30 May 2019
During an inspection looking at part of the service
BMI The Park Hospital is operated by BMI Healthcare Limited. The hospital has 66 beds. Facilities include five operating theatres, a five-bed level two care unit, and X-ray, outpatient and diagnostic facilities.
The hospital provides surgery, medical care and outpatients and diagnostic imaging. We inspected surgery.
We carried out an unannounced focused inspection of BMI The Park Hospital on 30 May 2019, in response to concerning information we had received in relation to the management of the regulated activities at this location.
During this inspection we inspected using our focussed inspection methodology. We inspected the key questions of safe and well-led only. We did not provide an overall or key question rating at this inspection, as we did not carry out a comprehensive inspection.
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.
Our findings were:
- The service provided mandatory training in key skills to all staff and made sure everyone completed it. Staff knew how to access systems to allow them to complete their training
- Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it.
- The service controlled most infection risks well. The service used systems to identify and prevent surgical site infections. Staff used equipment and control measures to protect patients, themselves and others from infection. They kept equipment and the premises visibly clean.
- The design, maintenance and use of facilities, premises and equipment kept people safe. Staff were trained to use equipment. Staff managed clinical waste well.
- Staff completed and updated risk assessments for each patient and removed or minimised risks. Staff identified and quickly acted upon patients at risk of deterioration.
- The service had enough nursing and support staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment.
- The service had enough medical staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment.
- Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date, stored securely and easily available to all staff providing care.
- The service used systems and processes to safely prescribe, administer, record and store medicines.
- The service managed patient safety incidents well. Staff recognised and reported incidents and near misses. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support. Managers ensured that actions from patient safety alerts were implemented and monitored.
- Leaders had the integrity, skills and abilities to run the service. They were visible and approachable in the service for patients and staff. They supported staff to develop their skills and take on more senior roles.
- The hospital had a vision for what it wanted to achieve and a set of values, to turn it into action. The vision and values were patient focused.
- Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service had an open culture where staff could raise concerns without fear.
- Leaders operated effective governance processes throughout the service. Staff at all levels were clear about their roles and accountabilities.
- Leaders and teams used systems to manage performance effectively. They identified and escalated relevant risks and issues and identified actions to reduce their impact. They had plans to cope with unexpected events.
- Staff could find the data they needed, in easily accessible formats, to understand performance, make decisions and improvements.
- Leaders and staff actively and openly engaged with patients and staff to plan and manage services. They collaborated with partner organisations to help improve services for patients.
- All staff were committed to continually learning and improving services.
However:
- Having a carpet in the corridor did not conform with Health Building Note 00-09: Infection control in the built environment.
- In two treatment rooms, both for clinical use, taps were aligned to run directly into the drain aperture. This meant contamination from the waste outlet could be mobilised and did not conform with Health Building Note 00-10 Part C.
- We found inconsistences with daily temperature checks and found there was a total of 11 days between 1 March 2019 and 30 May 2019 where there had been no fridge temperature checks.
Following this inspection, we told the provider that it should make improvements, even though a regulation had not been breached, to help the service improve. Details are at the end of the report.
Nigel Acheson