Clinical Diagnostic Services at BMI Hendon Hospital is operated by Clinical Diagnostic Services (CDS) LLP. CDS operates ultrasound services across two locations including Harley Street and Hendon. The BMI Hendon Hospital location is the registered address of CDS.

The service at BMI Hendon Hospital consists of one scanning and consultation room with an ultrasound machine, a reception area and an administrative office. The service is located within an acute independent hospital.

The service offers advanced ultrasound scanning and transvaginal scanning covering several specialties including gynaecology and women’s healthcare, fertility managements and In Vitro Fertilisation (IVF), early pregnancy assessments and prenatal screening.

The service provides ultrasound services to patients aged 17 and above. A small proportion of patients were under 17 years old.

We inspected diagnostic imaging services at Clinical Diagnostic Service, BMI Hendon Hospital location using our comprehensive inspection methodology. We carried an unannounced visit to the service on 7 November 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.

We rated Clinical Diagnostic Services at BMI Hendon Hospital as requires improvement overall.

• The service did not provide mandatory training in key skills to staff.
• There were no comprehensive systems to protect vulnerable people from avoidable harm. Most staff had not completed training on how to recognise and report abuse.
• There was no infection prevention and control policy or auditing of infection control practice. No hand hygiene or cleaning audits had been undertaken.
• We were not assured that staff recognised patient safety incidents. There had been no incident reported for this location in the last 12 months and there was no incident policy in place.
• The service did not have comprehensive systems to identify, review and mitigate risks.
• The service had no internal audit program to monitor its processes and identify where action should be taken. There were no policies to address key patient safety issues. In addition, the service did not have a system to review and update policies.
• Although staff informed us the service held regular meetings, minutes from meetings were not always recorded.

However:

• Staff kept detailed records of patients’ care and treatment. There were safe systems for sharing diagnostic results. Imaging reports were encrypted and sent by secure email.

• Patients were cared for by experienced staff who maintained appropriate registration with professional bodies.

• The service monitored the quality of its ultrasound services through an appraisal system from referring clinicians. Feedback about the quality of reporting was positive and there were quick report turnaround times.

• Feedback for the service inspected was positive. Staff respected confidentiality, dignity and privacy of patients.

• Services were developed to meet the needs of patients. Staff were aware of people’s individual needs and considered these when providing care.

• There was a positive culture in the unit and members of staff said they could raise concerns with the leadership team. The service had implemented a number of innovative services and developed these to meet patient’s needs.

Dr Nigel Acheson

Deputy Chief Inspector of Hospitals (London and South)

Patients we spoke with understood their treatment and choices available to them. They told us that clinical staff were communicative during the scan and that results were discussed immediately afterwards; typically followed by a written report within 24 hours.

Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. We selected 3 patient records. We saw that care was continually assessed and documented. For example, each record contained a signed referral form from the patient’s GP or consultant.

Patients told us they felt safe using the service and had confidence in staff. Typical comments included ”I’ve never felt uncomfortable”,”I’ve never had a reason to be concerned” and “I feel very comfortable here.”

The provider had worked continuously to maintain and improve high standards of care. We looked at provider records and saw that the Clinical Director routinely advised ultrasound manufacturers on machine specifications and lectured at international ultrasonic imaging conferences. We were told that these interactions enabled him to learn about, and share knowledge of, latest clinical and technical developments.

Patients who used the service were asked for their views about their care and treatment. Approximately 15 patient surveys had been received since the relocation of the service in September 2013. These were positive, with the service typically being described as “excellent“ and “very good.“