Alexandra Private Hospital

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We assessed 5 key questions within well-led and rated it as requires improvement. We found a breach of regulation 17 good governance. Whilst the service had audit tools in place these were not being used effectively. We were not assured that there was a robust governance process in place to ensure that audits were being completed correctly. Leaders always put patients first. They showed integrity and were open and honest. Staff felt able to approach leaders with concerns. Mandatory governance meetings took place and clear plans for monitoring safety and risk were in place. The service engaged with the local integrated care board and acute hospital trust to work together. Leaders were committed to continuous learning and improvement and staff were encouraged to share good practice.

This service scored 46 (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 Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Leaders were compassionate and supportive. Staff felt that the leadership team were approachable and respected them.

Staff and leaders always put patients first. Leaders told us that they had been approached by a private surgery company who wished to use their facilities. This was considered however as leaders felt that the company were not willing to adhere to the same level of safety as the service, they chose not to work with the external provider. This displayed integrity and showed that patient safety was a priority for leaders.

Leaders were open and honest about the difficulties that the service is experiencing due to the reduction in patient numbers since CQC last inspected. They understood that due to the reduction it had been difficult to embed new policies and procedures but felt confident that with the policies in place once patient numbers increased these would ensure safe and effective patient care. Leaders told us that they planned to build patient numbers slowly to ensure patient safety again displaying that this was a priority to the service.

We did not review any processes in this part of the assessment.

Staff told us that they felt comfortable raising concerns directly with leaders and that they felt that any concerns would be listened to and acted upon.

The Hospital has comment boxes for staff to speak up anonymously, and a freedom to speak up policy in place.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Leaders told us that since CQC had last inspected they had focused on improving governance procedures and that they were holding regular governance meetings. We were told of new audits which had been put in place ,however it was recognised that the governance of the hospital was still in its infancy and that due to the reduced number of patients they understood that there had not been enough flow of paperwork for the new processes to be embedded fully. Leaders had nominated one member of staff responsible for completing audits and checklists and told us that this member of staff was committed to completing all audits correctly to ensure patient safety.

Leaders held mandatory clinical governance meetings every six months. This was due to the reduced numbers of patients and the plan was to increase the meetings once the service was completing more surgeries. We reviewed the minutes of the previous two meetings. These meetings were attended by all leaders and senior clinical staff. The minutes of these meetings showed clear plans for the service and for ongoing monitoring of safety and risk. For example in January 2024 an action was set to ensure that when incidents happen learning and improvements are shared with staff. The minutes for the governance meeting in June 2024 demonstrated that an incident and the subsequent learning had been shared with staff.

Whilst governance meetings were taking place and audit tools were in place we were not assured that these were being used effectively, or correctly. We reviewed the medicines audit for July 2024 which noted no issues or actions required. However on 9 September 2024 we found out of date medication. We also saw that appropriate checks of resuscitation trolleys were taking place however we found an out of date endotracheal tube and missing defibrillator pads. In addition there was equipment present in the trolley which was not on the checklist. This was raised with leaders on the day and rectified immediately.

Whilst on site on 9 September 2024 we observed that daily theatre checklists had not been completed. We were told that this was due to the nominated member of staff not being in work and the person covering for that role being unaware of the checklist or how to complete it. Due to this we were not assured that there was a robust governance process in place to ensure that the audits were being completed correctly.

We did not speak with people in this part of the assessment

Leaders told us that there were agreements in place with the local acute hospital trust to ensure continuity of care and patient safety. They told us that they also engaged with the local integrated care board and acute hospital trusts to offer their services where required. Leaders were committed to working with NHS services to help relieve pressures on the services whilst the hospital had capacity to do so safely.

We did not speak with partners in this part of the assessment.

There were clear processes in place with the local acute hospital trust such as decontamination of surgical equipment, disposing of controlled drugs and deteriorating patients.

Leaders were committed to continuous learning and improvement. They told us that incidents and concerns were used as a learning exercise. One example of this was when an incident had occurred which related to patient confidential information being left unattended. This incident was discussed with the team with learning shared to ensure that staff were aware of correct procedures around patient documentation and the risks of this being left unattended.

Leaders were told that in addition to the mandatory training offered by the service leaders would complete additional training in the form of scenarios.

Staff told us that they were encouraged to share good practice when they recognise that it may improve the service. They told us that leaders were interested in how other hospitals worked and how they could implement ideas to improve.

Leaders told us that they did not have electronic access to patient test results which were completed in the pathology department of the local NHS hospital trust. They told us that they were committed to improving this and were exploring the possibility of introducing the electronic system used by GP surgeries and other hospitals.

We did not review any processes in this part of the assessment.

We did not review any outcomes in this part of the assessment.