Inspection report Independent Hospital BUPA South Bank Hospital by liuhongmei

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									Private and voluntary healthcare




Inspection report
Independent Hospital
BUPA South Bank Hospital
139 Bath Road
Worcester
Worcestershire
WR5 3YB
31st January, 1st and 2nd February 2005
The Healthcare Commission exists to promote improvement in the quality of
NHS and independent healthcare across England and Wales. It is a new
organisation, which started work on 1st April 2004. The Healthcare
Commission’s full name is the Commission for Healthcare Audit and Inspection.

The Healthcare Commission was created under the Health and Social Care
(Community Health and Standards) Act 2003. The organisation has a range of
new functions and takes over some responsibilities from other commissions. It:

•   takes over the private and voluntary healthcare functions of the National
    Care Standards Commission (NCSC), which ceased to exist on 31st March

•   replaces the work of the Commission for Health Improvement (CHI), which
    closed on 31 March

•   picks up the elements of the Audit Commission’s work which relate to
    efficiency, effectiveness and economy of healthcare

In taking over the private and voluntary healthcare functions of the National
Care Standards Commission, the Healthcare Commission now has responsibility
for the registration and inspection of private hospitals, clinics and doctors who
do not work for the NHS.

This report relates to an inspection, some of which was carried out by the NCSC
prior to 1st April 2004. In order to provide readers with some consistency, we
use the term Healthcare Commission rather than NCSC throughout.

It is important to note that the Healthcare Commission has full responsibility for
this report and the continued inspection of the private and voluntary healthcare
sector.
                        ESTABLISHMENT / AGENCY INFORMATION


Name of establishment/agency                                       Tel No:
BUPA South Bank Hospital                                           0190 535 0003

Address                                                            Fax No:
139 Bath Road, Worcester, Worcestershire, WR5 3YB                  0190 535 0856



Email Address

Name of Registered Provider(s)/Company (if applicable)
BUPA Hospitals Limited
Name of Registered Manager (if applicable)
Mr Ben Nicholson

Type of Registration                            No. of places registered (if applicable)

Independent Health                              41

Category(ies) of Registration, with (number of places)
Acute hospitals (with overnight beds) (41), Abortion Clinics (0)

Registration number
P030000021

Date First registered                           Date of latest registration certificate
1st April 2002                                  1st July 2003


Conditions Apply ?                                      NO         If Yes Refer to Part C

Date of last inspection                              27/10/03




BUPA South Bank Hospital                                                         Page 1
Date of Inspection Visit                  31st January 2005   ID Code

Time of Inspection Visit                  09:30 am

Name of Inspector                 1       Liz Oxford          131789

Name of Inspector                 2       Fiona Allinson      157029

Name of Inspector                 3       Elaine Harper       156961

Name of Inspector                 4

Name of Specialist Inspector      5       Merle Odlum         155876

Name of Pharmacist Inspector         6    Debbie Hughes       133373
Name of Lay Assessor (if applicable)
Lay assessors are members of the public
independent of the Healthcare
Commission. They accompany
Inspectors on some inspections and
bring a different perspective to the
inspection process.                       N/A
Name of Specialist (e.g.
Interpreter/Signer) (if applicable)       N/A
Name of Establishment Representative at
the time of inspection                    Mr Ben Nicholson




BUPA South Bank Hospital                                      Page 2
                                    CONTENTS

   Introduction to Report and Inspection
   Inspection Visits
   Brief Description of Services Provided

Part A:     Summary of Inspection Methods & Findings
   Statutory Requirements/Good Practice Recommendations from last Inspection
   Conditions of Registration
   Statutory Requirements/ Good Practice Recommendations from this Inspection

Part B:     Inspection Methods Used & Findings
   National Minimum Standards For Independent Healthcare Core Standards
   Information provision
   Quality of Treatment and Care
   Management and Personnel
   Complaints Management
   Premises Facilities and Equipment
   Risk Management Procedures
   Records and Information Management
   Research

   Service Specific Standards:
           Acute Hospitals

Part C:    Compliance with Conditions of Registration (if applicable)

Part D:    Lay Assessor’s Summary (where applicable)

Part E:    Provider’s Response
   E.1.    Provider’s comments
   E.2.    Action Plan
   E.3.    Provider’s agreement




BUPA South Bank Hospital                                                Page 3
                    INTRODUCTION TO REPORT AND INSPECTION

From 1 April 2004 the Commission for Healthcare Audit and Inspection (CHAI) will replace
the National Care Standards Commission (NCSC) as the body responsible for Private and
Voluntary Healthcare Regulation and Inspection. The Commission for Healthcare Audit
and Inspection will be known as the Healthcare Commission and will be referred to as
such throughout this report.

Every Independent Healthcare establishment/agency which falls within the jurisdiction of
the Healthcare Commission, is subject to inspection, to establish if the
establishment/agency is meeting the National Minimum Standards for Independent
Healthcare relevant to that setting and the requirements of the Care Standards Act 2000
as amended by the Health and Social Care Act 2003 and / or the Children Act 1989 as
amended.

This document summarises the inspection findings of the CHAI in respect BUPA South
Bank Hospital.

The inspection findings relate to the National Minimum Standards (NMS) for Independent
Health Care published by the Secretary of State under the Care Standards Act 2000 as
amended by the Health and Social Care Act 2003.

The Private and Voluntary Healthcare Regulations 2001 applicable to the inspected
service are secondary legislation, with which a service provider must comply. Service
providers are expected to comply fully with the National Minimum Standards. The National
Minimum Standards for Independent Healthcare will form the basis for judgements by the
Healthcare Commission regarding registration, the imposition and variation of registration
conditions and any enforcement action.

The report follows the format of the National Minimum Standards for Independent
Healthcare and the numbering shown in the report corresponds to that of the standards.

The report will show the following:
• Inspection methods used
• Key findings and evidence
• Overall ratings in relation to the standards
• Compliance with the Private and Voluntary Healthcare Regulations 2001
• Required actions on the part of the provider
• Recommended good practice
• Summary of the findings
• Report of the Lay Assessor (where relevant)
• Provider’s response and proposed action plan to address findings.

This report is a public document.




BUPA South Bank Hospital                                                      Page 4
                                   INSPECTION VISITS

Inspections will be undertaken in line with the agreed regulatory framework with additional
visits as required. This is in accordance with the provisions of the Care Standards Act
2000 as amended by the Health and Social Care Act 2003 and the Children Act 1989 as
amended. The report is based on the findings of the specified inspection dates.




BUPA South Bank Hospital                                                       Page 5
                 BRIEF DESCRIPTION OF THE SERVICES PROVIDED.
The South Bank Hospital is a member of the BUPA Hospitals group, which provides
healthcare services to the general public. This hospital is registered for 41 inpatient beds,
including 2 higher dependency beds.

Facilities within the hospital provide for inpatient, day patient and out patient surgical and
medical treatments to adults and consulting and surgical treatments to children aged 16
years and over. Currently children aged between 3 and 16 years are only seen as
outpatients and are not admitted for treatment.

There are 3 operating theatres, physiotherapy, pharmacy and X-ray departments as well as
7 outpatient consulting rooms. Mobile units from an external company provide services such
as MRI and CAT scanning through corporate contractual arrangements. The local NHS
Acute Hospital Trust provides pathology services to this hospital.




BUPA South Bank Hospital                                                           Page 6
PART A SUMMARY OF INSPECTION FINDINGS

 Inspector’s Summary
(This is an overview of the inspector’s findings, which includes good practice, quality issues,
areas to be addressed or developed and any other concerns.)
This service has been inspected against the National Minimum Standards introduced from
1st April 2002. These standards underpin the legislation of The Private and Voluntary Health
Care Regulations (England) 2001. This report may contain a number of recommendations
and requirements where standards and Regulations have not been fully complied with.

Any breaches in standards that pose a more immediate risk to patients have been
highlighted for urgent action. Where there areas of clear concern at the time of the
inspection that need to be addressed, requirements have been set out in the report in order
to address these issues.

The South Bank hospital has demonstrated that the majority of the National Minimum
Standards were met, with only a few areas of non-compliance. Since the last inspection,
efforts at both local and corporate level have been made to address the areas of non-
compliance identified in the previous report.

Overall, the hospital was providing a service that met the needs of its patients within an
environment that was clean, well maintained, comfortable and adequately staffed.
Equipment and facilities were of a good standard and members of staff were helpful,
professional and courteous at all times during the inspection. Patients interviewed were very
satisfied with the care and services they had received and analysis of patient feedback
systems indicated this was the usual trend.

Quality assurance and risk management systems have been significantly developed and
amended since the previous inspection, audits are being undertaken on a regular basis, with
the planning for continuous improvement of standards clarified. There was evidence of a
systematic approach towards training and development for all staff groups; the mandatory
training programme is now organised in a commendable manner. The senior managers at
South Bank hospital have developed networking systems with other local providers of health
care in order to help ensure professional practice is continually updated.

The quality of clinical care and treatment was delivered to a very good standard, in line with
accepted professional guidelines and recommendations.

Since the last inspection the hospital no longer provides termination of pregnancy services
or the use of prescribed techniques in ophthalmic surgery. Children under the age of 16
years are not currently admitted as in-patients although they will still be seen as outpatients.

BUPA South Bank Hospital                                                          Page 7
We would like to take this opportunity to thank the provider, their management team and all
the staff for the assistance given in this inspection.




BUPA South Bank Hospital                                                       Page 8
 Requirements from last Inspection visit fully actioned?                              YES

If No please list below



                              STATUTORY REQUIREMENTS
Identified below are areas not addressed from the last inspection report which indicate a
non-compliance with the Care Standards Act 2000 as amended by the Health and Social
Care Act 2003 and Private and Voluntary Healthcare Regulations 2001. The code in
"Standard" is a cross-reference to the Standards described in full in the section "Inspection
Findings".
 No. Regulation Standard                       Required actions                      Timescale
                                                                                     for action




No.    Refer to                   Good Practice Recommendations                      Actioned
       Standard                                                                      Yes/No




Action is being taken by the Healthcare Commission to ensure compliance in regard
to the above requirements.

CONDITIONS OF REGISTRATION                                                       MET
                                                                                 (YES/NO)




BUPA South Bank Hospital                                                         Page 9
         STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION

Action Plan: The Registered Person is requested to provide the Healthcare Commission
with an Action Plan, which indicates how requirements and recommendations are to be
addressed with the time scale within which such actions will be taken. The action plan will
be made available on request to the Regional Office.



                              STATUTORY REQUIREMENTS
Identified below are areas addressed in the main body of the report which indicate non-
compliance with the Care Standards Act 2000 as amended by the Health and Social Care
Act 2003, and accompanying Private and Voluntary Healthcare Regulations 2001, the
National Minimum Standards for Independent Healthcare and the relevant sections of the
Children’s Act 1989. The Registered Provider(s) is/are required to comply within the given
time scales. The code in "Standard" is a cross-reference to the Standards described in full in
the section "Inspection Findings".
 No. Regulation Standard                          Requirement                      Timescale
                                                                                   for action
                                The registered person must ensure that the
1.    26(3)         *RQN        visits required under Regulation 26 are carried         31/03/05
                                out at least once every six months.

                                The registered person must submit an
                                application to vary the certificate of registration
2.    30(h)         *RQN                                                                31/03/05
                                following the withdrawal of the termination of
                                pregnancy service.

                                The registered person must ensure that a
      19
3.               C9             recent photograph is kept of all members of             31/03/05
      Schedule 2
                                staff as positive proof of identity.

      15(1)(b)                  The registered person must ensure that all
                                required logs are comprehensively maintained
4.    15(3)(4)      A11         as per the requirements of HTM 2030 in                  Immediate
                                relation to the washer disinfector and the
      20                        ultrasonic washers.

                                The registered person must ensure that all re-
                                usable anaesthetic equipment is appropriately
5.    15(3)(4)(6)   A11         decontaminated on arrival to the SSU. All               Immediate
                                items must then be incorporated into the
                                hospital’s traceability system.



BUPA South Bank Hospital                                                              Page 10
                           The registered person must ensure that all
6.    15(3)(4)(6)   A11    contaminated items are safely transferred to       Immediate
                           the SSU.

                           The registered person must ensure that all
                           ophthalmic instrumentation is thermally
                           decontaminated in a washer-disinfector.
7.    15(4)(5)(6)   A11                                                       Immediate
                           The practice of manual processing of
                           instrumentation prior to the automated process
                           should be discontinued.

                    A11    The registered person must ensure that single
      15(1)(b)             use instrumentation and equipment are not re-
8.                         processed.                                         Immediate
      15(2)(3)(4)
                    C26    All LMA’s require full traceability labelling.

                           The registered person must ensure that
                    A27    instrument sets are properly sealed when
                           wrapped prior to autoclaving.
9.    15(3)(4)(6)                                                             Immediate
                           The registered person must ensure that an
                    A11    instrument checklist is provided with OPD
                           instrument sets.

                           The registered person must ensure that
10.   15(3)(6)      A11    appropriate racking systems are in place for       Immediate
                           the cooling and storage of instrument sets.

                           The registered person must ensure that sterile
      1591)         A23    instrument sets are safely and appropriately
                           stored.
11.   15(3)                                                                   Immediate
                           Instrument sets currently stored in the recovery
      37(1))(d)(ii) A11
                           area should be relocated.

                           The registered person must ensure that SSU
                    A22    personnel effectively clean equipment.
      15(1)(c)
12.                 A20    The registered person must ensure that SSU         Immediate
      37(1)                personnel routinely complete documentation
                    A11    relating to the cleaning of the department and
                           equipment.




BUPA South Bank Hospital                                                    Page 11
                           The registered person must ensure that a
                           system is in place to ensure SSU personnel
      9(1)(d)       A11    regularly monitor sterile supplementary packs
13.                        in the department.                                 Immediate
      15(2)         A20
                           A review of equipment and instrumentation is
                           required.

                           The registered person must ensure that all
                           rigid endoscopes soaked for use in the theatre
                    A20    department are subject to traceability
      15(1)(b)
                           procedures.
14.                                                                           Immediate
      15(3)(4)(6)
                           A review of equipment and instrumentation is
                    A11
                           required to encourage discontinuation of
                           soaking practices.

                    A22    The registered person must ensure that
                           anaesthetic personnel effectively clean
                           equipment.
      15(1)(c)
15.                 A20                                                       Immediate
                           The registered person must ensure that
      37(1)
                           anaesthetic personnel routinely complete
                           documentation relating to the cleaning of
                    A11    equipment.

                           The registered person must ensure that
                           pharmaceutical products are stored according
                           to manufacturer’s guidance.
16.   15(5)(6)      A20                                                       Immediate
                           Single use items such as Proflavine Cream
                           should be managed and subsequently
                           disposed of as directed.

                           The registered person must ensure that theatre
                           assistants are given appropriately delegated
                           duties.
      18(10
17.                 A20                                                       Immediate
                           The registered person must ensure that all
      19(2)(b)
                           personnel administering drugs are qualified to
                           do so and have attained the appropriate
                           competencies.

                           The registered person must ensure that
      15(1)(c)      A22    personnel routinely complete documentation
18.                                                                           Immediate
                           relating to the checking and cleaning of
      37(1)         A20
                           equipment.



BUPA South Bank Hospital                                                    Page 12
      15(1)(b)(c)          The registered person must ensure that
19.                  A20   endoscopy personnel maintain equipment               Immediate
      15(2)(c)             checking and cleaning records.

      37(1)(c)             The registered person must ensure that the
20.                  A20                                                        Immediate
                           swab board is fully utilised for all procedures.
      37(1)(d)(ii)

      2193)(a)             The registered person must ensure that all
                           required details in the surgical registers are
      Schedule 3 A27       recorded for each patient.
21.                                                                             Immediate
      Part 11,       A20   The registered person must ensure that a
                           procedural register is available for use and
      Para 2               maintained within the OPD treatment areas.

                           The registered person must ensure that all
                           consumable stock is monitored for expiry and
                     A22   so avoid the potential use of expired devices
      15(1)(c)
                           during the delivery of patient care.
22.                                                                             Immediate
      1592)(b)
                           The registered person must ensure that
                     A20
                           intubating bougies are available for use with
                           the manufacturer’s identification.

                           The registered person must ensure that single
      15(1)(b)             use filters are used with rigid sigmoidoscopes
                           and are changed after each patient use.
      !%(2)(c)
23.                  A20   The registered person must ensure that alerts        Immediate
      15(6)
                           and guidelines recommended by expert bodies
      37                   and professional groups such as the MDA
                           FEB. 2001 are reflected in practice.

                           The registered person must ensure that
24.   15(6)          A22   anaesthetic assistants routinely wear gloves         Immediate
                           during cannulation and intubation procedures.

      15(1)(c)             The registered person must ensure that all
25.                  A22   resuscitation equipment is properly checked for Immediate
      15(2)(b)             the expiry of items.

                           The registered person must ensure that all
                           equipment is fit for purpose and replaced as
      15(1)(c)             necessary.
26.                  A22                                                        Immediate
      15(2)(a)             The registered person must ensure that filters
                           are regularly changed on portable suction
                           units.

BUPA South Bank Hospital                                                      Page 13
                           The registered person is required to make
      9(1)(d)              good areas identified within A23 of this report.
27.   15(6)         A23                                                         31/07/05
                           The registered person must ensure that all
                           clinical hand washbasins are fit for purpose in
      25(2)
                           all areas identified.

      15(1)(d)(3)          The registered person must ensure that all
                           instrumentation used during ENT procedures
28.   15(4)(6)      A27                                                         Immediate
                           are subject to full traceability procedures for
      21(1)(a)(i)          each individual patient.

      21(1)                The registered person must ensure that all
29.                 C30    entries in patients’ health care records are         31/07/05
      15(1)(b)             dated, timed and signed.

                           The registered person must ensure that the
                           requirements and recommendations made at
30.   15(1)(b)      A32                                                         30/04/05
                           the last two inspections by the Radiation
                           Protection Advisor are addressed.




BUPA South Bank Hospital                                                      Page 14
                                  RECOMMENDATIONS
Identified below are areas addressed in the main body of the report which relate to National
Standards and are seen as good practice issues which should be considered for
implementation by the Registered Provider(s). The code in "Standard" is a cross-reference
to the Standards described in full in the section "Inspection Findings".
 No.     Refer to                            Recommendation Action
        Standard

      C10         Formal records of interviews held for employment and the granting of
1.
                  practising privileges should be kept.
      C9

                  The registered manager should continue to audit controlled drug registers
2.    C24         to ensure compliance with legal requirements for controlled drug record
                  keeping.

                  The processing of raw materials should be very limited. All items, as far
                  as possible, should be purchased as sterile items.

                  Appropriate signage should be available to identify hot and cooling
                  items/areas within the autoclave area.
3.    A11
                  Instruments lists should be amended to reflect which theatre and which
                  personnel used the set.

                  Non-conformance areas are identified within processing areas.

                  Emergency eyewash should be stored in eyewash stations.

                  A vented cabinet for the storage of flexible endoscopes should be
4.    A11
                  available in the endoscopy area.

                  The patients’ consents for procedure(s) should be completed prior to
5.    A21
                  entry to the department.

                  Green raytec gauze should be used to facilitate procedures in all
5.    A22
                  anaesthetic rooms.

                  Re-usable equipment on the resuscitation trolley remains with their
                  packaging following processing until used.

                  A review of the anaesthetic equipment located in the recovery area
6.    A22
                  should be undertaken.

                  Furniture located in clinical areas should possess covers that are intact
                  and washable for quick drying.

BUPA South Bank Hospital                                                        Page 15
     A27
                Tubes containing lubricating gels should be discarded on the day of use
7.
                and not retained.
     A22

                The registered person should continue to audit controlled drug registers to
8.   C24        ensure compliance with legal requirements for controlled drug record
                keeping.

                The registered person should ensure that the MGPS nominated
9.   A39
                Authorised Person has current certified competency.




BUPA South Bank Hospital                                                     Page 16
PART B                  INSPECTION METHODS & FINDINGS

The following inspection methods have been used in the production of this report


Direct Observation                                               YES
Indirect Observation                                             YES
Sampling          • Pre-inspection Questionnaire                 YES
                  • Records                                      YES
                  • Care Plans / Care Pathways                   YES
                  • Meals                                        YES
                  • Activities                                   NA
                  • Other <enter details here>                   NA
‘Tracking’ care and support                                      YES
Group discussion with patient/client                             NA
Individual discussion with patient/client                        YES
Group discussion with staff                                      NO
Individual discussion with staff                                 YES
Discussion with management                                       YES
Patient/client survey                                            NA
Visiting Professionals survey / feedback                         NA
Tour of Premises                                                 YES
Formal Interviews                                                YES
Document reading                                                 YES

Date of Inspection                                            31/01/05
Time of Inspection                                             09:00
Duration Of Inspection (hrs)                                     57




BUPA South Bank Hospital                                                     Page 17
The following pages summarise the key findings and evidence from this inspection,
together with the Healthcare Commission assessment of the extent to which the National
Minimum Standards have been met. The following scale is used to indicate the extent to
which standards have been met or not met by placing the assessed level alongside the
phrase "Standard met?"

The scale ranges from:

4 - Standard Exceeded             (Commendable)
3 - Standard Met                  (No Shortfalls)
2 - Standard Almost Met           (Minor Shortfalls)
1 - Standard Not Met              (Major Shortfalls)

"0" in the "Standard met?" box denotes standard not assessed on this occasion.
"9" in the "Standard met?" box denotes standard not applicable.
“X” is used where a percentage value or numerical value is not applicable or available.

Range of fees charged         From (£)       300.00     To (£)       8500.00

Any charges for extras?                       YES




BUPA South Bank Hospital                                                       Page 18
                                CORE STANDARDS


                        Information for Patients/Clients
                                     Core Standard C1

             The intended outcomes for the following set of standards are:

•    Patients\clients receive clear and accurate information about their treatment and
    its likely costs.

Standard C 1 (C1.1 – C1.7)
The establishment or agency has available for prospective patients/clients and their
families a patients’/clients’ guide expressed in clear, relevant language and in a
format suitable for the patient/client profile of the establishment or agency with regard
to language and translation, patients/clients with sensory disabilities or
patients/clients with learning disability.
Key findings/Evidence                                       Standard met?              0
The standards relating to this section were inspected at last year’s inspection, and therefore
this report should be read in conjunction with the 2003/2004 inspection report. In addition,
the registered provider has formally confirmed that this standard meets the criteria set out in
the National Minimum Standards.




BUPA South Bank Hospital                                                        Page 19
                        Quality of Treatment and Care
                        Introduction to Core Standards C2 to C7

             The intended outcomes for the following set of standards are:

•    The treatment and care provided are patient/client-centred.
•    Treatment provided to patients/clients is in line with the relevant clinical
    guidelines.
•    Patients/clients are assured that monitoring of the quality of treatment and care
    takes place.
•    The dying and death of patients/clients is handled appropriately and sensitively.
•    Patients’/clients’ views are obtained by the establishment and used to inform the
    provision of treatment and care and prospective patients/clients.
•    Appropriate policies and procedures are in place to help ensure the quality of
    treatment and services.

Standard C2 (C2.1 – C2.11)
The registered person has policies and procedures in place to ensure that the care
provided is patient/client-centred, as follows:

•   Assessment of patients’/clients’ health needs are carried out in line with
   procedures to be timely, appropriate and accurate.
• Patients/clients are informed of the recommended interventions for treatment
   and/or care.
• Patients/clients give verbal consent to all intimate examinations and are offered a
   chaperone if undergoing such an examination, or are able to bring a relative or
   friend with them if they wish.
• Patients/clients and relatives, if appropriate, are consulted about the planning and
   delivery of services provided to them, which includes taking into account their
   preferences and requests.
• Patients/clients have access to their health records in line with the Data Protection
   Act 1998.
• Patients’/clients’ rights are central to the resuscitation policy.
• Services are provided in such a way that facilitates access by people of different
   cultural and ethnic backgrounds and those with disabilities, sensory disabilities
   and learning disabilities.
• Patients’/clients’ privacy, dignity and confidentiality are respected at all times.
• Patients/clients are addressed by their preferred name and title.
• Patients/clients are treated with courtesy and consideration.
Key findings/Evidence                                      Standard met?             3
There are a range of policies and procedures in place to ensure that patient-centred care is
provided to those admitted to the hospital; A more robust and systematic approach to care
and treatment has been developed since the previous inspection; regular monitoring of the
services provided help to ensure that treatment and care remains patient centred.

Care protocols for patients have been developed with an underlying best practice
BUPA South Bank Hospital                                                      Page 20
philosophy; this approach is demonstrated in the care pathway documentation, clinical
governance report details and the review of both positive and negative treatment variances.

A care pathway for pre-admission assessment is in place; all prospective in-patients are sent
a postal questionnaire, which a designated pre-admission clinic nurse then screens before
inviting patients to attend a pre-admission clinic appointment.

A recent audit to review compliance with the Disability Discrimination Act (DDA) has helped
to ensure that services are provided in such a way that patients with physical or sensory
disabilities can more easily access services at the establishment. Three of the toilets used
by visitors to the hospital have been converted to meet DDA requirements and one patient
bedroom has been upgraded to provide a direct link to a bathroom with additional aids and
facilities.

The establishment implemented a revised corporate policy for obtaining informed consent to
treatment in August 2004; this policy ensures that the concept of “Gillick competency” is
followed when providing care to young people. The corporate policy also addresses what to
do when a patient does not have the capacity to give valid consent to treatment.

Patient’s confirmed to the inspectors that they felt they had been sufficiently informed about
proposed treatments or care prior to making any decision regarding their consent to
treatment. A review of patient’s health care records confirmed that completed consent forms
are kept with patients’ notes.

Individual consulting rooms and patient bedrooms help to ensure that patients are able to
have confidential discussions with health care professionals in privacy. During discussion
with the inspectors patients confirmed that they considered all members of staff respected
their privacy and dignity.

All members of staff were seen to wear identification badges showing their name and
position held at the establishment.



Standard C3 (C3.1 - C3.2)
The management of specific conditions takes account of evaluations by the National
Institute for Clinical Excellence (NICE) in relation to effective clinical practice and
patient/client safety and specific clinical guidelines from the relevant medical Royal
Colleges, health care professional institutions and the NHS National Service
Frameworks.
Key findings/Evidence                                       Standard met?              0
The standards relating to this section were inspected at last year’s inspection, and therefore
this report should be read in conjunction with the 2003/2004 inspection report. In addition,
the registered provider has formally confirmed that this standard meets the criteria set out in
the National Minimum Standards.




BUPA South Bank Hospital                                                         Page 21
Standard C4 (C4.1)
The written policy and procedures for clinical treatment and care include
arrangements for monitoring the quality of care including:

•    Clinical audit (informed by trends, for instance, in litigation, complaints, clinical
    outcomes and risk management).
• The performance indicators to be used by the establishment and how these are to
    be reported on.
• The outcomes of clinical and nursing audits.
• The use of comparative information on clinical outcomes.
• Evaluation against research findings and evidence based practice.
• Participation in national confidential enquiries (such as the National Confidential
    Enquiry into Peri-Operative Deaths).
• Effective information and clinical record systems.
• The identification and recording of the respective and common responsibilities of
    team members, for example in a job description or role profile.
• Procedures for identifying and learning from adverse health events and near
    misses.
• A complaints procedure.
Key findings/Evidence                                        Standard met?              3
Clinical governance within the hospital has been clarified since the last inspection to ensure
a programme of accountability for improving the quality of services is followed. A whole
systems approach is now in place to assist in the monitoring of quality of care provided to
patients; the clinical governance report provided to the inspectors identifies the
arrangements for monitoring the quality of clinical care and treatment within the
establishment.

The clinical governance framework has reporting mechanisms for monitoring the outcomes
of clinical and nursing care, and performance indicators are used to help identify any trends.
Inspectors saw copies of the quarterly quality reports that are produced and then reviewed
by both the clinical governance committee and the medical advisory committee (MAC).

Evidence of the varied audit activity seen by the inspectors included reports from the ward
areas and a review of medical notes within the establishment. The audit programme is
based on self-evaluation supported by key evidence sources, exception reporting and the
production of any action plans required.

The Quality Indicator Project (QIP) report includes information on any variances and adverse
incidents, unplanned re-admissions, surgical site infections, perioperative tissue damage
and any unplanned transfers to the high dependency unit. Review of this data by the clinical
governance working group is a key factor in the management of risk within the hospital; the
comparative data obtained is now used to help inform and guide practice.

There are documented procedures for identifying and learning from any adverse incidents;
all complaints, audit results, clinical incidents and near misses are reported quarterly to the
clinical governance working party, the clinical governance committee and the MAC
meetings.

The establishment recently achieved re-validation of the Investors In People Award in full for
BUPA South Bank Hospital                                                       Page 22
the next three years.




  No. of complaints from last inspection                                     87
  No. of complaints fully substantiated                                      68
  No. of complaints partly substantiated                                     10
  No. of complaints not substantiated                                         9
  No. of complaints not yet resolved                                          0
  Percentage of complaints responded to within 28 days                       76       %
  Deaths within 7 days of surgery                                             1
  Incidence of pressure sores as percentage of
  inpatients/clients seen:
                 Stage 1                                                      0       %
                  Stage 2                                                   0.02      %
                  Stage 3                                                     0       %
                  Stage 4                                                     0       %
  Adverse clinical incidents as percentage of inpatients/clients                      %
                                                                            1.06
  seen
  Pain management – percentage of patients/clients pain score                         %
                                                                              X
  > 2 on VAS 1-10 (or equivalent)
  Post operative nausea and vomiting – percentage of                                  %
  patients/clients > 2 on PONV assessment range 1-10 (or                      X
  equivalent)
  Infection rate                                                             0.2



Standard C5 (C5.1 - C5.7)
Care and comfort are given to patients/clients who are dying, their death is handled
with dignity and propriety, and their emotional, psychological and spiritual needs,
rites and functions observed.
Key findings/Evidence                                       Standard met?              0
The standards relating to this section were inspected at last year’s inspection, and therefore
this report should be read in conjunction with the 2003/2004 inspection report. In addition,
the registered provider has formally confirmed that this standard meets the criteria set out in
the National Minimum Standards.




BUPA South Bank Hospital                                                           Page 23
Standard C6 (C6.1 - C6.4)
A patient/client survey is carried out annually, as a minimum, to seek the views of
patients/clients on the quality of the treatment and care provided.
Key findings/Evidence                                       Standard met?              0
The standards relating to this section were inspected at last year’s inspection, and therefore
this report should be read in conjunction with the 2003/2004 inspection report. In addition,
the registered provider has formally confirmed that this standard meets the criteria set out in
the National Minimum Standards.



Standard C7 (C7.1 - C7.6)
All staff read the policies and procedures relevant to their area of work and sign a
statement to this effect.
Key findings/Evidence                                       Standard met?              0
The standards relating to this section were inspected at last year’s inspection, and therefore
this report should be read in conjunction with the 2003/2004 inspection report. In addition,
the registered provider has formally confirmed that this standard meets the criteria set out in
the National Minimum Standards.




BUPA South Bank Hospital                                                         Page 24
                           Management and Personnel
                        Introduction to Core Standards C8 to C13

            The intended outcomes for the following sets of standards are:

•   Patients/clients are assured that the establishment or agency is run by a fit
    person/organisation and that there is a clear line of accountability for the delivery
    of services.
•   Patients/clients are assured that the establishment or agency is run by a fit
    person/organisation and that there is a clear line of accountability for the delivery
    of services.
•   Patients/clients receive care from appropriately recruited, trained and qualified
    staff.
•   Patients/clients receive treatment from appropriately recruited, trained and
    qualified health care professionals.
•   Patients/clients are treated by health care professionals who comply with their
    professional codes of practice.
•   Patients/clients and health care professionals are not infected by blood borne
    viruses.
•   Children receiving treatment are protected effectively from abuse.

Standard C 8 (C8.1 – C8.4)
The manager can demonstrate that he/she has undertaken periodic training to update
their knowledge, skills and competence to manage the establishment.
Key findings/Evidence                                       Standard met?              0
The standards relating to this section were inspected at last year’s inspection, and therefore
this report should be read in conjunction with the 2003/2004 inspection report. In addition,
the registered provider has formally confirmed that this standard meets the criteria set out in
the National Minimum Standards.




BUPA South Bank Hospital                                                         Page 25
Standard C 9 (C9.1 - C9.4)
There is a written human resources policy and supporting procedures, in line with
current employment legislation.
Key findings/Evidence                                      Standard met?             2
The corporate human resources policy and supporting procedures are in line with current
employment legislation. A comprehensive database has been set up at the hospital since the
last inspection to help ensure that the required documentation is obtained and available for
inspection; staff records reviewed during the inspection demonstrated that the pre and post
employment checks required by legislation and the national minimum standards are now
carried out.

A review of 6 staff records indicated that;
       Proof of current registration is verified for all professional staff
       CRB checks have been obtained for all members of staff
       References are obtained prior to commencement of work
       All staff are provided with a job description
       Mandatory training is undertaken and recorded
       The performance of staff is appraised annually

The requirement for a recent photograph as positive proof of identity was discussed with the
matron, as the files reviewed did not contain photographs. The need to retain a formal record
of interviews carried out prior to employment was also discussed.

There is an active commitment towards meeting the training needs of the staff; this was
confirmed through discussions with members of staff and a review of training records. The
mandatory training records seen by the inspector were well documented and are integral to
the appraisal process; heads of department monitor participation at mandatory training
events and non-participation is followed up.

The inspector was informed that following a review of the education and training strategy in
2004 a training budget has now been allocated. Matron and the registered manager
acknowledged that arrangements in place for ensuring continuing professional development
(CPD) require further development.




BUPA South Bank Hospital                                                       Page 26
Standard C 10 (C10.1 - C10.6)
Where health care professionals are granted practising privileges (ie the grant to a
person who is not employed in the establishment of permission to practise in that
establishment) there are written policies and procedures on allowing practicing
privileges.
Key findings/Evidence                                        Standard met?             2
The Consultant’s Handbook sets out the corporate policy for the granting of practicing
privileges; a review of the records maintained for health care professionals granted
practicing privileges indicated that evidence of the checks required by legislation and the
national minimum standards prior to and following the granting of practicing privileges was
available.

The review of records showed: -
      Evidence of current professional indemnity is obtained
      Evidence of current registration with appropriate regulatory bodies is monitored
      Proof of identification kept
      CRB checks have been obtained for all professionals granted practicing privileges
      References are obtained prior to commencement of work
      Records of interviews are not routinely kept
      Details of travelling times or cover arrangements


The registered manager interviews all health care professionals applying for practicing
privileges before the application is presented to the MAC for comment; however no formal
record is currently kept of this interview.
The inspector was informed that consultant’s have arrangements for continuing professional
development (CPD) in place with their NHS Trust; little evidence of this CPD was available
at the inspection. All practicing privileges are reviewed every two years, and more frequently
if necessary.

The corporate handbook, which forms part of the application pack issued to practitioners
covers information relating to clinical governance, the establishments’ policies and
procedures, the complaints procedure, medical records, the role of the MAC committee,
incident reporting data protection and health and safety.



Standard C11 (C11.1 – C11.3)
All health care professionals are required to abide by published codes of professional
practice relevant to their professional role.
Key findings/Evidence                                       Standard met?              0
The standards relating to this section were inspected at last year’s inspection, and therefore
this report should be read in conjunction with the 2003/2004 inspection report. In addition,
the registered provider has formally confirmed that this standard meets the criteria set out in
the National Minimum Standards.




BUPA South Bank Hospital                                                         Page 27
Standard C12 (C12.1 – C12.3)
Any member of personnel who is identified as an infectious carrier of a blood borne
virus (Hepatitis B, Hepatitis C, HIV) is not permitted to undertake any exposure prone
procedure.
Key findings/Evidence                                       Standard met?              0
The standards relating to this section were inspected at last year’s inspection, and therefore
this report should be read in conjunction with the 2003/2004 inspection report. In addition,
the registered provider has formally confirmed that this standard meets the criteria set out in
the National Minimum Standards.



Standard C13 (C13.1 – C13.6)
Where children are treated there are child protection procedures in place, with which
all personnel are familiar, and are included in the induction programme for new staff.
Key findings/Evidence                                       Standard met?            3
The child protection policy and its supporting procedures are consistent with guidance from
the Department of Health and the local Area Child Protection Committee procedures.

Training in child protection has been given to all members of staff who care for children and
members of staff who care for children demonstrated an awareness of the need to respect a
child’s need for privacy and confidentiality.




BUPA South Bank Hospital                                                         Page 28
                             Complaints Management
                        Introduction to Core Standards C14 to C16

             The intended outcomes for the following set of standards are:

•   Patients/clients have access to an effective complaints process.
•   Patients/clients receive appropriate information about how to make a complaint.
•   Personnel are freely able to express concerns about questionable or poor
    practice.

Standard C14 (C14.1-C14.7)
The registered person ensures that there is a written policy and procedures for
handling and investigating complaints about all aspects of service, care and
treatment provided in, or on behalf of, the establishment/agency and that such a
policy includes the stages and time-scales for the process.
Key findings/Evidence                                       Standard met?              0
The standards relating to this section were inspected at last year’s inspection, and therefore
this report should be read in conjunction with the 2003/2004 inspection report. In addition,
the registered provider has formally confirmed that this standard meets the criteria set out in
the National Minimum Standards.



Standard C15 (C15.1-C15.3)
The complaints procedure, or information based upon it, is accessible to
patients/clients and their family members/carers.
Key findings/Evidence                                       Standard met?              0
The standards relating to this section were inspected at last year’s inspection, and therefore
this report should be read in conjunction with the 2003/2004 inspection report. In addition,
the registered provider has formally confirmed that this standard meets the criteria set out in
the National Minimum Standards.



Standard C16 (C16.1-C16.3)
Personnel are informed of their duty to express their concerns about questionable or
poor practice in accordance with the Public Interest Disclosure Act 1998.
Key findings/Evidence                                       Standard met?              0
The standards relating to this section were inspected at last year’s inspection, and therefore
this report should be read in conjunction with the 2003/2004 inspection report. In addition,
the registered provider has formally confirmed that this standard meets the criteria set out in
the National Minimum Standards.




BUPA South Bank Hospital                                                         Page 29
                     Premises, Facilities and Equipment
                       Introduction to Core Standards C17 to C19

             The intended outcomes for the following set of standards are:

•    Patients/clients receive treatment in premises that are safe and appropriate for
    that treatment.
•    Patients/clients receive treatment using equipment and supplies that are safe and
    in good condition.
•    Patients/clients receive appropriate catering services.

Standard C17 (C17.1-C17.15)
There is a preventive maintenance plan that covers all areas of the
establishment/agency’s buildings.
Key findings/Evidence                                       Standard met?            3
There is a comprehensive preventative maintenance plan in place, and a risk-assessed
approach is taken by staff to ensure patients’ safety throughout the establishment. Both in-
house staff and external contractors undertake the maintenance programme. All
requirements from the Environmental Health Officer (EHO) and Fire Services are complied
with.

Those areas routinely used by patients are compliant with the requirements of the Disability
Discrimination Act and appropriate changing room facilities are provided. The clinical and
non-clinical areas of the establishment are kept to a high standard of cleanliness, with
cleaning schedules followed and audited for compliance.

Records of all fire drills and training sessions for members of staff are available for
inspection. Safe temperatures are monitored for hot water supplies and the inspector saw
records for these checks at the inspection.

A waste management committee has been set up since the last inspection and the local
waste management policy has been reviewed and amended. A due diligence visit was made
to the hospital’s waste disposal contractor by the facilities manager, the infection control
liaison nurse and the H&S officer in 2004. There are written procedures to ensure that all
waste is segregated into clinical and non-clinical items and any clinical waste is labelled to
enable it to be traced back to its point of origin.

The maintenance records indicated that all plant is maintained and serviced as specified by
manufacturers and insurers. Records for the periodic checking and servicing of the
passenger lifts by an external contractor are kept by the facilities manager and were
available for inspection.




BUPA South Bank Hospital                                                        Page 30
Standard C18 (C18.1-C18.6)
Equipment is installed, checked and serviced in compliance with the manufacturer’s
instructions.
Key findings/Evidence                                        Standard met?            3
Equipment is installed and maintained in compliance with the manufacturer’s instructions
and the records for the servicing of all items of equipment are well maintained. Specialist
equipment is serviced and maintained by the manufacturers; appropriate records are kept for
these items and were available for inspection.

Efficient stock control and daily stock up of supplies helps ensure that products are used in
their optimum condition and within expiry dates.




BUPA South Bank Hospital                                                         Page 31
Standard C19 (C19.1-C19.10)
Food is handled, stored, prepared and delivered in accordance with food safety
legislation.
Key findings/Evidence                                       Standard met?              0
The standards relating to this section were inspected at last year’s inspection, and therefore
this report should be read in conjunction with the 2003/2004 inspection report. In addition,
the registered provider has formally confirmed that this standard meets the criteria set out in
the National Minimum Standards.



                         Risk Management Procedures
                        Introduction to Core Standards C20 to C28

             The intended outcomes for the following set of standards are:

•    Patients/clients, staff and anyone visiting the registered premises are assured that
    all risks connected with the establishment, treatment and services are identified,
    assessed and managed appropriately.
•    The appropriate health and safety measures are in place.
•    Measures are in place to ensure the safe management and secure handling of
    medicines.
•    Medicines, dressings and medical gases are handled in a safe and secure manner.
•    Controlled drugs are stored, administered and destroyed appropriately.
•    The risk of patients/clients, staff and visitors acquiring a health care associated
    infection is minimised.
•    Patients/clients are not treated with contaminated medical devices.
•    Patients/clients are resuscitated appropriately.
•    Contracts ensure that patients/clients receive goods and services of the
    appropriate quality.

Standard C20 (C20.1-C20.6)
The registered person ensures that there is a comprehensive written risk
management policy and procedures, which covers:

•  The identification and assessment of risks throughout the establishment.
•  The precautions in place control the risks identified.
•  Health and safety.
•  Infection control.
•  Decontamination.
•  Arrangement for the identification, recording, analysing and learning from adverse
  health events or near misses.
• Arrangements for responding to emergencies.
• Protection of vulnerable children and adults, including protection from abuse.
Key findings/Evidence                                   Standard met?         3



BUPA South Bank Hospital                                                         Page 32
The establishment has implemented a planned and systematic approach to risk assessment;
policies and their supporting procedures include the determining of control measures,
records to be maintained, departmental manager’s responsibilities, identification of training
needs and review of the monitoring systems.

Supporting procedures that are in place cover such key areas as health and safety, infection
control and decontamination; staff are encouraged to report incidents and near misses with
reassurance that they will not be unfairly blamed. This “open door” approach to management
was confirmed in discussions the inspectors had with members of staff.

The audit programme, health and safety management and the clinical governance
committee have been developed since the last inspection to provide a more structured
approach for identifying, analysing and learning from adverse incidents or near misses within
the establishment. Matron has introduced significant event reviews this year and two such
reviews have taken place so far; the review files are kept by matron who manages them in
liaison with the registered manager.

Matron is the named person for making arrangements to deal with any hazard or alert
notification received; during the last year she has introduced a new process to ensure an
audit trail of activities in this area through the use of a database.

A local policy sets out the manager’s responsibilities for notifying the Healthcare
Commission of any member of staff suspended on professional or clinical grounds.
Reference to this policy is also included in the practicing privileges agreement.




BUPA South Bank Hospital                                                       Page 33
Standard C21 (C21.1 - C21.9)
Arrangements are in place for obtaining competent Health and Safety advice.
Key findings/Evidence                                        Standard met?               3
Arrangements are in place to obtain health and safety advice through a corporate contract;
these arrangements include the provision of a helpline and an external health and safety
audit report. There are written policies and procedures in place for the classification, storage
and disposal of all categories of waste.

The health and safety procedures reflect the need to demonstrate compliance with the
relevant legislation; a robust and pro-active approach is taken by the health and safety lead
within the establishment in ensuring that workplace risk assessments are undertaken in a
systematic manner.

The contract for occupational health services has recently been changed; services provided
include a register of Hepatitis B status, pre-employment and new employee health checks,
lung function tests where required and support in long term sickness reviews. There is also
access to additional support from an occupational health physician at corporate level.
Members of staff are able to self refer themselves to the occupational health nurse at her
monthly visits if they so wish.

Members of staff are provided with appropriate protective equipment and clothing and the
need to use this equipment is discussed at the induction programme.
Records are maintained for all mandatory training such as fire safety, basic life support, first
-aid and moving and handling; managers regularly monitor attendance at this training.
The accident register was correctly maintained when reviewed at inspection; the records of
clinical incidents were also seen during the inspection, inspectors were advised that the
database is analysed and a quarterly report then sent to the clinical governance committee.




BUPA South Bank Hospital                                                          Page 34
Standard C22 (C22.1 - C22.12)
Medicines are handled according to the requirements of the Medicines Act 1968 and
the Misuse of Drugs Act 1971; and with nursing staff following the UKCC Guidelines
for the Administration of Medicines (October 2000) and pharmacists their professional
Code of Ethics.
Key findings/Evidence                                         Standard met?              3
Documents seen and discussions with staff members demonstrated that medicines handling
is in accordance with legal requirements and within professional guidelines.
There is a corporate written medicines policy, supported by local procedures, which covers
all aspects of medicines handling as required by this standard. These include procurement,
receipt, storage, administration and disposal of medicines; drug error reporting and linking of
this to the clinical incident procedure; adverse reaction and anaphylaxis management.
Medicines for resuscitation and other emergency treatments are kept accessible on
designated trolleys in a number of clinical areas.
Medicines are prescribed in writing and signed by an authorised prescriber. There is also
provision for administration from a list of homely remedies which nurses may administer
according to their own professional judgement once only prior to medical authorisation. This
procedure is being replaced by the introduction of Patient Group Directions.
Emergency administration of medicines is detailed in the resuscitation policy.
Members of staff confirmed that no medicines labelled for a named patient would be given to
another patient; and that doses are prepared immediately prior to administration.
Patient information leaflets as produced by the relevant manufacturer are supplied and the
pharmacist provides verbal medicines counselling when discharge medicines are issued.
There is a specific leaflet explaining the use of unlicensed medicines.
An appropriate range of medicines reference texts was seen in the pharmacy department
and current copies of the British National Formulary were available in clinical areas. Use of
medical information reference websites was also discussed.
There is a procedure governing use of medicines outside the summary of product
characteristics or for unlicensed products. This requires that a form is completed to record
the patient name, batch number and expiry date of each dose administered; examples of this
document were seen although it was mentioned that they are not always fully completed.
There is a research policy regarding participation in clinical trials, though none are currently
in progress.
A number of patient group directions under development in line with current guidance were
discussed with the pharmacist inspector.




BUPA South Bank Hospital                                                         Page 35
Standard C23 (C23.1 - C23.6)
A record is kept of ordering, receipt, supply, administration and disposal of all
medicines, dressings and medical gases in order to maintain an audit trail.
Key findings/Evidence                                          Standard met?          3
Electronic or paper records were available for medicines orders, receipts, supplies,
administration and disposal.
Appropriate lockable storage was seen for various categories of medicines including those
for internal and external use, temperature sensitive items, controlled drugs and flammable
products.
Medical gases in cylinders and bulk tanks of liquid oxygen were stored in locked, clean and
tidy purpose-built facilities displaying suitable hazard signs.
Safe custody of keys to medicines storage was evident during the inspection.
A number of designated lockable drug refrigerators were located in various departments.
These have the minimum and maximum temperatures monitored and recorded by pharmacy
department staff.
There is a procedure to follow if the temperature goes out of the normal range and a recent
instance of this was discussed with the pharmacy inspector.



Standard C24 (C24.1 - C24.6)
Controlled drugs are handled in compliance with the requirements of the Misuse of
Drugs Act 1971 and its regulations.
Key findings/Evidence                                        Standard met?            2
The handling of controlled drugs as observed was compliant with relevant legislation, except
some instances of record keeping as noted below.
A valid, in date Home Office licence authorising stock of a range of controlled drugs was
seen.
Documentation seen confirmed that controlled drug orders and issues are under the direct
control of a pharmacist.
Controlled drug registers examined by the pharmacist inspector demonstrated compliance
with record keeping standards, except for some in the operating department. Entries were
seen where the administering anaesthetist bracketed multiple patient entries and signed
once only; this has been noted in previous audits. These examples however were dated,
timed, wasted portions were recorded and corrections made legibly.
The general manager is authorised by a valid Home Office licence to witness destruction of
controlled drugs, this procedure was verified by entries in the pharmacy controlled drug
registers.




BUPA South Bank Hospital                                                      Page 36
Standard C25 (C25.1)
Key infection control policies are in place, including:

•    Universal infection control precautions.
•    Hand hygiene.
•    Prevention of occupational exposure to blood borne viruses (BBVs) and post
    exposure prophylaxis.
• Safe handling and disposal of clinical waste.
• Housekeeping and cleaning regimes for all patient/client areas.
• Relevant training and access to advice on infection control.
• Occupational health policies for prevention and management of communicable
    infections in health care workers, including those infected with blood borne
    viruses.
Key findings/Evidence                                          Standard met?             3
The infection control manual contains key policies and supporting procedures, these
corporate policies are supplemented by local operational policies and procedures.
Infection control is covered on clinical and non-clinical mandatory training days for all
members of staff and additional advice is available from the lead nurse for infection control.
Audits of infection control practices are carried out by the lead and link nurses.


Every resuscitation event is audited against European Resuscitation               YES
Council treatment algorithms.


Standard C26 (C26.1-C16.2)
Medical devices intended for single use are not reprocessed for reuse.
Key findings/Evidence                                   Standard met?                   2
Single use items were reprocessed in the department’s SSU.




BUPA South Bank Hospital                                                         Page 37
Standard C27 (C27.1-C27.4)
There is a written resuscitation policy for the establishment/agency, which is:

• Developed in discussion with (as a minimum) the senior health care professionals.
• In line with Resuscitation Council (UK) guidelines.
• Includes a section on ethical/legal consideration.
Key findings/Evidence                                           Standard met?              3
There is a corporate resuscitation policy written in line with current European guidelines, it
includes a section on ethical and legal considerations.
The inspector was advised that the resuscitation policy is brought to the attention of
personnel, a printed copy is kept in clinical areas and the master copy is available on the
hospital intranet.
All care staff have annual updates in basic life support as a minimum and training records
confirmed this. Several qualified staff members have undertaken further training to advanced
or immediate life support level.
The exploration of the wishes of patients with life-limiting illness or at risk of adverse events
is detailed in the policy.



Standard C28 (C28.1-C28.2)
There are written, dated and signed contracts between the establishment/agency and
those organisations or individuals with which it contracts for the supply of, or
provision to, goods and services.
Key findings/Evidence                                     Standard met?               3
The inspector saw copies of formal written agreements, which were dated and signed,
between the hospital and external suppliers of goods and services. These included
maintenance contracts for and building services, such as electrical, gas, heating, ventilation,
alarm, call and paging systems and catering equipment.

An additional contract exists for biomedical equipment maintenance with the local NHS
Trust. The standard corporate contract agreement includes provision for quality monitoring
arrangements. Service calls provided as part of contractual arrangements are monitored for
compliance using a custom software program.




BUPA South Bank Hospital                                                          Page 38
                   Records and Information Management
                       Introduction to Core Standards C29 to C31

             The intended outcomes for the following set of standards are:

•    Records are created, maintained and stored to standards that meet legal and
    regulatory compliance and professional practice recommendations.
•    Patients/clients are assured of appropriately completed health records.
•    Patients/clients are assured that all information is managed within the regulated
    body to ensure patient/client confidentiality.

Standard C29 (C29.1-C29.6)
The registered person ensures that there is a records policy for the creation,
management, handling, storage and destruction of all records that ensures that
records are managed, and stored securely, in accordance with the Data Protection
Act 1998.
Key findings/Evidence                                         Standard met?          3
The policy in place for the creation and management of records is in line with the
requirements of the Data Protection Act 1998. Timescales for the retention of any records
are also in line with the relevant periods prescribed by legislation.

There are back-up arrangements in place for handling technical breakdown in the
information systems to avoid loss or corruption of information held. An authorised contractor
carries out the destruction of records on an annual basis; a certificate of destruction is
provided for this service.

A post holder responsible for the up dating and safe keeping of records has been nominated
since the previous inspection.




BUPA South Bank Hospital                                                        Page 39
Standard C30 (C30.1-C30.7)
All entries in patients’/clients’ health records by health care professionals are dated,
timed and signed, with the signature accompanied by the name and designation of
the signatory.
Key findings/Evidence                                         Standard met?            2
Entries in the patient’s health care records reviewed by the inspectors were mostly legible;
nurses’ entries were also dated and signed. However recordings made by medical
practitioners did not generally include the time that an entry was made, a legible signature or
the designation of the signatory. The inspector was advised this is an area that is now
subject to audit scrutiny.

Care pathways are used extensively with health care professionals recording the care and
treatment they have given to patients. Entries from all members of the multi-disciplinary team
were seen in the records reviewed by the inspector. The medical records committee now
audit compliance with this standard.

Information is sent to the patient’s GP, but only after the patient’s consent has been
obtained, within 24 hours of discharge. A copy of the discharge summary is always given to
the patient at the time of their discharge from hospital.


Standard C 31 (C31.1-C31.6)
There is a written information management policy which sets out how the
establishment ensures that information held by the establishment on patients/clients,
their families and staff is handled confidentially.
Key findings/Evidence                                         Standard met?            3
There is a corporate policy setting out how the hospital will manage information in a
confidential manner; this policy and its supporting procedures reflect both the relevant
legislation and recommended good practice. Three training events have been held over the
last year to promote an awareness of the importance of confidentiality and data protection by
members of staff.

Discussions with members of staff and observation of practice demonstrated that staff are
familiar with the policy for information management and comply with its instructions.

Information for patients on how to access their health care records is outlined in the patient’s
information guide. Information is submitted to the Healthcare Commission and other national
data sets as required.




BUPA South Bank Hospital                                                          Page 40
                                         Research
                            Introduction to Core Standard C32

             The intended outcomes for the following set of standards are:

•   Any research conducted in the establishment/agency is carried out with
    appropriate consent and authorisation from any patients/clients involved, in line
    with published guidance on the conduct of research projects.

Standard C32 (C32.1-C32.12)
There is a written policy which states whether or not research is carried out in the
establishment.
Key findings/Evidence                                       Standard met?              0
The standards relating to this section were inspected at last year’s inspection, and therefore
this report should be read in conjunction with the 2003/2004 inspection report. In addition,
the registered provider has formally confirmed that this standard meets the criteria set out in
the National Minimum Standards.




BUPA South Bank Hospital                                                         Page 41
Service Name      South Bank Hospital        Visit Date     31/01/05


           Service Specific Standards for Acute Hospitals

   1. Information provision
   2. Human resources
   3. Risk management
   4. Children’s services
   5. Surgery
   6. Critical Care
   7. Radiology
   8. Pharmacy services
   9. Pathology services
   10. Cancer services




BUPA South Bank Hospital                                  Page 42
                                    Acute Hospitals
                            Introduction to Standards A1 to A45



                               Information Provision
             The intended outcomes for the following set of standards are:

•    Patients receive clear information about their treatment.
•    Patients are not misled by advertisements about the hospital and the treatments it
    provides.
Standard A1 (A.1-A1.5)
Information materials for patients are written in concise, plain language and explain in
non-technical language what the procedure involves and treatment alternatives.
Key findings/Evidence                                        Standard met?             3
There is a range of information, both generic and treatment specific, available for patients to
take away after a consultation at the hospital. Information leaflets concerning the 20 most
common procedures carried out at the hospital were issued in July 2004; the information is
written in plain language and explains the procedures and any alternatives, any risks are
also stated explicitly.

Patient’s rights and special needs are addressed and information is provided in large print,
Braille and different languages; translation services are available if required.

Written instructions are available for post-discharge care, this provision was confirmed in
discussions with patients during the inspection.

The corporate patient information leaflets have been reviewed with some consultant input.


Standard A2 (A2.1-A2.4)
All advertising complies with Advertising Standards Authority standards.
Key findings/Evidence                                       Standard met?              0
The standards relating to this section were inspected at last year’s inspection, and therefore
this report should be read in conjunction with the 2003/2004 inspection report. In addition,
the registered provider has formally confirmed that this standard meets the criteria set out in
the National Minimum Standards.




BUPA South Bank Hospital                                                         Page 43
                                   Human Resources
                                      Standards A3 – A8

             The intended outcomes for the following set of standards are:

•    Patients receive investigation and treatment from appropriately trained, qualified
    and insured medical practitioners.
• Medical practitioners who work independently in private practice are competent in
    the procedures they undertake and the treatment and services they provide.
• Patients receive treatment from medical practitioners who have the appropriate
    expertise.
• Patients have an appropriately skilled and trained doctor available to them at all
    times within the hospital.
• Patients receive treatment from appropriately skilled and qualified members of the
    allied health professions.
• Patients receive treatment from appropriately skilled and qualified members of the
    allied health professions.
Standard A3 (A3.1-A3.4)
All medical practitioners (i.e. including medical practitioners undertaking independent
private practice whether employed, contracted or self-employed providing health
screening or resident medical officer services on behalf of and as part of the hospital)
are registered with the General Medical Council as medical practitioners.
Key findings/Evidence                                      Standard met?             3
There has been an improvement in the obtaining and maintenance of information required
regarding medical practitioners since the last inspection.
The 5 files reviewed contained evidence of both current registration with the General Medical
Council (GMC) and appropriate professional indemnity insurance. There is a system in place
to remind all medical practitioners when expiry dates are due.

The consultant processes policy is being updated to ensure that all medical practitioners
receive annual appraisals; as part of their application for practising privileges practitioners
must confirm that they participate in an appraisal system within their NHS post. The hospital
has recently developed links with the NHS Acute Hospital Trust for the sharing of evidence
of practitioner’s appraisals for review.

Information regarding clinical outcomes and performance indicators are required to be
provided by practitioners as part of the granting of practising privileges; the data is then
included in both the quarterly and annual clinical governance reports.




BUPA South Bank Hospital                                                           Page 44
Standard A4 (A4.1-A4.3)
Medical practitioners who work independently in private practice:
• Clearly demonstrate that they have the necessary qualifications, expertise and
   experience to undertake competently and safely the treatment and services they
   provide.
• Have arrangements in place for continuing medical education relevant to the
   treatment and services they provide.
Key findings/Evidence                                       Standard met?              2
There was evidence within the five files reviewed, to indicate that medical practitioners have
the necessary qualifications, expertise and experience to undertake safely and competently
the services they currently provide. As stated previously there was little evidence of
continuing professional development within the files reviewed at this inspection.

The methods of monitoring and reviewing the scope of practise for medical practitioners
were discussed with the registered manager and matron; the clinical governance committee
has also considered this issue recently. The bookings department, theatre manager and
matron liaise to ensure that activities undertaken by practitioners at South Bank reflect their
NHS activities, their expertise and their experience. All qualifications and experience are
checked through the procedures followed when practicing privileges are applied for.

All medical practitioners, including those undertaking cosmetic surgery, are on the specialist
register of the GMC.


Standard A5 (A5.1-A5.4)
Where medical practitioners are granted practicing privileges there is a medical
advisory committee for the hospital, which is responsible for representing the
professional needs and views of medical practitioner to the registered manager of the
hospital.
Key findings/Evidence                                        Standard met?              3
The medical advisory committee (MAC) meets on a quarterly basis and formal minutes are
kept of the meetings. A constitution outlining terms of reference for this committee is in
place.

Agenda items for discussion at medical advisory committee meetings include clinical
governance, new applications for practicing privileges, review of those privileges due for
renewal and any new techniques being considered by practitioners.

Evidence is available to indicate that the MAC reviews information collected on the clinical
work undertaken at the hospital, by practitioners with practicing privileges, through the
quarterly clinical governance report that it receives from matron.




BUPA South Bank Hospital                                                         Page 45
Standard A6 (A6.1-A6.9)
Where the establishment provides in-patient care there is a resident medical officer
available on immediate call at all times to manage urgent patient care in the absence
of the consultant under whom the patient is admitted.
Key findings/Evidence                                        Standard met?            3
A contract with Cape Medical Services ensures that there is a suitably trained resident
medical officer (RMO), available at all times, to manage patient care in the absence of the
admitting consultant.
The RMO on duty at the time of the inspection felt confident that he has the relevant post
registration experience required for this role; he has undertaken training for advanced life
support and paediatric life support techniques during 2004.

A written job description for the RMO includes line management arrangements and on call
and shift patterns; matron provides line management support.
The RMO confirmed to the inspector that he had received induction training specific to his
role; he was able to access advice and support from consultants generally as opposed to a
named mentor. Contact lists and communication arrangements are documented.

On site accommodation with a telephone connection to the hospital’s internal switchboard is
provided for the RMO.


Standard A7 (A7.1-A7.6)
Patients requiring consultation with, or treatment from, a member of one of the allied
health professions is seen by a practitioner who is registered with the Health
Professions council.
Key findings/Evidence                                       Standard met?              3
Evidence was seen to confirm that all health professionals are registered with their relevant
regulatory body. Guidelines from their professional bodies are followed and members of
staff comply with codes of practice when treating patients.

Out of hours arrangements for evening and weekend work are covered by the use of
permanent bank staff. There is a local on call policy for this establishment.

Good lines of communication are maintained between various members of the multi-
professional team caring for the patients. The care provided for in-patients is recorded in the
care pathways used by all staff; the physiotherapists in outpatients department keep a
separate set of records.




BUPA South Bank Hospital                                                         Page 46
Standard A8 (A8.1-A8.10)
The registered person ensures that health care professionals are qualified and trained
for the roles they undertake.

Key findings/Evidence                                       Standard met?              0
The standards relating to this section were inspected at last year’s inspection, and therefore
this report should be read in conjunction with the 2003/2004 inspection report. In addition,
the registered provider has formally confirmed that this standard meets the criteria set out in
the National Minimum Standards.




                                  Risk Management
                                     Standard A9 – A13

             The intended outcomes for the following set of standards are:

•   Patients, staff and anyone visiting the hospital are assured that all steps are taken
   to ensure the safety of the hospital environment through the ongoing assessment
   and management of risks, in relation to all the hospital’s activities.
• The risk of patients, staff and visitors acquiring a health care associated infection
   is minimised.
• Patients are not infected by contaminated medical devices.
• Patients are resuscitated appropriately.
Standard A9 (A9.1)
An annual health and safety report is produced by the hospital. The report
summarises the actions taken to ensure a safe, healthy environment, including, for
example, training given to staff, risk assessments undertaken and action taken as a
result, and an outline plan for health and safety actions to be implemented in the year
ahead.
Key findings/Evidence                                       Standard met?            4
A well structured health and safety report has been compiled by the head of non-clinical
services; the draft report for 2004 includes an executive summary and covers clinical and
non-clinical risk management, health and safety audits undertaken, adverse incidents, an
analysis of training needs and an action plan.




BUPA South Bank Hospital                                                         Page 47
Standard A10 (A10.1-A10.13)
There is an infection control team (ICT), either within the hospital or in another
organisation to which the hospital has formal links and membership of the infection
control team of that organisation.
Key findings/Evidence                                         Standard met?             3
A multi-disciplinary infection control team has formal links with the local NHS Trust; the
infection control team has input from a microbiologist and a nurse specialist in infection
control as well as from matron, the link nurses, maintenance and health and safety
representatives.

There is a nurse with designated responsibilities for infection control included within her job
description; she has undertaken specific corporate training for this role. Link nurses from
different departments within the hospital support the lead nurse.

Meetings are now held with the occupational health nurse and matron to ensure that
infection control advice relating to health and safety matters and the possible transmission of
infection from members of staff to patients is addressed.

Audits into infection control practices are carried out and provide comparative data on
performance indicators on a corporate as well as local level. An audit carried out in
September 2004 identified the need for a link nurse in the theatre department; this is
currently being actioned.

Written guidance on infection control, which reflects the relevant legislation and published
professional guidance, is available throughout the hospital; it contains all of the relevant
corporate and local policies and procedures. Risk assessments carried out include
references to legislation and guidance as well as links to relevant HTM’s.

The liaison nurse set up an infection control notice board in 2004; displays are aimed at
improving the understanding of potential infection control issues and risks. The board is
updated regularly and topics covered have included MRSA, hospital acquired infections and
hand washing.


Standard A11 (A11.1-A11.25)
Clear lines of accountability for all parts of the decontamination cycle are established.
Key findings/Evidence                                       Standard met?            2
The inspector was advised that the current structure of the Sterile Service Unit (SSU) is due
for an imminent upgrade. The current structure does not meet the principles of HBN13.
Dedicated personnel work within the area.

The washer disinfector was not managed in accordance with HTM 2030 due to no daily
checks being carried out or maintained. The ultrasonic washers (USWs) were not managed
in accordance with HTM 2030 as no daily or weekly log records were maintained. The USWs
were used without filters contrary to the manufacturers instructions. It was noted that items
placed within the USWs were not rinsed prior to further thermal decontamination procedures.

Records of manual processing procedures were not maintained. The inspector was advised
BUPA South Bank Hospital                                                          Page 48
that ophthalmic instrumentation was manually processed prior automated processing.

The format of instrument lists did not require information as to theatre usage.

It was noted that the emergency eyewash solution was available, in the decontamination
area, but not appropriately stored.

The instrument assembly and packing room is shared with the autoclave room. Thick dust
was noted on high level surfaces. A commercial traceability system is in operation. It was
noted that sterile instrumentation was stored in the area, some on solid shelving. Items
wrapped in tray wrap were not routinely effectively wrapped, as evidenced and discussed. A
number of raw consumables were being produced in the SSU. It was noted that single use
theatre consumables were reprocessed.

A large quantity of sterile supplementary items were found to be out of date; some as old as
1998. A number of items had missing traceability labels. Items were located on shelf areas
and on speciality trolleys. It was noted that Laryngeal Masks (LMA’s) and processed re-
usable red rubber endotracheal tubes did not have full traceability labelling.

Single use items appeared to have been reprocessed.

No cooling signs were available for appropriate placement on hazards.


ENDOSCOPY

There is a dedicated area for endoscopic procedures located within the theatre department.
The area has undergone a recent upgrade. Flexible endoscopes were hung on a wall for
storage.

An in-house traceability system was in operation and appeared to be working effectively. A
separate processing room was available adjacent to the procedure room. It was noted that
the automatic endoscopic reprocessor (AER) was not managed in accordance with HTM
2030, as daily checking procedures were not undertaken. Neither bacteriological sampling of
the final rinse water from the AER nor efficacy testing were carried out. The registered
person was advised of the need to urgently address these issues.

History logs were available for flexible endoscopes.

It was noted that rigid endoscopes, accessories and cameras were soaked in a demarcated
area within the prep room. It appeared that no traceability system was in operation to
support these procedures for either retention in the department or within the patients’ notes.




Standard A12 (A12.1-A12.11)
The registered person ensures that patients’ rights are central to decision making on
resuscitation, including taking account of advance directives (living wills).

BUPA South Bank Hospital                                                          Page 49
Key findings/Evidence                                         Standard met?               3
The resuscitation policy makes reference to patient’s rights, consideration of advance
directives, the management of ‘do not resuscitate’ decisions and treatment withdrawal
judgement. The inspector was advised that this is also covered in the Advanced Life
Support training course.
The policy also describes the procedures for documenting and reviewing resuscitation
decisions and there is a specific form to record the discussions held and decisions reached
in the case of patients expressing the wish not to be resuscitated; this is filed inside the front
cover of the medical notes.
The policy defines responsibilities and states the team approach to application of the policy;
there is always a doctor plus members of the nursing staff with an understanding of this on
duty.
The RMO holds current advanced training certificates for adult and paediatric life support
and it was also evident that several nurses hold advanced and/or paediatric life support
qualifications.
Resuscitation drills are now carried out in accordance with the policy every two months;
audit forms for each drill carried out were available for inspection.
Review of these drills forms an audit of the operation of the policy and a member of staff
discussed with the inspector how practice has progressed since information from the drills
has been considered.



Standard A13 (A13.1-A13.1)
Resuscitation equipment is readily available.
Key findings/Evidence                                       Standard met?               3
Resuscitation trolleys are easily accessible in various departments. Specific paediatric drugs
and equipment are kept where children may be seen; this is under current review.
Trolleys are stocked with the necessary equipment as recommended by the European
Resuscitation Council to secure the airway and gain intravenous access, plus a defibrillator
and resuscitation drugs. Additional peri-arrest drugs are kept in specified areas; it was noted
that the range of these was not as recommended by the Resuscitation Council UK, though is
compliant with the corporate policy.
A checklist was seen on each trolley examined detailing the contents and signed records
verified that they are checked daily.
The equipment consists of single use disposable items and therefore there is no
decontamination procedure.




BUPA South Bank Hospital                                                            Page 50
                                 Children’s Services
                                    Standards A14 – A19

             The intended outcomes for the following set of standards are:

•   The non-clinical needs of children are recognised and addressed.
•   Children receive treatment from appropriately trained and qualified health care
    professionals.
• Children’s treatment is provided with the appropriate facilities and equipment.
• Children receive appropriate treatment in connection with surgery.
• Children receive appropriate pain control.
• In emergencies, children are transferred quickly and safely to paediatric units.
Standard A14 (A14.1-A14.4)
There is a pre-planned programme and the opportunity for a pre-admission visit to
allay anxiety on the part of the child.
Key findings/Evidence                                      Standard met?               0
This standard was not assessed at this inspection, currently the hospital is not admitting as
in-patients, children under 16 years of age.




Standard A15 (A15.1-A15.16)
There is a written admission policy for children, which identifies the criteria for
paediatric admissions for which the hospital has the relevant services, facilities and
trained personnel.
Key findings/Evidence                                      Standard met?              0
This standard was not assessed at this inspection, as currently the hospital is not admitting,
as in-patients, children under 16 years of age.




BUPA South Bank Hospital                                                         Page 51
Standard A16 (A16.1-16.4)
Children are seen in a separate outpatient area, or where the hospital does not have a
separate outpatient area for children, they are seen promptly.
Key findings/Evidence                                       Standard met?            3
Children and young people are seen in the outpatients department, which does not have a
separate area for children. The inspector was advised that all children are seen promptly in
designated ENT and paediatric clinics. A paediatric environmental audit and risk assessment
of the outpatients department has been carried out by the RSCN.
Toys and books are available for children in the outpatients department.


Standard A17 (A17.1-A17.8)
Prior to surgery, children are left without food or drink for as short a time as possible,
in consultation with the anaesthetist.
Key findings/Evidence                                      Standard met?               0
This standard was not assessed at this inspection, currently the hospital is not admitting as
in-patients, children under 16 years of age.




Standard A18 (A18.1-A18.4)
There are written procedures for the assessment of pain in children and the provision
of appropriate control.
Key findings/Evidence                                      Standard met?               0
This standard was not assessed at this inspection, currently the hospital is not admitting as
in-patients, children under 16 years of age.




Standard A19 (A19.1-A19.5)
There is a written policy for a child who becomes unwell, or unstable, or who
develops complications as a result of planned surgery, to be immediately transferred
to a paediatric unit.
Key findings/Evidence                                      Standard met?               0
This standard was not assessed at this inspection, currently the hospital is not admitting as
in-patients, children under 16 years of age.




BUPA South Bank Hospital                                                        Page 52
                                          Surgery
                                     Standards A20-A28

             The intended outcomes for the following set of standards are:

•   Patients are assured that effective procedures for surgery are in place.
•   The procedures for surgery assure patients of safe and effective treatment.
•   Patients receive the appropriate level of care when receiving surgical treatment.
•   Operating theatres have appropriate facilities, equipment, support services and
   staffing arrangements.
• Patients are assured of safe and effective dental treatment under general
   anaesthesia.
• Patients are clear as to what cosmetic surgery entails, and are assured about the
   skills and experience of those carrying out those procedures.
• Patients undergoing day surgery receive appropriate treatment and support,
   including the pre and post-operative periods.
• Transplantation takes place safely and sensitively.
Standard A20 (A20.1-A20.8)
There are written policies and procedures for the carrying out of surgical operations,
covering staffing arrangements, equipment, installations, facilities and theatre
practice.
Key findings/Evidence                                    Standard met?           2
The department does not comply with the principles of HBN 26.

A number of good management systems appeared to be in place within the department. A
number of local policies were in place.

Sharps bins were located directly on the floor within the theatres.

Scrub personnel routinely checked patient consent forms and allergy status. Good practices
were observed with swab needle and instrument count procedures. It was noted that counts
entered on the swab board were not linked to the patient undergoing the procedure as no
patient details/ID number or allergy status were documented. Used instrumentation was not
routinely contained prior to transfer to the decontamination area.

A rigid sigmoidoscopy procedure was undertaken without the use of a single patient use
filter.

NMS 20.8 was not met, as operating registers were not fully completed. In theatre 2 there
was currently no register available; sheets of paper were in use. Omissions observed
included: times and signatures of personnel. There was unclear documentation of
procedures as to laterality and location. Ophthalmic procedures were not routinely fully
completed; this was due to cataract only being documented when an intraocular lens implant
had also been carried out. It was noted that no system was in place for the validation of
entries.

BUPA South Bank Hospital                                                     Page 53
The walls of the preparation room required cleaning. The area was found to contain expired
consumable items. Bottles of Proflavine Cream and water were opened but not dated. Tubes
of lubricating gels were generally reused until empty.

ENDOSCOPY

The inspector was advised that personnel had received training with the endoscope
manufacturer and one staff member was in possession of ENB 906. Personnel have
received training. Good patient checking and transfer procedures were observed. It was
noted that the consent form for one patient was obtained in the procedure room immediately
prior to the procedure. An appropriate number of personnel facilitated procedures. It was
noted that the theatre assistant administered oxygen to the patient.

Processed endoscopes were safely handled. It was noted that an effective traceability
system to identify endoscopes and the accessories used per patient. The endoscopist’s
assistant did not wear all appropriate PPE.

It was noted that patient privacy and dignity issues were potentially compromised during
endoscopic procedures. A door leading from the procedure room to a storeroom utilised by
hospital porters and housekeeping personnel, contained a viewing panel.

Expired blood bottles were found in the area.



Standard A21 (A21.1-A21.10)
All surgery patients have a pre-admission appointment with the surgeon/practitioner
who will be carrying out the procedure.
Key findings/Evidence                                       Standard met?              2
Consultants generally, pre-admission see their patients, this is supported by local policies. It
was noted during patient tracking procedures that one patient was consented in the
endoscopy procedure room immediately prior to the procedure taking place.

The inspector was informed that all patients are seen pre-admission. Patients when
interviewed by the inspector confirmed this.

NMS A21.9 and A21.10 were not applicable.




BUPA South Bank Hospital                                                          Page 54
Standard A22 (A22.1-A22.16)
The anaesthetist who is to give the anaesthetic visits the patient before the operation
and assesses the general medical fitness of the patient, reviews any medication being
taken, and assesses any specific anaesthesia problems.
Key findings/Evidence                                      Standard met?        1
A number of issues were highlighted during the inspection.

The anaesthetic rooms were in need of cleaning. High level areas contained a large quantity
of dust. Up to date records for the checking of anaesthetic equipment were seen. Cleaning
records were not maintained for anaesthetic rooms and equipment. Anaesthetic equipment
located in anaesthetic rooms, operating theatres and the recovery area were in need of
cleaning. Probes and leads were not routinely cleaned between patients. Bair hugger hoses
were contaminated without exception.

Consumable items were not well managed. It was noted that: endotracheal tubes (ETTs)
were pre-cut and prepared, guedal airways were not in any packaging and intubating
bougies no longer had manufacturers’ information available.
Expired stock was found in anaesthetic rooms and storage areas, as evidenced.

There was poor management of LMAs during procedures. In one anaesthetic room a
number of LMAs were opened and packets removed. There was no traceability system in
operation to allow for the retention of documentation of LMAs used, within patient records.
Anaesthetic breathing filters were prepared for an entire afternoon list well in advance. The
filters, on checking, appeared to be moist due to condensation.

Blue dressing gauze was in general use in the anaesthetic rooms. Though it was evident
that some anaesthetic equipment had been autoclaved they were not always appropriately
tracked. Anaesthetic assistants did not routinely wear gloves during cannulation and
intubation procedures.

Table supports for use with patient positioning were maintained on the floor; they were in
need of cleaning.

Patient checking procedures and manual handling manual handling procedures were
observed to be good.

The recovery area is located within the theatre department. It contained two fully equipped
bays. All monitoring equipment appeared to meet relevant guidelines.

Patient care, communication and documentation in notes were of a good standard.
Observation of patient handover was evidenced. It was observed to be comprehensive.

Insufficient screens were available to provide patients with privacy and dignity. Available
screens were deployed for the screening of instrumentation and equipment within the area.

NMS A22.16 was fully met, as discharge criteria are available.

Resuscitation trolley was found to contain intubating bougies and guedal airways without
BUPA South Bank Hospital                                                         Page 55
manufacturers’ details regarding lot nos. and expiry dates, as packaging had been removed.
The emergency portable suction unit was in need of cleaning and the filter required
changing. The suction end was found to be uncovered.

An anaesthetic machine is available for use in the area. The equipment was poorly
managed. No check or cleaning records were maintained. The Blease MP3 ventilator was
thickly covered with dust. The inspector was advised that it had not been used for a long
period. Evidence was seen that the ventilator had been serviced. It was noted that 1997 and
2004 AAGBI guidelines were available for reference. There was poor management of the
breathing circuit.



Standard A23 (A23.1-A23.9)
Operating theatres have available instruments and equipment from a sterile services
unit.
Key findings/Evidence                                       Standard met?            1
All instrumentation is processed in the hospital’s SSU; see A11 above. It was noted that
sterile instrumentation was stored within the recovery area on shelves and on the floor, as
evidenced.

The fabric of the department was in general need of attention. Door architraves and panels
were in a poor state and required repair, as evidenced.
The fabric of the anaesthetic room also required work.

An area of exposed plaster was seen in theatre 1 also an area of cladding was broken. Floor
coving was loose and unsealed in places; in theatre 1 and the scrub room adjacent to
theatre 2. The scrub room adjacent to theatre 1 and the preparation room required repairs to
the walls due to holes. The scrub sink required resealing of the sink area, as evidenced.

Furniture within the department was in a poor state of repair; torn seat covers were seen on
stools, and the anaesthetic chair in theatre 2, heavy corrosion was noted on some theatre
equipment.

The condition of the operating table mattress in theatre 2 appeared poor.

The fabric of the recovery area was in a poor state of repair. The registered person was
advised of the urgent need to make good the area. The chair in the recovery area was
inappropriate for a clinical area as it was made of fabric; it was also in a poor state of repair.
The sealant around the clinical hand washbasin in the area required renewal.

A number of clinical hand washbasins within the department did not comply with HTM 64.

A warming cabinet is located within the department’s preparation room. Manufacturer
guidance on the storage of intravenous and irrigation fluids in warming cabinets was not
available. The cabinet was found to contain a selection of endotracheal tubes; one tube was
very discoloured. Skin prep solutions and bottles of pharmaceutical lotions were also stored
within the cabinet.


BUPA South Bank Hospital                                                            Page 56
NMS A23.3 – A23.5 were fully met. Some portable suction units required filter changes.

There is a management hierarchy within the department that ensures that an experienced
RN1 is on duty at all times. The theatre manager manages staffing requirements. Personnel
know their duties a week in advance. Evidence of job descriptions was seen.

ENDOSCOPY

The fabric of the minor ops room was in need of completion. A visual inspection of the area
with the theatre manager and maintenance personnel was undertaken to identify the areas
for attention.




Standard A24
Establishments carrying out dental surgery under general anaesthesia meet the
Department of Health, General Dental Council and Royal College of Anaesthetists
guidance with regard to procedures and facilities.
Key findings/Evidence                                      Standard met?    2
The procedures for dental surgery are the same as for all surgery.




Standard A25 (A25.1-A25.15)
Cardiac surgery must take place in operating rooms fully equipped for cardiothoracic
surgery.
Key findings/Evidence                                Standard met?            0
Not undertaken at this facility.




BUPA South Bank Hospital                                                       Page 57
Standard A26 (A26.1-A26.7)
Surgeons performing cosmetic surgery procedures belong to a relevant professional
organisation, which provides continuing medical education and adheres to the
principles of the GMC’s Good Medical Practice.
Key findings/Evidence                                    Standard met?      2
The procedures for cosmetic surgery are the same as for all surgery.




Standard A27 (A27.1-A27.5)
There are procedures for appropriate patient selection for day case surgery. These
include consideration of social factors such as whether the patient lives alone or has
someone available to stay with them.
Key findings/Evidence                                  Standard met?            2

Out Patient Department (OPD)

All areas appeared clean and tidy. A good transfer system for the returning of used
instrumentation and clean returns from the SSU was in operation.

Minor Procedure Room

No procedural register is maintained. A quantity of expired consumables was located on the
gynae trolley stored in the area. Sterile instrument sets were inappropriately stored. No lists
accompanied the instrument sets. The clinical hand washbasin in the area contained an
overflow.

Treatment Room

A number of sterile supplementary instrumentation was found to have expired. German
ophthalmic swabs contained no CE marking, lot number or expiry date. The inspector was
advised that the flexible nasendoscope was cleaned with soap and water and then wiped
with a steret between patients and a sheath employed.

The inspector was advised that reusable supplementary ENT instrumentation is removed
from packaging provided by the hospital’s SSU in advance of procedures. The registered
person has provided an action plan addressing these issues.

Filters were routinely used during rigid sigmoidoscopy procedures. Expired blood bottles
were found in the area.



Standard A28 (A28.1-A28.9)
The requirements of the Human Organs Transplants Act 1989 are complied with.
Key findings/Evidence                             Standard met?           0
BUPA South Bank Hospital                                             Page 58
Not undertaken at this facility.




BUPA South Bank Hospital           Page 59
                                       Critical Care
                                     Standards A29-A30

             The intended outcomes for the following set of standards are:

•   Appropriate post-operative and emergency arrangements are in place for patients
   who undergo surgery.
• Patients are assured that where level 2 or level 3 critical care is provided, as
   appropriate, within the hospital, it is done so effectively.
Standard A29 (A29.1-A29.12)
There are level 1 critical care facilities available for patients who have received
treatment under general anaesthetic and require:

•     Frequent observation by nursing staff.
•     Frequent or continuous cardiovascular monitoring.
•     High risk intravenous infusions, for example anti-arrhythmic, vasodilators or
     inotropes.
Key findings/Evidence                                         Standard met?            3
All patients who have received treatment under general anaesthetic will receive level 1
critical care on the wards post operatively; this care includes frequent monitoring and
observation by nursing staff. Cardiac monitors, infusion pumps, syringe drivers and patient
controlled analgesia pumps are currently available for monitoring patients’ progress post
operatively on the ward areas.

Patients are assessed at the pre-admission screening clinic to determine the likely post-
operative level of care needed; no patients are admitted where there are identified pre-
operative conditions, which would indicate the need for critical care, level 3 post-operatively.

The admitting consultant or anaesthetist is responsible for determining the level of care
required post operatively and for ensuring the appropriate handover to the nursing team in
the recovery area.

Patients are observed at regular intervals by the nursing staff and their observations are
recorded in the care pathways now used to plan patient’s care and treatment. Arrangements
are in place should a patient’s condition deteriorate; patients may be transferred to the
hospital’s HDU for additional support at level 2 for 48 hours or transferred to the local NHS
Acute Hospital Trust if intensive care is required. A transfer protocol is in place.
It is the admitting consultant who is responsible for determining whether level 2 or 3 critical
care is required.




BUPA South Bank Hospital                                                          Page 60
Standard A30 (A30.1-A30.3)
Establishments with critical care facilities at level 2 or 3 have arrangements in place in
line with the Intensive Care Society’s Standards for ICU (1998) and the Department of
Health’s Comprehensive Critical Care Report (May 2000), including;

•    Written criteria for the admission of patients to critical care beds.
•    A written policy and protocols for post-operative management.
•    Staff is briefed on the policy and protocols so that they are aware of what they
    should do in specific circumstances.
• Pathology services, including a blood bank.
• Critical care beds situated so that nursing staff are able to effectively observe the
    patient at all times.
• Critical care beds have sufficient space on both sides to enable care to be
    delivered whilst all the necessary equipment is in place.
• Arrangements for immediate back up and/or replacement in the event of
    equipment failure.
• Records kept of the use of each ventilator (to enable appropriate servicing
    arrangements in line with the manufacturer’s instructions).
Key findings/Evidence                                            Standard met?            3
Critical care facilities up to level 2 are provided in theatre recovery and the hospital’s high
dependency unit (HDU). Two high dependency beds are available for patients who have
been assessed as requiring this level of care and observation by nursing staff following a
general anaesthetic.

A nurse trained to look after patients at level 2 critical care is always on duty when patients
are admitted to this unit. Staffing levels are adjusted according to the level of need identified
at the patient’s pre-operative assessment. A 4 person named cardiac arrest team, that
includes the RMO and 2 ILS trained nurses, is on duty at all times.
The critical care policy describes the support services and facilities available on site for
imaging and at Worcester Royal Hospital for pathology services.

Visits by the admitting consultants and anaesthetists are recorded in the patient’s medical
notes according to the hospital’s critical care policy.

Formal arrangements are in place with the local NHS Trust for an immediate transfer to a
critical care facility if a patient’s condition deteriorates to that requiring level 3 critical care.
The intensive care transfer protocol includes the provision of a transfer team from the South
Bank hospital to the Royal Worcester Hospital.




BUPA South Bank Hospital                                                               Page 61
                                        Radiology
                                     Standards A31-A32

             The intended outcomes for the following set of standards are:

•  Patients and staff are assured that ionising and non-ionising radiation are
   undertaken in a safe and protective environment.
• Radiological treatment is provided by appropriately trained and qualified health
   care professionals.
Standard A31 (A31.1-A31.7)
The provision and use of facilities using ionising radiation re undertaken in
compliance with:

• The Ionising Radiations Regulations 1999.
• The Approved Code of Practice and Guidance.
• The Ionising Radiation (Medical Exposure) Regulations 2000.
• Associated professional guidance.
Key findings/Evidence                                       Standard met? 0
The standards relating to this section were inspected at last year’s inspection, and therefore
this report should be read in conjunction with the 2003/2004 inspection report. In addition,
the registered provider has formally confirmed that this standard meets the criteria set out in
the National Minimum Standards.




BUPA South Bank Hospital                                                         Page 62
Standard A32 (A32.1-A32.7)
In establishments where ionising radiation, radiopharmaceuticals or sealed sources
are used, a qualified and experienced person is appointed as a radiation protection
adviser.
Key findings/Evidence                                       Standard met?              2
Radiation protection advice is obtained through a corporately arranged contract; the annual
visit of the RPA took place in July 2004. A quality assurance and audit programme forms
part of this contract. However a number of requirements for action identified from this and
the previous visit by the RPA remain to be actioned.

The doctors who interpret the diagnostic images are all clinical radiologists on the specialist
register of the GMC and hold NHS consultant posts locally.
Only state registered diagnostic radiographers who are registered with their professional
body undertake any procedures in the department.
All ultrasound examinations are performed and reported on by an experienced medical
practitioner.

A mobile MRI unit provided by a third party supplier visits the establishment on a regular
basis; a policy for referrals to this facility is in place.




BUPA South Bank Hospital                                                          Page 63
                                Pharmacy Services
                                    Standards A33-A39

            The intended outcomes for the following set of standards are:

•   Responsibility for obtaining, prescribing, storing, use, handling, recording and
   disposal of medicines is clear.
• Medicines, dressings and gases are handled in a safe and secure manner.
• Prescription, supply and administration conform to the requirements of relevant
   legislation and best practice. Prescription, supply and administration of medicines
   is undertaken only by appropriately qualified, competent staff.
• Patients are assessed, consulted and advised before they are enabled to self-
   administer medicines.
• Measures are in place to ensure the safe and secure handling of medicines.
• Aseptic dispensing is carried out safely and appropriately.
• Medical gases are stored and supplied appropriately.
Standard A33 (A33.1-A33.5)
The registered manager ensures that the safe and secure handling of medicines and
medicines management is clearly defined.
Key findings/Evidence                                        Standard met?           3
Responsibilities for medicines management and handling are clearly defined in the
medicines policy; all drug orders are authorised by a pharmacist.
The pharmacy department provides a comprehensive pharmaceutical service; out of hours
cover is provided under an agreement with the local NHS Trust pharmacy department.
A Royal Pharmaceutical Society registration certificate for the pharmacist on duty was seen
on display in the pharmacy department.
Most departments are supplied with medicines by means of a top up service to agreed stock
levels.
The pharmacist offers ward based clinical services such as review of drug charts; advice on
drug therapy for healthcare professionals and individual discharge medicines counselling to
patients. A record of pharmaceutical interventions is kept.
Out of hours access to the pharmacy is restricted by a double lock entry system to the RMO
and the senior nurse on duty, accompanied access was evidenced by dual signatures on the
out of hours recording sheets. The pharmacist commented that this was also auditable using
the newly installed surveillance equipment within the hospital.




BUPA South Bank Hospital                                                     Page 64
Standard A34 (A34.1-A34.10)
All medicines, medical gases and interactive wound dressings are obtained by, and
stored under the control of a pharmacist, medical practitioner or registered nurse.
Key findings/Evidence                                       Standard met?             3
The pharmacist inspector observed satisfactory medicines control by appropriately qualified
staff in each area inspected.
Medicines were seen clearly labelled with printed instructions and stocks showed the batch
number and expiry date.
Individual patient medication charts were seen with spaces to record all of the required
information; a number of drug administration charts examined in detail were accurately
completed.
The medicines charts form part of the patient case notes and are retained for the time
specified in the medical records policy.
Use of patients’ own medicines is described in the medicines policy and there is specific
documentation to record quantities received on admission. There is a secure locker in each
bedroom to store medicines dispensed individually for each patient. The matron advised that
there has been a significant reduction in drug administration error reports since the
implementation of this system.
Pharmaceutical waste is returned to the pharmacy department for disposal in designated
waste bins. The pharmacist inspector was informed that controlled drug waste is denatured
before disposal according to current guidelines. An authorised contractor collects containers
of these types of waste. The pharmacist showed completed consignment documentation to
confirm tracking of waste to the inspector.
The medicines policy states that medicines specifically dispensed for a patient who dies in
hospital are retained for a month before disposal.




BUPA South Bank Hospital                                                       Page 65
Standard A35 (A35.1-A35.5)
Medicines are administered by a medical practitioner or a registered nurse in
accordance with the NMC’s Guidelines for the administration of medicines (April
2002), or by another health care professional assessed as competent to administer
those medicines.
Key findings/Evidence                                      Standard met?              3
Administration of medicines as described to the pharmacist inspector is in accordance with
legislative and professional guidelines.
A revised competency assessment policy has recently been produced and the inspector was
advised that this will be implemented when the patient group directions are introduced. All
nurses have passed a basic assessment for general medicines administration.
Medical practitioners or competent qualified nurses administer drugs by specialised
techniques.
Controlled drugs administration was stated as by a qualified clinician and witnessed; dual
signatures in CD registers demonstrate this, except as noted under standard C24.
Whenever possible, medicines are administered from the individual drug cabinet, otherwise
they are transported in a lockable drug trolley.
Any medicines no longer required are returned to pharmacy or collected by the pharmacist.



Standard A36 (A36.1-A36.6)
There is a written policy and procedure for self-medication, which conforms to the
duty of care inherent in the relationship of the hospital to the patient.
Key findings/Evidence                                         Standard met?                2
The corporate medicines policy includes the procedures for self-administration of medicines
and defines the labelling obligations and checks on compliance to be made by nursing staff.
The general limitations to this were explained to pharmacist inspector, since the majority of
patients are short stay surgical cases and self-administration during the perioperative and
recovery periods is inappropriate. In addition, the local policy will be to limit self-medication
to patients’ own medicines.
Locally developed draft forms for assessing patient capability to self-medicate were
discussed with the pharmacist inspector. Once these are ratified and training completed then
self-administration can be implemented.
Secure lockable personal storage is available to safely keep medicines for self-
administration in each patient room as well as the medicines lockers.




BUPA South Bank Hospital                                                          Page 66
Standard A37 (A37.1-A37.2)
The organisation reports adverse incidents involving medicinal products and devices
to the relevant agency (the Medicines and Healthcare Products Regulatory Agency),
and appropriately manages any subsequent required action.
Key findings/Evidence                                        Standard met?             3
There is a policy that defines the procedure for reporting adverse incidents to external
agencies and the inspector was advised that such reports had been made in compliance
with the policy, though copies were not available for inspection.
Responsibility for medicines policy is that of various corporate and local committees under
the clinical governance framework.



Standard A38 (A38.1-A38.2)
Arrangements for the provision of services such as parenteral nutrition, intravenous
additives, and cytotoxics comply with the principles of EL(97)52 regarding unlicensed
aseptic dispensing in hospital pharmacies.
Key findings/Evidence                                    Standard met?            9
The pharmacist inspector was advised that no aseptic dispensing or pharmaceutical
manufacture is undertaken.
A minimal amount of repacking for two items is completed by a worksheet system; examples
of these seen in the pharmacy were suitable.




Standard A39 (A39.1-A39.6)
There is a named Authorised Person MGPS (medical gas pipeline systems)
responsible for the storage, identification, quality and purity of all gases at the
terminal units, and for maintaining gas pipelines, and compliance with HTM 2022 This
may be an appropriately qualified employee or through a contract with a medical gas
company.
Key findings/Evidence                                       Standard met?              2
A satisfactory corporate policy was seen for management of the medical gas pipeline system
and bulk liquid oxygen; this is supported by local procedures for medical gas cylinder
handling.
The nominated Authorised Person is employed on site though his certified qualifications had
lapsed. It was confirmed that the pharmacist has attended basic training in medical gas
safety.
Work on the pipeline and associated plant is sub-contracted to a medical gas company,
including fault callouts, routine servicing and development work. Evidence was seen of the
maintenance contract and completed service records.
A permit to work procedure is in place to authorise work on the plant and pipeline. A sample
of permits examined demonstrated that they were accurately completed and signed
appropriately by relevant personnel. Quality control reports following work to the pipeline
were also inspected.
Documentation was shown to the pharmacist inspector to demonstrate accurate monitoring
of medical gases by records of cylinder change logs.
BUPA South Bank Hospital                                                      Page 67
BUPA South Bank Hospital   Page 68
                              Pathology Services
                                 Standards A40-A45

            The intended outcomes for the following set of standards are:

•   Pathology services are provided by appropriately qualified and trained staff
•   The process by which pathology services are undertaken provides quality
   assurance for patients.
• Quality control arrangements for pathology services provide quality assurance for
   patients.
• Pathology services are provided using safe and effective facilities and equipment.
• Patients receive safe chemotherapy treatment.
• Patients receive safe radiotherapy services.
Standard A40 (A40.1-A40.3)
The provision of services is under the clinical supervision of a medically qualified
pathologist or, in appropriate disciplines, a non-medical scientist of equivalent
standing.
Key findings/Evidence                                      Standard met?             3
There is no pathology department at this establishment; Royal Worcester Hospitals NHS
Trust provides a contracted service. The pathology department at the Trust has full CPA
accreditation; monitoring visits are made to the pathology department annually.




BUPA South Bank Hospital                                                  Page 69
Standard A41 (A 41.1-A41.4)
Written policy and procedures describe the organisation and overall scope of the
laboratory services, and describe:

•   The provision of diagnostic and consultancy services to clinicians including the
   provision of reports.
• The scientific direction of the department including any research and
   development programmes.
• The maintenance of performance standards including quality control.
• Safety aspects of the department.
• Medical and technical responsibilities which are delegated to medical or other
   qualified laboratory personnel.
• The arrangements for the supply, storage, distribution and return of blood and
   blood components.
Key findings/Evidence                                       Standard met?      9
This standard is not applicable to this service; see previous standard.




Standard A42 (A42.1-A42.4)
Written policies and procedures are in place for internal quality control and external
quality assurance and indicate sources, dates of adoption and evidence of regular
review.
Key findings/Evidence                                  Standard met?            9
This standard is not applicable to this service.




Standard A43 (A43.1-A43.3)
Space is available for the collection of specimens, separate from the laboratory
working areas.
Key findings/Evidence                                  Standard met?           9
This standard is not applicable to this service.




Standard A44 (A44.1-A44.11)
There is a clinical director for the chemotherapy service who is a consultant medical
oncologist, or a consultant haematologist, or other suitably qualified consultant.
Key findings/Evidence                                   Standard met?          9
BUPA South Bank Hospital                                                   Page 70
A radiotherapy service is not provided at this hospital.




Standard A45 (A45.1-A45.13)
Radiotherapy services are provided under the clinical direction of a consultant
clinical oncologist.
Key findings/Evidence                                    Standard met?         9
A radiotherapy service is not provided at this hospital.




BUPA South Bank Hospital                                                 Page 71
PART C                 COMPLIANCE WITH CONDITIONS
                                (where applicable)



Condition                                       Compliance


Comments




Condition                                       Compliance


Comments




Condition                                       Compliance


Comments




Condition                                       Compliance


Comments



Lead Inspector     Liz Oxford            Signature
Regional Manager Sally Windsor           Signature
Date




BUPA South Bank Hospital                                     Page 72
PART D                    LAY ASSESSOR’S SUMMARY
                                    (where applicable)




Lay Assessor                                 Signature

Date


Public reports

It should be noted that all Healthcare Commission inspection reports are public
documents.




BUPA South Bank Hospital                                                      Page 73
                           PROVIDER’S RESPONSE TO IDENTIFIED
PART E
                           STATUTORY REQUIREMENTS


E.1    Registered Person’s comments/confirmation relating to the content and
       accuracy of the report for the above inspection.

We would welcome comments on the content of this report relating to the Inspection
conducted on 31st January 2005 and any factual inaccuracies:

Please limit your comments to one side of A4 if possible




Action taken by the Healthcare Commission in response to Provider comments:


BUPA South Bank Hospital                                                    Page 74
      Amendments to the report were necessary                                         NO


      Comments were received from the provider                                        YES


      Provider comments/factual amendments were incorporated into the final
                                                                                      NO
      inspection report

     Provider comments are available on file at the Regional Office but have not
                                                                                   YES
     been incorporated into the final inspection report. The inspector believes
     the report to be factually accurate
Note:
In instances where there is a major difference of view between the Inspector and the
Registered Provider both views will be made available on request to the Regional Office.

E.2     Please provide the Healthcare Commission with a written Action Plan which
        indicates how requirements are to be addressed and stating a clear timescale
        for completion. This will be kept on file and made available on request.

You will also note that the Healthcare Commission has identified in the inspection report
good practice recommendations and it would be useful to have some indication as to
whether you intend to take any action to progress these.

Status of the Provider’s Action Plan at time of publication of the final inspection
report:

      Action plan was required                                                        YES


      Action plan was received at the point of publication                            YES


      Action plan covers all the statutory requirements in a timely fashion           YES


      Action plan did not cover all the statutory requirements and required further
                                                                                      NO
      discussion


      Provider has declined to provide an action plan                                 NO


      Other: <enter details here>




BUPA South Bank Hospital                                                          Page 75
E.3   PROVIDER’S AGREEMENT

      Registered Person’s statement of agreement/comments: Please complete the
      relevant section that applies.

E.3.1 I Clare Hollingsworth of South Bank Hospital confirm that the contents of
      this report are a fair and accurate representation of the facts relating to the
      inspection conducted on the above date(s) and that I agree with the
      requirements made and will seek to comply with these.


       Print Name

       Signature

       Designation

       Date

Or

E.3.2 I Clare Hollingsworth of South Bank Hospital am unable to confirm that the
      contents of this report are a fair and accurate representation of the facts
      relating to the inspection conducted on the above date(s) for the following
      reasons:




       Print Name

       Signature

       Designation

       Date

Note: In instance where there is a profound difference of view between the Inspector and
the Registered Provider both views will be reported. Please attach any extra pages, as
applicable.




BUPA South Bank Hospital                                                     Page 76

								
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