Archived: BMI The Cavell Hospital

Updated 4 June 2019

Our inspection team was led by a CQC lead inspector.The team included a  a GP specialist advisor.

Enfield Community Gynaecology offers consultant led gynaecological consultations from facilities located at the BMI Cavell Hospital, Enfield. The service is commissioned by the local Clinical Commissioning Group and patients access the service via referral from their GP.

The service provides a clinic every Wednesday from The Cavell Hospital between 9am-5pm and occasional clinics on Mondays. A monthly Saturday clinic is also provided at Green Lanes Surgery, Winchmore Hill, a separately registered location. The Green Lanes Surgery location was not visited as part of this inspection.

The service sees 200-500 patients per month across the two sites and has a staffing team consisting of eight gynaecologist specialists, two doctors (who are also the service’s directors), three health care assistants, a service manager and three administrative staff. We were advised that the service treats approximately 80% of all gynaecological referrals in the local CCG area. The service does not provide care and treatment to patients under 16 years of age.

We carried out an inspection of Enfield Community Gynaecology on 8 May 2019. The inspection team comprised a CQC inspector and a GP specialist advisor. Before visiting, we reviewed a range of information we hold about the practice. During our visit we:

• Spoke with the clinical director, service manager, one of the doctors and members of the administration team.
• Reviewed a sample of the personal care or treatment records of patients.
• Reviewed comment cards where patients and members of the public shared their views and experiences of the service.
• Reviewed protocols, policies and procedures.

How we inspected this service

To get to the heart of patients’ experiences of care and treatment, we always ask the following five questions:

• Is it safe?
• Is it effective?
• Is it caring?
• Is it responsive to people’s needs?
• Is it well-led?

These questions therefore formed the framework for the areas we looked at during the inspection.

Updated 4 June 2019

This service is rated as Good overall. The service was previously inspected in March 2018.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We carried out an announced comprehensive inspection at BMI The Cavell Hospital as part of our ratings inspection programme for Independent Health Providers.

Enfield Community Gynaecology offers consultant led gynaecological consultations from facilities located at the BMI Cavell Hospital, Enfield. The service is commissioned by the local Clinical Commissioning Group and patients access the service via their GP.

The Service Manager is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Fifteen people provided feedback about the service.

Our key findings were:

• The service had systems to manage risk so that safety incidents were less likely to happen.
• The service routinely reviewed the effectiveness and appropriateness of the care it provided. Clinical staff ensured that care and treatment was delivered according to evidence-based guidelines.
• Clinical staff were qualified and had the skills, experience and knowledge to deliver effective care and treatment.
• The practice was actively engaged in activities to monitor and improve quality and outcomes.
• Facilities and premises were appropriate for the service being delivered.
• All 15 of the CQC comment cards we received were positive, with key themes being that reception staff were kind, clinical staff were knowledgeable, communicative and compassionate; and that the overall environment was clean.
• There was a proactive approach to understanding the needs of the local community and towards delivering care in a way that met these needs.
• The culture of the service encouraged candour, openness and honesty.
• People could access appointments and services in a way and at a time that suited them.
• We saw examples of inclusive and effective leadership.
• Governance arrangements facilitated the delivery of safe and high quality clinical care.

We saw the following outstanding practice:

• The service employed clinical staff who worked across several CCG areas and was conscious this provided an opportunity to identify and share good practice and learning. The service was able to show examples of when it had used this capacity to benefit patients, including developing guided clinical assement forms to support GPs making fertility referrals in a way which helped minimise avoidable disappointment and distress to patients who did not meet certain criteria, a process which allowed its clinicians to refer patients directly to hysteroscopy from the triaging stage without being required to attend assessment consultations which were not clinically necessary and sharing learning between CCGs relating to a conservative approach to the management of asymptomatic polyps. In each case, the service or it’s clinical director developed the improvement in one CCG area and shared this in other CCG areas.

Dr Rosie Benneyworth BM BS BMedSci MRCGP 

​Chief Inspector of Primary Medical Services and Integrated Care