The Saxon Clinic

We carried out an announced inspection visit of BMI The Saxon Clinic on 26 and 27 January 2016 and an unannounced inspection on 9 February 2016.

Our key findings were as follows:

Overall the hospital required improvement. However, caring was rated good in all the four core services we inspected, medical care (chemotherapy), surgery, children and young people and outpatients, as was effective and responsive in surgery.

Are services safe at this hospital?

• Systems and processes were not always reliable and appropriate to keep people safe. There was an infection prevention and control programme in place, led by an infection prevention and control nurse and supported by a consultant microbiologist. National guidance and specifications on cleanliness, hygiene and infection prevention and control was not always complied with.
• There was no audit tool or audits of patients who developed neutropenic sepsis; however the hospital reported to us that no patients had developed neutropenic sepsis during the previous 12 months.
• The rooms used for chemotherapy, were often used for other services if needed. This meant those patients who may have been immuno- compromised were put at risk of getting a hospital acquired infection.
• There was a policy in place and staff were aware of the impact of duty of candour legislation. We saw that this had been applied where appropriate.
• The director of nursing and the lead nurse for children and young people’s services were trained to the appropriate level with regards to safeguarding. Staff were aware of their responsibilities to ensure patients, both adults and children, were protected from abuse and avoidable harm.
• Incidents were reported appropriately. There was some learning, particularly amongst the more senior staff.

• There was a system in place to recognise the deteriorating patient. Appropriate triggers were in place to ensure patients, who had deteriorated were treated according to their clinical needs.
• There was transfer agreement in place with the local trust to ensure that both adults and children could be transferred swiftly to a higher level of care, should this be required.
• There was an RMO on site 24 hours a day and although they had good general skills, and said they were confident, not all of them had specific qualifications to care for both patients undergoing chemotherapy or children and young people.
• Handovers between consultants, RMOs and nursing staff were effective.

Are services effective at this hospital?

• There was limited evidence of how practice was audited against current evidence-based guidance, standards and best practice. The quality and risk manager post had been vacant for eight months prior to the inspection. This had affected the hospital’s audit programme.
• There was also limited evidence of patient reported outcome measures in the medical (chemotherapy) and children and young people’s services service at the time of our inspection. This meant that staff were unable to confirm how this information was used to improve patient services. There was, however, participation in national audits in surgery, which showed outcomes within an expected range.
• Patients’ treatment, with regards to chemotherapy, was discussed within the local NHS multidisciplinary (MDT). None of the Saxon Clinic staff were involved in these MDT meetings.
• The Medical Advisory Committee (MAC) worked closely with the senior hospital managers and the clinical governance committee to ensure that the hospital was supported by the medical society
• The MAC reviewed all new consultants before practising privileges were approved; this included their scope of practice. The hospital had an effective system in place to ensure that practising privileges were updated with the relevant information, for example appraisal, GMC and MDU membership.
• All staff were aware of their responsibilities with regard to gaining valid consent from adults, children and those who lacked capacity.

Are services caring at this hospital?

• Patients were overwhelmingly complementary about the service they received at the hospital.
• The service provided emotional support to both patients who attended the hospital, and their families. This service extended to counselling and one to one consultations.
• The Friends and Family survey results, for the period April to September 2015 which had a response rate of 60% showed almost 100 % satisfaction with the quality of care. Over 80% of respondents to the inpatient survey rated the quality of care provided as excellent. The BMI patient satisfaction survey, showed a similar high satisfaction, however the response rates were low at 17%. Another shorter survey undertaken of patients had a response rate of 69%.

Are services responsive at this hospital?

• There were some shortfalls in how the needs of different people were taken into account. For example there were no formal mechanisms in place to ensure the service was able to meet the individual needs of people living with dementia, or a learning disability.
• A risk assessment to ascertain patients’ mental capacity was carried out at pre-admission clinics or on admission. However, staff had not completed any training in these areas and were unable to describe any formal links to obtain specialist advice in such circumstances. However staff could not recall caring for people with these needs in this specialist service and therefore the perceived impact was low.
• The services provided reflected the needs of the local population. Services were flexible, offered choice and continuity of care.
• The booking system was conducive to patient needs, as where possible patients could select times and dates to suit their family and work commitments.
• Operating theatre lists for elective surgery were planned with the operating theatre manager and bookings team. This was to ensure all aspects were checked and considered before booking patient on to the list to ensure patients safety and needs were met. In addition it ensured available operating time was used effectively.
• Children were cared for in an area of the adult ward. The physical environment had not been sufficiently adapted to ensure it was suitable for children and young people’s needs.
• All surgical patients were risk assessed using American Society of Anesthesiology (ASA) guidelines. If they were unsuitable for surgery, for example they had multiple comorbidities and may require high dependency care post operatively; their surgery was not undertaken at The Saxon Clinic.
• There was a culture of learning from complaints and concerns, particularly at senior level. However, not all verbal complaints were recorded or processed in a systematic manner.

Are services well led at this hospital?

• Key risks were not always recognised. It was not clear how often the risk register was updated. Some risks had been on the register for several years and no further action to mitigate the risks had been taken. The service reviewed and acted on feedback about the quality of care received. There were some arrangements for monitoring the quality of the service provided.
• There was good local leadership and an open culture where staff felt valued.

• The quality and risk manager post had been vacant for eight months prior to our inspection. A senior member of staff was covering for this post as well as their own role. It was clear that this had directly impacted on the pace at which risk management had been managed.
• The vision and values of the hospital were incorporated into the appraisal system. However not all staff had undergone an appraisal which meant there was mixed awareness and understanding of the vision’s principles.
• Staff we spoke with could not describe any defined cancer strategy in place other than a proposed move to new facilities. We noted these plans, but saw no evidence of when they would be implemented.
• Each department had a business plan which was incorporated into the hospital plan.

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

Action the hospital MUST take to improve

• The hospital must ensure compliant sinks and taps are available in the clinical areas and patient rooms which conform to Health Building Note 00-10 Part C Sanitary Assemblies to allow correct hand hygiene practice.
• Improve handwashing facilities in the physiotherapy and outpatients department.
• The hospital must ensure carpets in clinical areas are replaced with flooring that meets the requirements of Health Building Notice (HBN) 00-09: Infection control in the built environment.
• The hospital must ensure compliance with national guidance for monitoring and reporting neutropenic sepsis, although the hospital reported that they had not admitted any patients with neutropenic sepsis.
• The hospital must ensure that when risks are identified that they are recorded, reviewed regularly and timely action is taken to mitigate them.

Action the hospital SHOULD take to improve

• An audit programme should be in place to ensure compliance with national guidance and to measure patients’ outcomes.
• Review the MDT arrangements, for patients undergoing treatment for cancer with the local trust.
• Improve staff attendance at some aspects of mandatory training, for example basic life support, paediatric basic life support and acute illness management.
• Ensure all staff have an annual appraisal.
• Ensure that complaints are dealt with consistently.
• Implement specific children’s and young people’s audits, according to BMI policy, in order to measure patients’ outcomes.
• Carry out a risk assessment on the children and young people’s service and the areas in which children are cared for.
• Review the requirement to make child friendly information available.
• Consider the risks and sustainability surrounding the paediatric service, when there is only one person in a substantive post, supported by temporary staff only, carrying sole responsibility for delivering it.

Professor Sir Mike Richards

Chief Inspector of Hospitals