Bupa Cromwell Hospital is operated by Medical Services International Limited. The hospital was purpose built in 1981 and acquired by Bupa in 2008. Facilities includes 114 beds and four suites, five operating theatres, a seven -bedded level three critical care unit, MRI and X-ray, outpatient and diagnostic facilities.
In the reporting period July 2015 to June 2016, the hospital treated 155,735 patients. The majority of these (89%) were outpatient attendance, 11,166 (7%) were inpatient and 6,689 (4%) were day-case discharges.
Of these, 49% of the patients were UK insurance, 23% self pay, 17% Embassy patients and 1% were NHS patients.
We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 29 November 2016 – 1 December 2016, along with an unannounced visit to the hospital on 6 December 2016.
The Bupa Cromwell Hospital provides
We inspected all services provided at this hospital during our visit.
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.
Services we rate
Overall we rated The Bupa Cromwell Hospital as requires improvement because,
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There were issues with the environment and infection control prevention (IPC). In the dialysis day unit, there was no sluice directly attached to the ward. During the course of inspection, we observed bags of dirty linen being left in the entrance of the unit, to be collected by domestic staff. In the neurology ward’s sluice, linen bags were found incorrectly disposed of in the green recycling bin. In both the dialysis unit and the oncology wards, there was no documentation of daily or weekly cleaning of equipment, although we did see evidence that green ‘I am clean’ stickers were in use. Some patients that we spoke to felt that the cleaning standards had dropped since their last visit. In patients’ en-suite bathrooms, bars of soap were provided for hand washing.
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Not all portable equipment we checked had been recently serviced and labelled to indicate the next review date. We found seven pieces of equipment in the dialysis day unit that had stickers on them that exceeded review date, as well as one item on the neurology ward, two items in the general/cardiac ward and two pieces of equipment in the iodine suites. The hospital later provided us with records to indicate that service reviews had taken place on most of these items of equipment, but stickers were used inconsistently at the time of the inspection to indicate that they were safe to use.
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In the dialysis day unit, we found 11 boxes of disposable equipment that had expired. Senior staff told us that some of this was waiting to be returned, and some was for teaching purposes. However, these boxes were not segregated or marked to indicate as such.
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Nursing staff did not always check medication fridge temperatures daily, such as on the general/cardiology ward and oncology ward. Appropriate actions were not always taken when these were out of normal range. On some of the wards, room temperatures had consistently exceeded recommended levels of 25 degrees centigrade. No actions had been taken even though nursing staff told us that they had contacted building services.
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Across the hospital, 90% of all staff had completed basic life support training and 90% had completed intermediate life support training. However, there was no effective system in place to ensure that competencies of staff in the dialysis day unit were checked on a regular basis.
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Bank and agency usage of both nurses and healthcare assistants (HCAs) in the hospital inpatient departments was higher than the average of other independent acute hospitals that CQC holds this type of data for (July 2015 to June 2016). In the same period, bank and agency usage varied between 25.9% to 44.7% for nurses, and 29.4% to 56.4% for HCAs. However, staff told us that they tried to use the same bank and agency staff where possible, so that they were familiar with local protocols and procedures. The hospital provided evidence that indicated that regular members of bank staff were usually used in most cases, rather than agency staff who were unfamiliar with the unit.
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Although guidance stated that RMOs should only cover a 48-hour shift at the hospital in an emergency, we found several instances of this in rotas dated between August and December 2016 for medical and paediatric services.
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There was one paediatric resuscitation trolley shared between two theatres, which was not safe.
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The hospital operational policy said shifts should be coordinated to ensure there was always an EPLS trained nurse on duty in paediatrics. However, the paediatric service was not always achieving this.
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The service had closed its paediatric intensive care unit the week before our inspection. However, there were no formal plans in place on what to do in the event of a deteriorating patient.
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Starfish ward and the paediatric outpatient department were not always meeting the Royal College of Nursing's guidelines with regards to children’s nurses being on each shift.
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Some incidents indicated that the WHO surgical checklist was not embedded into day-to-day practice.
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The hospital participated in six national audits. The medical service submitted data to the British Cardiovascular Intervention Society (BCIS) but did not participate in any other national audits related to medical care or end of life care. This was due to the fact that the hospital provided a limited number of services to a comparatively smaller patient base than NHS hospitals. This meant that it was limited in terms of the national audits that it could submit data to. The hospital had started to submit data to Private Healthcare Information Network (PHIN) in order to perform benchmarking functions, although this project remained in the early stages. There was a plan for local audit for the coming year, although many had not yet taken place at time of inspection.
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The angiography department was not undertaking the recommended amount of percutaneous coronary interventions (PCIs) per year. However, discussions were underway with high volume NHS Institutions to explore 'job-share' partnerships that would allow non-medical staff (nurses/physiologists) to gain further experience. The hospital also hoped to encourage NHS Waiting list initiative programmes to increase the volume of procedures performed in the hospital.
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Many training records for staff competencies within medicine services were inconsistent and unclear, with no assured mechanism in place for senior staff to ensure staff in the dialysis day unit were up to date with required training.
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The palliative care clinical nurse specialist (CNS) had no formal supervision structure.
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We found issues with the environment in the endoscopy department. Although only one patient underwent a procedure at a time, we found several patients present in the unit in various stages of preparation or recovery on the days of the inspection. We found that the waiting and recovery areas were cramped, with no effective means of separation as curtains were not routinely drawn across bays. Relatives could sit with patients but were usually discouraged due to the lack of space, as patients could spend up to three hours in recovery. On the day of inspection, a patient in a gown was waiting in the corridor post-procedure as there was only one changing room.
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There was a lack of space in some other areas of the hospital, too. The dialysis day unit had no waiting room. Patients were called from the downstairs reception. Staff told us that limited space in the unit meant that relatives often had to wait in reception due to limited space by the beds or chairs in the facility.
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In many areas of the hospital, patient information leaflets were not standardly available in languages other than English, although the hospital told us that any information could be readily translated as required.
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Some staff described the environment as very corporate and business focused. They felt more could be done to support both patients and staff, making them the centre of care.
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We were not assured the service had taken appropriate provisions to ensure they could care for the deteriorating patient before closing the paediatric intensive care unit.
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We were not assured risks were being appropriately managed. There were a number of risks we identified within medicine, surgery and paediatric services, which were not on the services risk register and the critical care risk register had not timeline or action plan.
However, we also found good practice in relation to surgery:
Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with two requirement notices that affected children and young people core services. Details are at the end of the report.
Professor Sir Mike Richards
Chief Inspector of Hospitals