance, patient safety and incidents. Each acted as a filter for other Comm Cells so everyone in the hospital knew what was happening both in their own department and across the hospital.

• The SMT had recently taken a decision to reduce the amount of services they provided to children, removing inpatient services, and emergency care provision. This had been taken quickly and policies and procedures had not been updated to reflect this but evidence showed if they had carried on the inpatient provision, it would have been a safety risk.

• There was a focus on governance across the hospital and this had led to improvements with learning and actions from incidents to improve practice. Auditing had also improved with a range of audits and monitoring taking place in each of the services provided.

• There was a clear nursing strategy directed by the Director of Nursing focusing on the 6 Cs and catering for patient needs such as those living with dementia.

• The SMT were mostly aware of the areas they needed to improve including infection control, catering and staffing levels. The hospital was risk aware although there were improvements needed with the appropriateness of items on the risk register and the BMI template used for root cause analysis.

• A strong hospital vision was in place with key performance metrics that were continually monitored and reviewed which had both commercial and clinical performance at the forefront, although some benchmarking was lacking. The hospital was aspirational but knew there were many improvements needed to achieve their targets.

We saw several areas of outstanding practice including:

• The hospital had a good system of raising issues and concerns across the hospital in a timely manner through its ‘Comm Cells’ meetings and display boards. This meant that hospital staff could access up-to-date information about the hospitals performance and any concerns or changes in practice in a timely manner. This had been embedded throughout the hospital and staff spoke positively of how much communication had improved across the entire site.
• The emergency care centre (ECC) had introduced reflections about a year ago and a means to support staff when there had been a difficult shift and there was no one to talk to about it. Staff are encouraged to write up what’s happened, their feelings, what action they have taken and what difference they have made. We saw good examples which were open and honest for example when a patient has fallen, where there had been staff shortages, concerns about a patient who deteriorated post discharge, and when there had been a busy shift. It gave staff an opportunity to express how they felt. Staff reported that this promoted discussion within the team and allowed the centre manager to support and guide them.

However, there were also areas of poor practice where the provider needs to make improvements.

Importantly, the provider must:

• Ensure the ITU environment and equipment is clean and the hospital meets infection prevention and control guidance such as ensuring staff have clean hands and wear personal protective equipment when necessary.
• Take action to ensure the phlebotomy administrative office and storage room is suitable for the purpose for which it is being used for and ensure floors in the area are clear of boxes and consumables to allow for appropriate cleaning.

In addition the provider should:

• Review all policies relating to children to denote the service now being provided at the hospital and provide staff with a clear policy and procedures in relation to children using outpatient services.
• Ensure that there is additional nursing cover available in the ECC when staff from the centre attend a cardiac arrest.
• Review the statement of purpose to reflect that post discharge reviews and all medical admissions are assessed and transfers from NHS and other providers are admitted via the ECC.
• Take action to ensure all equipment is safe to use.
• Ensure that the guidance from the College of Emergency Medicine is followed which states that a ‘service should have a minimum of ST4 or equivalent working in the department when the service is open’.
• Ensure patient records are complete and up to date including care plans and nursing assessments.
• Ensure the ITU audits and benchmarks its performance so it can monitor and improve its service.
• Ensure there are sufficient staff available to cover any additional admissions from the ECC.

Professor Sir Mike Richards

Chief Inspector of Hospitals