Archived: BMI The Cavell Hospital

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