Alexandra Private Hospital

Updated 17 August 2023

The Alexandra Private Hospital is operated by Alexandra Health Care Limited. It is a private hospital located in Chesterfield. The hospital facilities include 21 beds which are split between 2 floors; however, the service mainly utilise the beds that are located on the first floor. There are also 2 theatres on the lower ground floor, 1 of which is mainly used by a third party for their procedures. There are also consultation rooms on the ground floor where patients receive their pre-operative consultations.

The hospital provides cosmetic surgery for self-funding patients. The hospital also offers cosmetic dental procedures. We did not inspect these services.

The service currently has 3 registered managers, 2 of which have been in this position since the service registered with the CQC in October 2010.

The Alexandra Private Hospital has been inspected by CQC 6 times since they were registered. The most recent inspection was a comprehensive inspection on 11 October 2022. Following this inspection, the service was rated inadequate overall.

The service is registered to provide the following regulated activities:

• Diagnostic and screening procedures.

• Surgical procedures.

• Treatment of disease, disorder, or injury.

At our previous inspections, we found the following breaches of regulation:

• The service must ensure they support patients to give informed consent for revision or return surgery following the original procedures. (Regulation 11 (1): Need for Consent).
• The service must ensure electrical items are safety tested and safe to use. (Regulation 15 (1c, e): Premises and equipment).
• The service must ensure governance processes are effective to enable sufficient oversight of performance, quality, and risk. (Regulation 17(1, 2): Good Governance).
• The service must ensure all patient and staff information is stored as per General Data Protection Regulations. (Regulation 17(2d): Good Governance).
• The service must ensure patients are able to access appropriate and timely clinical advice following surgical procedures. (Regulation 12 (2b, c, i): Safe Care and Treatment).
• The service must ensure they have oversight of staff training and competency levels. (Regulation 18 (2a): Staffing).
• The service must ensure they are reporting outcome measures to external agencies in line with legal requirements. (Regulation 17 (1,2a): Good Governance).

Updated 17 August 2023

Alexandra Private Hospital is an independent hospital which provides cosmetic surgery to self-funding patients.

We carried out an unannounced focused inspection to follow up on concerns we found at our last inspection when we rated the cosmetic surgery core service overall as inadequate.

We only inspected the key questions of safe, effective, and well led as this is where the breaches of regulation were found for our previous inspection, published on 7 December 2022. We did not inspect the safe, effective, and well led key questions in full; instead, we focused on the key lines of enquiry where serious concerns had been previously identified to see if improvement had been made.

We collated enough evidence to rate both safe and well led key questions.

We did not rate the effective key question as we did not collect sufficient evidence to rate this key question.

We did not inspect the service for the caring and responsive key questions during this inspection.

Our rating of this location stayed the same. We rated it as inadequate because:

• The service did not have oversight if staff were compliant with mandatory training and competence requirements for their roles. Staff did not have adequate training on how to recognise and report abuse. The service did not control infection risk well. Equipment and premises were not visibly clean. Staff used out-of-date products to wash their hands. Staff did not monitor the effectiveness of infection prevention and control measures. The design, maintenance and use of facilities, premises and equipment were not sufficient to keep patients safe. Staff did not always complete risk assessments for each patient. Staff did not identify or quickly act upon patients at risk of deterioration. The service could not evidence that patients knew who to contact to discuss complications or concerns following their surgery. Staff did not keep detailed records of patients’ care and treatment. Records were not comprehensively and consistently completed and did not follow best practice guidance. The service did not consistently use systems and processes to safely manage medicines.
• The service did not monitor the effectiveness of care and treatment. Therefore, they did not use findings to make required improvements to the service to ensure patients received safe care.
• Leaders did not have the necessary skills and abilities to run the service in relation to governance and managing performance and risk. They did not understand or effectively manage all the priorities and issues the service faced. They were not always visible and approachable in the service for patients and staff. They did not always support staff to develop their skills. Leaders did not operate effective governance processes, throughout the service and with partner organisations. Some staff were not clear about their roles and accountabilities and some non-clinical staff were asked to work outside of their competency level. Staff did not have regular opportunities to meet, for example at team meetings, to discuss and learn from the performance of the service. Leaders and teams did not use systems to manage performance effectively. They did not identify or escalate relevant risks and issues and therefore were unable to identify actions to reduce their impact. The service did not collect enough data in easily accessible formats, to understand performance, make decisions and improvements. The information systems at the service did not always support the delivery of the business.

However:

• Staff managed clinical waste well.
• Controlled drugs were safely secured.
• The service had a vision for what it wanted to achieve.

Updated 16 June 2023