Archived: The Hospital Group - Dolan Park Hospital

Updated 10 November 2015

The Hospital Medical Group Holdings Limited, also known as The Hospital Group, has been established for over 20 years. Dolan Park Hospital commenced operating in 2006 and provides specialist private hospital care to patients from all over the UK. It is a purpose built hospital that offers a comprehensive range of cosmetic surgery and weight loss surgery options, including breast enlargement, liposuction and gastric band.

The hospital has specialist General Medical Council registered cosmetic surgeons. They are able to offer operations seven days a week, 52 weeks of the year at a time that suits the patient.

The Registered Manager has been registered for the hospital since 1 October 2010.

We inspected the surgical and outpatient service provided at Dolan Park Hospital, including dentistry.

The hospital had an onsite inspection in December 2013, where the hospital was compliant with the following standards: Consent to care and treatment; Care and welfare of people who use services; Cleanliness and infection control; Safety, availability and suitability of equipment. However, were non-compliant with the standard: Assessing and monitoring the quality of service provision. We then found the hospital complaint with this standard in September 2014.

Updated 10 November 2015

The Hospital Medical Group Holdings Limited, also known as The Hospital Group, has been established for over 20 years. Dolan Park Hospital commenced operating in 2006 and provides specialist private hospital care to patients from all over the UK. It is a purpose built hospital that offers a comprehensive range of cosmetic surgery and weight loss surgery options, including breast enlargement, liposuction and gastric band.

The hospital has 30 private rooms, five consulting rooms and four operating theatres. The hospital also has private twin room facilities for friends or relations who are having procedures together. In total the hospital had 31 beds.

We carried out a comprehensive announced inspection of Dolan Park Hospital on 19 and 20 May 2015 and an unannounced inspection on 28 May 2015, as part of our second wave of independent healthcare inspections. This was a pilot inspection and was undertaken to further develop the methodology we will use to inspect all independent healthcare providers.

We have not published a rating for this service. CQC does not currently have a legal duty to award ratings for those hospitals that provide solely or mainly cosmetic surgery services.

We inspected the following two core services:

• Surgery
• Outpatients department.

The hospital also hosts the head office functions of The Hospital Group which were not directly inspected.

Our key findings were as follows:

Are services safe?

By safe, we mean that people are protected from abuse and avoidable harm.

• Staff were encouraged to report incidents and there was an incident reporting system in place that staff were aware of. However, we found examples of incidents that had not been reported.

• Feedback from incidents was varied and we were not reassured that staff learnt from all reported incidents.
• There were clear strategies for minimising the risk to patients. Staff demonstrated a good understanding of the assessed risks and how to avoid these. The hospital did not have the facilities to manage patients who required critical care support. A transfer policy was in place in the event a critically ill patients needing to be transferred to a NHS hospital via an emergency ambulance for higher level care. The hospital had a screening system in place to ensure that patients were assessed pre-operatively to ensure their suitability for surgery and used an early warning system to alert them should a patient’s condition deteriorate in the post-operative phase. We noted that there had been five cases of unplanned transfers to an NHS hospital in the past twelve month reporting period.
• Dolan Park Hospital did not have a formal service level agreement with an ambulance company or NHS hospital for transfer of patients. Staff told us that if there was a requirement to transfer a patient West Midlands Ambulance Service provided support and the patient was accepted into The Alexandra Hospital in Redditch. This meant that there was a risk patient treatment and care planning could be delayed because patients would need to go via an emergency department.
• As part of planned urgent contingency care, senior staff told us that they had an informal agreement in for the transfer of bariatric patients to a local NHS hospital which provided bariatric surgery.
• Staff did not know when this agreement would be formalised.
• Most staff were not aware of the new duty of candour regulations (where people who use services are told when they are affected by something that goes wrong, given an apology and informed of any actions taken as a result).
• Surgical procedures were carried out by a team of consultant surgeons and anaesthetists registered with the General Medical Council (GMC) who were mainly employed by other organisations (usually in the NHS) in substantive posts and had practising privileges (the right to practice in a hospital) with Dolan Park Hospital.
• The three dentists worked with practising privileges. Their General Dental Council registration, Disclosure and Barring Services (DBS) check, hepatitis B status and professional indemnity cover were checked prior to them being able to work at Dolan Park Hospital.
• The RMO provided out-of-hours medical cover 24 hours a day and staff said that consultants could be contacted out of hours.
• No system was in place to analyse arrangements for planning and monitoring the number of staff and mix of staff needed to meet patients’ needs in theatre. There was general agreement that recruitment and retention of nursing staff was seen as a priority by the provider.
• Between June and December 2014, there was between 23 to 63% nursing agency usage across the hospital, with the highest user being theatres using up to 40%.
• The records showed that there were no vacancies within the outpatient department or in patient wards.
• Staff were aware of their role and responsibilities with regards to safeguarding and the majority of staff were up to date with adult’s safeguarding training. However, staff including the hospital leads for safeguarding were unsure what level training had been provided.
• Staff and managers told us they were up to date with their mandatory training. However, training records examined did not always support this.
• Despite procedures being in place to check equipment we found equipment in surgery that had passed service dates, including all three ward defibrillators. This put patient safety at risk. There were no up to date records to demonstrate that a robust system was in place to maintain equipment on the wards.
• Medications in the outpatients and dental department were stored inside a locked cupboard and/or fridge as required. However, medicines in surgery were not stored safely and securely to prevent theft, damage or misuse, including Controlled Drugs.
• Services were generally clean and equipment was cleaned between patients; however we noted that some areas in patient rooms and the reception area that did not appear to have been cleaned.
• There were adequate hand-washing facilities and soap dispensers, hand hygiene foam and paper towels for staff and patients to use. However, staff did not always use hand sanitiser gel before entering the theatre area and we found clinical waste guidance was not always adhered to in dental services.
• Patient records were up to date, risk assessments had been completed and documented for patients undergoing surgery, including the World Health Organisation (WHO) surgical safety checklists.

Are services effective?

By effective, we mean that people’s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence.

• Surgical and outpatient care delivered was evidence based and in line with nationally agreed policies and practice.
• We saw assessments of people’s needs were comprehensive and included the assessment of pain.
• There was limited evidence that audits were being undertaken in all services. There was limited recording of patient reported outcomes.
• There was evidence of good multidisciplinary working across the hospital.
• Services could be provided over seven days to reflect demand.
• The role of the Medical Advisor Committee (MAC) included ensuring that consultants were skilled, competent and experienced to perform the treatments undertaken.
• There was a process in place for checking General Medical Council and Nursing and Midwifery Council registration, as well as other professional registrations.
• There was a lack of formal supervision and competency arrangements for nursing staff. Staff had yearly appraisals. However, none of the dental nursing staff had received an appraisal in the last 12 months.
• Staff were confident about seeking consent from patients. However, staff had a varied understanding of the mental capacity assessment process and not all staff reported receiving training on the Mental Capacity Act 2005.
• We found that consent forms in dental services were not always completed. Staff told us that patients were given a copy of their consent form on receiving their care and treatment. However, we observed that outpatients were not always given a copy of their new consent form regarding additional treatment received. This meant that patients could not confirm accurately what further treatment they had received to support any queries they may have.
• Unplanned re-admissions between January and December 2014 was 1%, which was ‘tending towards worse than expected’ compared to the other independent acute hospitals we hold this type of data for. An audit of the re-admissions had been undertaken but the analysis of the audit would not be available until the end of June 2015.

Are services caring at this hospital/service

By caring we mean that staff involve and treat patients with compassion, dignity and respect.

• Patients were treated with dignity and respect.
• We observed good interaction between patients and staff. Staff explained procedures and gave appropriate information to patients to help them to understand and be involved in decisions concerning their treatment. Initial consultations and pre-admissions assessments were thorough and included consideration of patients’ emotional well-being.
• Most patients spoke positively about the care provided by staff. Patients we spoke with commended staff saying they were friendly and very attentive.
• The outpatients department had a patient questionnaire to gain feedback about the service but the response rate was less than 1% of all 6905 outpatients discharged from Dolan Park Hospital during 2013/14. Those that had replied commented that staff were “lovely” and “very attentive.”
• In most cases patients privacy was protected, however we found that in some clinic rooms were not soundproofed and conversations could be overheard and the patient comment book held personal details, which could affect the privacy of patients.

Are services responsive at this hospital/service

By responsive we mean that services are organised so they meet people’s needs.

• The patient care coordinators supported patients throughout their time with Dolan Park Hospital and care was flexed to meet the needs of patients. The patients we spoke told us that access to the hospital was good and did not have any concerns in relation to their admission, waiting times or discharge arrangements.
• Patients had an initial consultation at various clinics throughout the country to determine whether they were suitable for surgery, followed by a pre-operative assessment. When a patient agreed to go ahead with surgery, staff were able to plan for the patient in advance so they did not experience delays in their treatment when admitted to the hospital.
• Information about services provided at the hospital was provided in a way patients understood and appreciated. Staff told us that should a patient have communication problems they were able to address their individual needs. However, not all staff were aware that the hospital had access to an interpreting service.
• Staff said they were able to accommodate people’s religious needs both pre and post operatively. They said they could contact the local community that offered support for example, church, mosque, temple or synagogue.
• There was information on the process for making complaints for patients. The hospital had received between 35 complaints between January and May 2015, with 21 related to inpatient care (51%). Seven complaints had got to the appeal stage. Ninety-eight percent of complaints met the 2 working day target for acknowledgement; and 37% met the 20 working day target for an initial response. Average open to close time for complaints and appeals in 2015 was 32 working days. This had improved form 72 working days in 2014 but the complaints lead acknowledge that further work was to be done to improve the process.
• Staff received feedback about complaints and we saw some learning from complaints across the hospital.

Are services well led at this hospital/service

By well-led, we mean that the leadership, management and governance of the organisation, assure the delivery of high-quality person-centred care, supports learning and innovation, and promotes an open and fair culture.

• Staff said that the hospital’s values were discussed during their appraisals. However, staff were not familiar with the vision for services.
• Staff spoke positively about the high quality care and services they provided for patients and were proud to work for the hospital. Staff reported that all their managers, including the registered manager were visible. Staff told us that senior management were supportive and front line staff felt able to raise concerns.
• There was a clear governance structure in place, with committees such as the governance and risk team feeding into the medical advisory committee (MAC) and hospital management team. The governance and risk committee was also responsible for clinical governance in the hospital. There was no dental representative at governance and risk meetings or on the Medical Advisory Committee, this had not been identified by the groups as a risk.
• The governance and risk committee met quarterly, however one of the clinicians had been on sick leave and the meetings had been deferred until June 2015.
• We were not assured that the senior management team had sufficient control of or oversight of risk within the hospital. The hospital had a risk register in place, however it only had two risks identified. We identified risks that should have been on the register, the senior management team also identified risks that should have been on the risk register during our inspection. The senior management team told us that they would be reviewing the risk register to ensure it reflected the service.
• The senior management team told us that the CQC inspection process had already made a positive impact for staff. For example, the appraisal rates had increased across the hospital and were at 76% in May 2015, compared to 39% at the end of 2014. We were told this was because the team had ‘nagged managers’ to complete appraisals for our visit. However, we could not be reassured the sustainability of staff receiving annual appraisals.
• The senior management team recognised that the recording of mandatory training within the hospital was an issue and that the data did not always correlate with the training delivered and received by staff. They also acknowledged that there was no escalation to the governance and risk committee regarding poor mandatory training data. This meant that staff were at risk of not receiving appropriate training because the provider did not have accurate records. They assured us that a plan was in place to improve the recording of staff training.
• There was limited evidence that audits were being undertaken in all services to measure the quality of the service. Of the audits that were carried out, we noted that these did not always adequately identify potential risks to patients. For example resuscitation equipment not being serviced. This meant that we could not be assured that risks could be adequately assessed, monitored and mitigated against.
• We saw evidence of practising privileges of anaesthetists and consultant surgeons being reviewed. We saw practising privileges were discussed at the MAC.
• Senior managers attended a weekly meeting, however, there were no formal minutes taken. This meant that establishing a clear audit trial to ensure all actions had been completed was difficult.
• Obtaining feedback from patients was not consistent across the service. Staff told us they were aware of the lack of feedback and were looking at ways of increasing patient involvement.
• The remit of managerial responsibilities for dental services were unclear.
• The hospital became subject to a new regulation (Regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014) on 27 November 2014. This regulation says that individuals in authority (board members) in organisations that deliver care are responsible for the overall quality and safety of that care. The regulation is about ensuring that board members are fit and proper to carry out that role.
• The hospital was preparing to meet the requirements related to fit and proper persons. A policy was in draft form and we found evidence that a new senior management member had been subject to the fit and proper persons test before their recruitment had been completed.

We saw several areas of outstanding practice including:

• Excellent multidisciplinary working across the hospital, to ensure that patients received appropriate and timely care.
• A caring and responsive approach to patients after their surgery.

However, there were also areas of poor practice where the provider needs to make improvements.

Importantly, the provider must:

• Ensure that all equipment used by the service is clean and properly maintained.
• Ensure there are up to date records to demonstrate that a robust system is in place to maintain equipment.
• Ensure the disposal of teeth (including those containing amalgam fillings) follows the waste segregation regulation Health Technical Memorandum 01-07.
• Ensure staff understand the principles and codes of conduct associated with the Mental Capacity Act 2005.
• Ensure consent forms are accurately completed.
• Ensure effective systems are in place to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users, including ensuring that the risk register is reflective of service risks.
• Ensure that staff mandatory training records are accurate.
• Ensure that dental services have a clear leadership structure and has representation at governance and risk meetings and/or on the Medical Advisory Committee.
• Ensure all medicines are managed and stored safely and securely to prevent theft, damage or misuse, including Controlled Drugs.
• Ensure the provider has a service level agreement in place to ensure timely care planning can take place to ensure the health, safety and welfare of the service users that require transfer to a NHS hospital.

In addition the provider should:

• Ensure all incidents are recorded and staff receive feedback and learn from incidents.
• Ensure staff are aware of the new duty of candour regulations (where people who use services are told when they are affected by something that goes wrong, given an apology and informed of any actions taken as a result).
• Ensure a system is in place to analyse arrangements for planning and monitoring the number of staff and mix of staff needed to meet patients’ needs.
• Ensure all staff use hand sanitiser gel before entering the theatre area.
• Ensure that staff receive formal supervision, appraisals and appropriate competencies.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Updated 10 November 2015

Medical and nursing staffing levels met the needs of patients using the service and there was good emergency cover. There were good procedures and processes for the management of medicines within the service. However, systems were not in place to monitor all medications in dental services.

There was a culture of incident reporting. However, staff said they did not receive feedback from incidents reported. The environment and equipment were visibly clean and staff followed the provider’s policy on infection control but did not always follow national clinical waste guidance.

Treatment and care was provided in accordance with evidence-based national guidelines. There was good practice in monitoring and management of aftercare. This included wound management. Multidisciplinary working was evident. We found there were inconsistencies with regard to the training data. Staff reported their training was up to date but this was not supported by human resources records. Consultant-led, seven-day services had been embedded into the service.

Staff confirmed they had not received training on the Mental Capacity Act 2005. However, they were confident about seeking consent from patients. Staff were able to explain benefits and risks in a way that patients understood. We found that consent forms in dental services were not always completed and patients were not always given a copy of their new consent form regarding additional treatment received.

Patients told us that staff treated them in a caring way and were kept informed and involved in the treatment received. We saw patients being treated with dignity and respect.

The outpatient services were responsive to people’s needs. Most patients were seen on time and patients said the service was quick and efficient. There were information leaflets available in the reception area which provided patients with information on the services available. An interpreting service was available when required. There was no clear system in the outpatients department for staff to learn effectively from complaints received by the provider.

Although staff were aware of the hospital’s mission and values they were unable to identify any actions/developments to improve the service. However staff said they could openly discuss any issues with their colleagues and felt this was positive in making improvements to the service.

Not all risks within outpatient and dental services had been identified and highlighted on the risk register with action taken to mitigate the risk. There was no dental representative at governance and risk meetings or on the Medical Advisory Committee.

There was a lack of audits to measure performance in the outpatient department. Obtaining patient feedback was variable across the service.

Updated 10 November 2015

Potential risks to patients due to the resuscitation trolleys and hoist not being serviced in accordance with the manufacturers guidelines. Systems, processes and standard operating procedures were not always reliable or appropriate to keep patients safe. Monitoring whether safety systems were implemented was not robust.

Incidents were investigated to assist learning and improve care. Patient areas were clean, apart from a small number of dusty areas and infection prevention and control procedures were adhered to by the majority of staff. The staffing levels and skills mix was sufficient to meet patients’ needs and staff assessed and responded to patient risks.

Patients received care according to national guidelines such as National Institute for Health and Clinical Excellence (NICE) and Royal College of Surgeons guidelines. Patients received pain relief suitable to them in a timely manner.

There was evidence of out-of-hours services, when needed. Staff were varied in their insight into the mental capacity assessment process to protect patients’ rights under the Mental Capacity Act 2005 (MCA). There was a lack of awareness by nursing staff regarding the MCA and why they would need to know this information.

Nursing and medical staff were caring with patients treating them with dignity and respect and patients were positive about their care and experiences. They received information in a way that they could understand, including the risks and benefits of potential surgery. Patients’ privacy and confidentiality was respected at all times.

Surgery services were responsive to meet the needs of the patients using the service. The admission, treatment and discharge pathways were well organised and functioned in a responsive manner to changes. Staff worked in a flexible manner to meet the theatre schedule. Information about the hospitals complaint procedure was available for patients and their relatives. The service reviewed and acted on information about the quality of care that it received from complaints.

The arrangements for governance did not always operate effectively. We could not be assured that risks could be adequately assessed, monitored and mitigated against.

The hospital recognised the importance of patient and staff feedback and there were mechanisms to hear and respond to patient views. Staff were encouraged and knew how to identify risks and make suggestions for improvement.