Alexandra Private Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We assessed all key questions within safe and rated it as requires improvement.

We found a breach of regulation 12 safe care and treatment. We found that the service did not have a robust process in place for incident reporting which resulted in incidents not being investigated in a timely manner. We found that theatres were staffed with the appropriate numbers and mix of staff . The service was fully equipped with suitable equipment however audits and safety checks of the equipment were not always being completed in line with policy. We found out of date and missing equipment on the ward and an out of date oxygen cylinder in theatre. In the patient bathrooms the emergency pull cords were tied up and not free hanging.

Sharps bins were labelled correctly; however, we observed sharps bins in the consultation room and theatre that had been left open

Patient rooms were clean and tidy with appropriate waste bins in each room. The consultation room was mainly clean and tidy.

Staff were confident about raising concerns and that they were investigated by management with the outcome of investigations used as a learning opportunity.There was a safe system in place for recording the patient pathway. A safe pathway was in place should a patient deteriorate and require emergency care. Staff were aware of their safeguarding responsibilities and how to take appropriate action. Patients were involved in discussions around the risks and benefits of their surgery. Staff received appropriate training.

The hospital was safe and secure with all areas secured with key coded locks.

The service had an infection prevention and control policy and hand hygiene policies in place. Controlled drugs were kept safely in an appropriate location which had been approved by the home office. We saw evidence that regular counts of controlled drugs were taking place.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at people's experience in this part of the assessment.

Staff were confident about raising concerns, were aware of the process for doing so and felt that they were investigated by management with the outcome of investigations shared as a learning opportunity. Staff were aware of duty of candour, when it was required and were confident in speaking to patients.

The service did not have a robust process in place for incident reporting. Staff reported incidents via email to the leadership team who would then log the incident on the incident tracker. When we were on site on 9 September 2024 we found out of date medication and reported this to staff. We then reviewed the incident tracker off site at a later date, this incident had not been recorded. Leaders reported that this was due to the member of staff responsible for updating the tracker being absent. Therefore, we were not assured that incidents were always reported or investigated in a timely manner.

The use of a the patient pathway booklet allowed for safe, continuous care throughout their surgical journey. This is used from the first consultation and allows for all patient details to be recorded to ensure that when they interact with any clinician they have all relevant information available to them.

Leaders told us that since CQC last inspected they had developed a new patient pathway booklet which was in use to ensure continuity of care. This was included in all patient medical records and was required to be used by all staff. They told us that all staff had been trained to use the pathway and that the paperwork was reviewed by leaders. They explained that the use of the patient pathway allowed leaders to identify where staff were not completing paperwork correctly so that this could be addressed when required.

We did not speak with partners as part of this assessment.

A safe pathway was in place should a patient deteriorate and require emergency care. A policy was in place which included guidance on how patients should be monitored and when, and how, to escalate care should it be required. To support this the provider had an agreement in place with Chesterfield Royal Hospital regarding the transfer of patients requiring emergency care.

We did not look at people's experience in this part of the assessment.

Staff were aware of their safeguarding responsibilities and how to take appropriate action. They were able to provide examples of concerns that they would escalate and show us where information on how to report concerns was for guidance. Staff received training in adult and children safeguarding levels 1,2,3 and 4 and as of September 2024 100% of staff had received this training.

The safeguarding adult’s policy, was in date and detailed. As the provider does not allow anyone under the age of 18 on the premises, they do not have a safeguarding children policy in place. However, the safeguarding adults policy does provide guidance around how to raise concerns relating to children. Information on who to contact when there is a safeguarding concern was easily accessible to all staff on the noticeboard in the nurses room.

People were involved in discussions around the risks and benefits of their surgery. People were provided with information on who to contact and what steps to take if their condition deteriorated following discharge.

Data from patient satisfaction surveys indicates that patients always felt involved in their care and treatment and that the surgeon listened to what they had to say. Patients felt that they were provided with enough information at their consultation and that they were given the opportunity to discuss and anxieties or fears.

Leaders told us that discussions around the risks of surgery took place during initial consultation with all patient's. They explained that where the risks outweighed the benefit of surgery this would be discussed with the patient and where appropriate staff knew when to decline surgery. In situations where the risk of a surgery was too high alternatives would be explored by considering the risks.

The service had a risk register which is regularly reviewed during governance meetings.

PHQ-9 and GAD-7 psychological testing was completed with all patients to ensure that any patients experiencing difficulty with their mental health were identified and risk assessed appropriately. Audits of these tests showed that patients had been identified through this process and that their GP had been informed of the results.

We did not look at people's experience in this part of the assessment.

Leaders told us that there was a further ward available for use on the third floor however there was no intention to open this ward to patients at present. Leaders told us they completed regular checks on the building and that since CQC had last inspected window security and fire doors had been improved.

The service was fully equipped with suitable equipment to allow them to safely care for patients. However, audits and safety checks of the equipment were not always being completed in line with the hospital’s own policies. As a result of this we found out of date equipment and missing equipment in a resuscitation trolley on the ward and an out-of-date oxygen cylinder on a patient trolley in theatre. This potentially created risks that had not been effectively detected or controlled and it could not be said that all equipment supported the delivery of safe care.

All equipment in the hospital had been PAT tested and was in date, all fire extinguishers had been serviced in August 2024.

Patient rooms were clean and tidy, and all had ensuite bathrooms. In the ensuite bathrooms the emergency pull cords were tied up and not free hanging, we were concerned that should a patient suffer a fall or medical episode whilst unattended they could not easily call for assistance. This is not in line with building regulations 2010 approved document M which states ‘pull cords for emergency alarm systems are coloured red, located as close to a wall as possible and have two red 50mm diameter bangles, one set at 100mm and the other set between 800mm and 1000mm above the floor’ This was raised with leaders on the day and we were advised that this was only in unoccupied rooms due to cleaning and that when a room was to be used by a patient this would be loose hanging.

Sterile equipment and hazardous chemicals were being stored appropriately behind a locked door with appropriate signage. All sterile equipment was stored off the floor on metal racks and when we checked expiry dates ,all equipment was in date.

Sharps bins were labelled correctly; however, we observed sharps bins in the consultation room and theatre that had been left open. This was raised on the day and rectified however when we returned on 20 September 2024, we found sharps bins in the consultation room to be open again.

The service had an agreement with the local acute hospital for decontamination of surgical equipment. During this assessment we observed visible rust on sterile instruments whilst the sterile trolley was being set up for surgery, staff acted appropriately and discarded this immediately before obtaining a new set. The service had a number of audits which were completed with the aim of maintaining a safe service, these included fire safety, sterile supplies, safe handling and disposal of linen, management of patient equipment, waste management, safe disposal of sharps.

We did not look at people's experience in this part of the assessment.

Staff who were employed by the hospital told us that they received annual appraisals.For those who were not directly employed by the service appraisals did not take place. Leaders were involved in the annual appraisals of the surgeons and anaesthetists who also work in other healthcare settings.

The theatres were staffed with an appropriate number and mix of staff and the hospital was working in line with national guidance.

We observed the scrub nurse working a dual role and supporting as a surgical first assistant. We were assured that this was safe and that there is a safe staffing dual role policy in place. This policy is in line with the Perioperative Care Collaborative position statement and ensures that all staff are aware of the expectation and scope of their role.

Staff received appropriate training, including an induction. Leaders monitored staff compliance with training on a database. All agency staff were required to provide evidence of mandatory training from their primary place of employment.

We did not look at people's experience in this part of the assessment.

Leaders told us that in addition to the standard cleaning which takes place an external agency is used to complete a deep clean following surgery.

Patient rooms were clean and tidy with appropriate waste bins in each room. The consultation room was mainly clean and tidy however it was noted that the windowsills had dead insects and cobwebs present. We were told that this room was cleaned weekly. When we were on site on 30 September 2024 this had been cleaned.

During this assessment we raised concerns that there was inadequate hand sanitiser throughout the hospital. The service contacted us the following day and submitted photographic evidence that this had been addressed.

We observed a clinical member of staff with nail varnish working in theatres on both 9 and 30 September. We reviewed hand hygiene audits for April, June, July and August 2024 and it was noted that this had also been identified in April and August. We raised this with leaders on 9 September 2024. Leaders had spoken to the member of staff and we were told that they would have a further discussion with them. However, on 30 September 2024 the same member of staff had nail varnish in clinical areas. Further action is required to ensure that infection prevention control principles are fully adhered to.

We observed staff using personal protective equipment in theatres, we identified clinical staff were not always removing gloves and gowns correctly therefore we were not assured that all staff were following the correct process. Since we were on site on 9 September 2024 the service has advised us that posters have been put up in the hospital to remind staff of the correct process. We saw these posters when we attended on 30 September 2024.

The service had an infection prevention and control policy and hand hygiene policies in place. All staff received level one and two infection prevention and control training.

Regular audits of hand hygiene, aseptic non touch technique and infection prevention and control took place.

There had been no post operative infections in the twelve months prior to this assessment.

We did not look at people's experience in this part of the assessment.

Leaders told us that controlled drugs were managed in line with recommendations from the Medicines and Healthcare Products Regulatory Agency (MHRA) and the Home Office. Leaders told us that they felt medicines management at the hospital was good and that the process in place worked well. Leaders told us that controlled drug stock was checked daily but that this was not recorded. We were told that when controlled drugs were required in theatre they would be signed out of the ward pharmacy by the anaesthetist and then taken to theatre where they are placed in a locked cupboard and recorded in the theatre controlled drugs log. When they are dispensed to the patient this was recorded and any stock which was required to be returned would then be signed out of the theatre stock and returned to the ward pharmacy. We were told that controlled drugs were only present in theatre when surgery was being completed.

We observed daily checks of all medications taking place however when we checked the medicines stock we found out of date medicines. This was raised with the provider who acted appropriately and addressed this immediately.

Controlled drugs were kept in a locked room on the ward which had been approved by the home office with CCTV cameras monitoring who accessed the room. We observed controlled drugs being transferred from the ward to theatre. This process was completed following the hospitals policy and the controlled drugs register was completed correctly.

The ward emergency drug box was appropriately sealed and in date with an expiration of December 2024.

Daily checks and medicines audits were taking place however we could not be assured that these checks were being completed correctly. All medications were signed out and this was recorded on the drugs register.