BMI Southend Private Hospital

Independent Healthcare Org · East

Overall Rating
Requires Improvement Last inspected 17 October 2016
Domain Ratings
Safe
Requires Improvement
Effective
Good
Caring
Good
Responsive
Requires Improvement
Well-led
Inadequate

View Full CQC Report

7 must-do actions
3 should-do actions

Must-Do Actions (7)

Legal requirements based on regulation breaches identified during inspection.

Must Do
Safe
The provider must ensure that risks to patients are identified through surgical pre-assessment prior to surgery being undertaking under local anaesthetic.
Regulation 12 (Safe care and treatment)
There was inconsistent use of risk assessments for venous thromboembolism prior to surgery. The undertaking of surgical pre-assessment for local anaesthetic procedures was also not consistent.
Must Do
Safe
The provider must ensure that the need for VTE screening is assessed by the service and administered to patients as per the service’s policy in line with national best practice.
Regulation 12 (Safe care and treatment)
We looked at two sets of surgical notes during our announced inspection. These were patients having surgery under local anaesthetic. There were no records to show that a venous thromboembolism (VTE) had been carried prior to surgery for either patient. This was not in line with the National Institute of …
Must Do
Safe
The service must ensure that there are safe processes in place for monitoring of the deteriorating patient. Including the safe transfer of a patient to another healthcare facility.
Regulation 12 (Safe care and treatment)
There was a policy in place at provider level for the management of the deteriorating patient. However, staff did not know what it contained. There was no local SLA in place with a hospital or the ambulance trust in relation to safely transferring a deteriorating patient out. The senior managers …
Must Do
Well-led
The provider must ensure that governance and risk management processes are effective in identifying risks.
Regulation 17 (Good governance)
We identified several areas of risk during our inspection, which had not been identified by the service. The hospital risk register was not fit for purpose. There was a lack of data that the risk was added, no review date specified, no control measures, no forward plans for mitigation and …
Must Do
Well-led
The providermust ensure that there is an effective process for the monito
Regulation 17 (Good governance)
We identified several areas of risk during our inspection, which had not been identified by the service. The risks around not monitoring outcomes, providing dementia and learning disability support and language support were also risks identified by the inspection, not by the service. This was despite the hospital conducting and …
Must Do
Safe
The provider must improve training rates for safeguarding adults, safeguarding children and patient moving and handling.
Regulation 18 (Staffing)
Training rates for safeguarding adults and children level two was low in surgery. Data provided showed that 0% of theatres nursing staff completing any level two training. Patient moving and handling training rates were low across all staff groups, except theatres nurses. Ward based nurses, theatre healthcare assistants and ODPs …
Must Do
Well-led
The provider must improve the quality and legibility of patient records.
Regulation 17 (Good governance)
We found poor management of patient records, some of which were illegible in surgery. We were unable to identify consultants or nurses who were involved in the patients care, due to illegible signatures and not providing a printed name. The operation records completed by the surgeon were illegible due to …

Should-Do Actions (3)

Recommended improvements to enhance service quality.

Should Do
Safe
The provider should ensure that equipment monitoring and checks are undertaken as required by service policy.
Should Do
Safe
The provider should improve hand hygiene practices within the service.
Should Do
Caring
The provider should undertake further work to improve the area where patient confidential information is discussed to ensure the privacy and dignity of patients.
Location Details
CQC ID: 1-108774735
Local Authority: Southend-on-Sea
Region: East
Inspection Report
Type: Comprehensive inspection
Date: 17 October 2016
Rating: Requires improvement
Actions: 7 must-do , 3 should-do
AI-extracted 17 Feb 2026