Chief Inspector of Hospitals publishes his findings on the BMI Mount Alvernia Hospital, Guildford

23rd February 2015

England’s Chief Inspector of Hospitals has published his findings on the standards of treatment and care provided by BMI Mount Alvernia Hospital, Guildford, following a Care Quality Commission inspection in November.

The hospital, in Pewley Way, Surrey is one of the first independent hospitals to be inspected under CQC’s new methodology which asks whether services are safe, effective, caring, responsive to people’s needs, and well led.

Findings from the inspection have been published on the CQC website:

CQC found that staff were cared for by kind and compassionate staff who went out of their way to support patients. Patients who spoke to inspectors were positive about their care and treatment.

CQC also found, that the hospital had good systems and processes in place that supported staff in providing a good service. For example allocating time for post discharge telephone calls to check that everything was well once the patient returned home and having adequate staff on duty which gave them time to interact with patients and their families

The provider, BMI Healthcare Limited, had a documented vision and clinical strategy  which was clear to all staff.

CQC identified six areas where BMI Mount Alvernia must make improvements including :

The provider must ensure that CQC is notified of any serious incidents which have occurred without delay if a patient receives an injury or any allegation of abuse or incident investigated by the police.
The investigation and reporting of incidents and systems for organisational and local learning was not robust enough. The provider must consider feedback mechanisms following the reporting of incidents, and should review the arrangements for monitoring the implementation changes and other actions.
The service does not provide Level two critical care. The provider must amend its Statement of Purpose to ensure it reflects the service provided and the range of patients’ needs the service can meet.
Mental capacity assessments were not always completed and recorded, when necessary, such as when considering consent or Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) orders. The provider must consider the formal arrangements required to support patients living with dementia or learning difficulties. This must include appropriate training and monitoring processes for the assessment of people who lack capacity to consent.
The provider must ensure that the records relating to the safe use of lasers in theatre are updated and provide assurance that the consultants are trained
CQC also identified an area of outstanding practice. Inspectors noted that the quality of the hospital’s response to patient complaints was of a high standard.

CQC’s Chief Inspector of Hospitals, Professor Sir Mike Richards, said:

“People deserve to receive treatment and care which is safe, effective, caring, responsive to their needs, and well led.

“Since our last inspection of BMI Mouth Alvernia in 2013, there has been significant and consistent improvement, however there is still room for more. We saw that staff were caring and compassionate in their dealings with patients, and patients praised the treatment and care that they received. We also, saw, however, that some improvements were still needed such as making their governance processes more robust and systematic in incident reporting and compliance with practicing privileges.

“We will return in due course to check that those improvements have been made.”