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Quality and standards

image of various nursing staff and a doctor

Bupa Cromwell Hospital aims to provide the highest standard of patient care and takes clinical governance extremely seriously.

The hospital is also inspected by the Care Quality Commission to ensure compliance to the national minimum standards and the Private and Voluntary Healthcare (England) Regulations.

To this end a number of quality improvement processes are in place to ensure that patient care and treatment is continuously updated, improved and reflective of the latest evidence available. Our quality programme includes:

An adverse incident is any event that causes a patient, visitor, member of staff, consultant, or the hospital unintended or unexpected harm and includes clinical and, or, non-clinical incidents.

All incidents that occur within the hospital are reported and logged so that further investigations can take place if necessary. This enables us to learn lessons from incidents so that safety can be enhanced and future risk prevented. The hospital also encourages reporting of "near misses". Near misses can be defined as: an occurrence which but for luck or skillful management would in all probability have become an incident.

The information from near misses identifies potential problem areas and opportunities to learn and improve practice. It also provides useful information on preventing future adverse incidents.

Bupa Cromwell Hospital has implemented DATIXWeb which is an integrated system for reporting incidents, complaints and compliments. The system went live in October 2011.

Staff are able to submit electronic incident reports, patient complaints or compliments.  Photographs, witness statements and other documents relevant to the incident/complaint can be imported into DATIXWeb and accessed by any staff who need to use them.

The DATIXWeb also includes a risk register module for recording risks and a module for issuing and acting on safety alerts. The next stage will be to complete the configuration of these modules and train the department managers prior to rollout.

Clinical Audit is the systematic process of setting standards for good practice, comparing a sample of current practice with these standards, identifying areas which might be improved and, most importantly, implementing appropriate change, and re-auditing to complete the process.

Clinical Audit is a valuable tool for measuring and improving quality of care and is one of the drivers for Clinical Governance. The hospital has a well-established infrastructure for supporting and monitoring Clinical Audit.

Each patient we treat has their own personal care pathways programme.  This is an outline of the care a patient is gauged to need to effectively address their needs during their hospital stay.

Variations from the initial pathway can be planned as a result of developing intelligence about a patient’s individual case as care continues.

CQC finds Cromwell fully compliant

Bupa Cromwell Hospital had an unannounced Care Quality Commission inspection in October 2013 and we are pleased to say they found us to be fully compliant, with no specific recommendations required.

Staff across the hospital have worked hard over the past few years to ensure that we offer the highest possible standards of care, and it is very reassuring when this is recognised, both by patients and by the CQC.

Read the full CQC inspection report published 21 November 2013.

Hospitality Assured is the standard for service and business excellence in hospitality, championed by the Institute of Hospitality and supported by the British Hospitality Association.

Bupa Cromwell Hospital was awarded the mark in 2005, and we are tested annually. 

We constantly strive to deliver high standards in accommodation and food and drink for wide and discerning audiences.

Clinician washing hands at Bupa Cromwell Hospital

The prevention and control of infection at our hospital is our highest priority.

We have a dedicated infection prevention and control team that consists of a consultant microbiologist, a consultant nurse and specialist nurse and who can give advice and guidance on infections and how to prevent them. Our medical director is also the director of infection prevention and control.

Keeping our hospital infection free

All our in-patients have their own rooms with en-suite facilities reducing the potential for transmitting infections.

All staff are taught the value of maintaining high standards of cleanliness including:

  • cleaning their hands at the right times
  • wearing disposable gloves and aprons
  • keeping the hospital environment and medical equipment clean. Our lead nurses, sisters and managers have a particular responsibility to ensure high standards of hygiene
  • using special procedures to take care of drips, drains and catheters
  • taking great care of wounds.

Patients and visitors can help in a number of ways:

  • hand hygiene is one of the best ways of preventing infection – the hospital has hand sanitizing gel containers available
  • avoid touching wounds or any drips, drains or catheters
  • If family members or visitors are feeling unwell with colds, flu or stomach upsets, they should delay visiting the hospital until they are feeling better.

MRSA Screening Programme

To help protect patients, visitors and staff from risk of infection, we screen certain high risk patients admitted to the hospital to ensure they are free of the MRSA bacteria. 

Our policy is to screen inpatients at least 1 week in advance of their admission date. The test is simple and involves swabbing both nostrils. The specimens are then sent to our on-site laboratory for testing. The results are available within a day and those whose test shows they have MRSA bacteria the skin will be contacted and given an ointment for the nose and a body and hair wash to use for five days.

The MRSA swab result is valid for six weeks. In cases where patients are admitted to another hospital whilst waiting for surgery, the MRSA swab will have to be repeated prior to surgery.

For more information download our leaflet: MRSA suppression treatment for outpatients.

The cost of the MRSA test performed at Bupa Cromwell Hospital will be covered by the hospital, even if you see your consultant elsewhere.

If you choose to have the MRSA screening done elsewhere or though your consultant, you will be responsible for any costs. You must provide a printed laboratory report of your MRSA status to the pre-admission team at the hospital before your admission can be confirmed.

Download a leaflet which will explain our MRSA Screening Programme.

MRSA and MSSA, the difference:-

Most strains of S. aureus are sensitive to the more commonly used antibiotics, and infections can be effectively treated. Some S. aureus bacteria are more resistant. Those resistant to the antibiotic methicillin are termed methicillin-resistantStaphylococcus aureus (MRSA) and often require different types of antibiotic to treat them. Those that are sensitive to methicillin are termed methicillin-sensitive Staphylococcus aureus (MSSA). MRSA and MSSA only differ in their degree of antibiotic resistance: other than that there is no real difference between them.


Clostridium difficile infection

Clostridium difficile (often referred to as C.diff) is a bacteria that can live in the bowels of adults and children.

In healthy people C .diff does not normally cause any problems, but can affect older people and people with other underlying illness. Signs and symptoms of the illness are diarrhoea, abdominal pain and sometimes fever.

Infection figures 2014

Norovirus and Influenza

Norovirus also known as the winter vomiting bug, is the most common stomach bug in the UK and it affects people of all ages.

Influenza or flu is a viral infection that affects mainly the nose, throat, bronchi and, occasionally, the lungs. Infection usually lasts for about a week, and sufferers experience high fever, aching muscles, headache, a dry cough, sore throat and rhinitis.

Most people recover within one to two weeks without requiring medical treatment. However, in the very young, the elderly, and those with other serious medical conditions, infection can lead to severe complications.

During high risk periods the hospital introduces additional infection and control measures. For everyone’s safety, anyone who has suspected flu is not admitted to the hospital.

For further information on infection control at Bupa Cromwell Hospital please email info@bupacromwellhospital.com or call +44(0) 20 7460 5597.

Investors in People Standard at Bupa Cromwell Hospital

The Investors in People standard is a business development tool, designed to ensure that a workforce’s learning and development is clearly linked to an organisation’s goals and objectives.

Bupa Cromwell Hospital was first measured against the standard in 1998 and has been re-assessed periodically since then.

The Investors in People standard indicates that Bupa Cromwell Hospital:

  • supports the development of its people, in line with the hospital’s aims and objectives
  • has a plan with clear aims and objectives which are understood by everyone
  • encourages its employees to improve their own and other people’s performance and understand the impact of the development of people on the performance of the organisation, teams and individuals
  • recognises the contribution to the organisation by individuals
  • is committed to ensuring equality of opportunity in the development of its people.

Award Winning

In 2010, Bupa Cromwell Hospital was awarded the new Investors in People Health and Wellbeing Good Practice Award. This gives recognition for employers who have strengthened their organisation by investing in the health and well-being of their employees.

The Radiotherapy and Medical Physics Department is committed to continual improvement and offering a quality service. The departments operate a quality management system to the standards BS EN ISO9001:2008, verified by a recognised Certification body. Certificate renewal was achieved in September 2009, extending the scope to include Gamma Knife.

Accreditation was initially achieved in 2003 and regular audits of all aspects of the service ensure that the department continues to meet the aims of their Quality Policy. This policy is fulfilled through the adoption and implementation at all times of the Quality Management Systems and Procedures required by BS EN ISO 9001: 2008 and documented patient practices.

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