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Spire Murrayfield Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 7 April 2017

Spire Murrayfield Hospital is a private hospital which has been providing independent health care services on the Wirral since 1982. It is part of Spire Healthcare. Spire Murrayfield is registered to provide the following regulated activities:

  • Diagnostic and screening
  • Family planning
  • Services in slimming
  • Surgical procedures, including cosmetic surgical procedures
  • Termination of pregnancy
  • Treatment of disease

We carried out an announced inspection of Spire Murrayfield on 20 and 21 September 2016 and an unannounced inspection on 29 September 2016. We carried out this inspection as part of our comprehensive inspection programme of independent healthcare hospitals. Overall we have rated Spire Murrayfield Hospital as Requiring Improvement.

During our inspection we looked at three core service areas; surgery, outpatients and diagnostics and the termination of pregnancy service. We have not provided a rating for termination of pregnancy services because the service dealt with very small numbers of patients, meaning there was insufficient evidence to arrive at a rating.

There was a mobile computerised tomography (CT) service which visited the hospital on a weekly basis. This service was not registered at Spire Murrayfield and was therefore not inspected by the inspection team.

Are services safe at this hospital?

  • Staff were trained in the recording of incidents on the electronic incident system. When we spoke with staff, all staff knew how to record incidents and what type of events constituted an incident.
  • The hospital did not have any clear policies or use a dependency tool that indicated how many staff were needed to safely care for patients. A dependency tool is important as it determines the individual needs of patients which is then used to calculate the total number of staff required. Following the end of the inspection period, the management team provided information which indicated that they had recognised the need for implementing such a system.
  • All staffing levels complied with recommended guidelines; however we found instances when the number of qualified nurses were below the specified level identified by Spire Murrayfield in the data sent by the hospital to the CQC prior to inspection.
  • There was a duty of candour policy in place and all staff that we spoke with understood the principles of duty of candour. We saw an example of where harm had been caused and how the hospital had taken the appropriate steps to comply with the duty of candour legislation. However, the hospital had not taken all the required steps to inform patients when a cluster of venous thrombo-embolism (VTE) incidents had occurred.
  • There had been a cluster of eight cases of VTE which occurred at the hospital in the reporting period. From these eight cases, seven patients developed a pulmonary embolism. The senior management team and the medical advisory committee (MAC) were aware of the issue. Serious adverse event forms had been completed and had not identified any breach of policy or clinical protocols. However, a more detailed root cause analysis investigation had not been completed, which was required in the Spire Healthcare policy. This meant that potential opportunities to learn from them and prevent recurrence may have been missed.
  • Services were consultant led and there was a resident medical officer (RMO) on site 24 hours a day, seven days a week.
  • Compliance with mandatory training was low throughout the hospital. This included a low number of staff who were up to date with training for basic and immediate life support.
  • We found some instances where medication was prescribed on paper prescription charts that were not always clear and two occasions of more than one chart present in patient notes.
  • We found that health care assistants were completing VTE risk assessments, without the assurance of having their competency to do so assessed. The hospital addressed this immediately and put in place an action plan to introduce competency assessments for this task in the two weeks following the inspection.

Are services effective at this hospital?

  • Local policies, procedures and care pathways for all services were based on evidence and guidelines produced by Royal Colleges’ and National Institute for Health and Care Excellence (NICE).
  • The hospital had an annual audit timetable that was followed by all departments. The timetable was reviewed regularly by a number of committees, including the Clinical Governance and Medical Advisory Committees.
  • Outcomes data indicated that the hospital was performing at a comparable level with other independent hospitals for the services it provided.
  • Patients were assessed for fluid and nutrition requirements using formal tools. Fluid and nutrition intake was monitored and recorded in patient records. All records that we reviewed contained fluid balance charts. Patients were fasted for surgery in line with national guidelines.

Are services caring at this hospital?

  • We observed that patients were treated in a caring and compassionate way at all times. Staff addressed patients with respect and dignity and discussed the emotional needs of patients with inspectors.
  • We found that the senior management team placed great emphasis on considering patients’ emotional needs and treating patients with compassion. The hospital promoted the six C’s (care, compassion, courage, communication, commitment and competence) and encouraged a person –centred approach to care.
  • Patients told us that they were treated with kindness and respect at all times. We also received thirty comment cards related to our inspection, which reported that staff were kind, caring and that they were treated with respect.

Are services responsive at this hospital?

  • We found that the senior management team worked collaboratively to plan services for patients using the hospital. This team reviewed how services were delivered and considered the needs of patients when redeveloping services. An example of this is the recent redesign of outpatients services in line with patient needs.
  • The hospital had an admissions policy with detailed criteria for patients who could be safely treated at the hospital. We found this policy was being implemented.
  • The hospital was highly responsive in terms of access and flow for all services, particularly termination of pregnancy and outpatients. All patients were seen in a timely manner and referral to treatment times were being met.
  • The hospital considered the needs of patients with complex needs who used its services.

Are services well led at this hospital?

  • There was a clear vision and strategy for the hospital. The senior management team were able to articulate this vision and disseminated it throughout the hospital.
  • We found that there were robust governing structures in place, which included a number of groups with different functions and included clinical governance, combined health and safety/risk and senior management team.
  • The hospital had developed a set of standard operating procedures and working instructions to support the Spire corporate policies that already existed. However, we found that the provider’s policy for VTE was not in line with national NHS recommendations. This was because the provider’s policy stated that VTE incidents that occurred within 30 days post-surgery should be investigated. Guidelines from the national VTE prevention programme (2013) state that incidences of VTE can be attributable to surgery and should be investigated up to 90 days post-surgery.
  • The hospital did not provide sufficient management overview of the termination of pregnancy service.
  • The hospital did not have a formal staffing policy in place.
  • The Medical Advisory Committee (MAC) was well attended and had representation from each medical/surgical specialty. The MAC reviewed all applications for practising privileges. The MAC was well integrated into the clinical and corporate governance arrangements and reported a strong working relationship with the hospital management team.
  • There was a focus on safety and risk in the governance structures and this was reflected throughout the hospital.
  • There was strong leadership in evidence at the hospital. The hospital director working closely with a small senior management team to provide a focus on the quality and safety of services provided to patients.
  • Staff morale was extremely high, with all staff we met with reporting high levels of satisfaction within their roles and with the leadership and senior management team.

We saw one area of outstanding practice;

  • Two members of the physiotherapy team attended a six week pilates course approved by the Australian Physiotherapy and Pilates Institute (APPI) in order to offer a complimentary pain relief therapy for patients. Pilates is used as a preventative and multi-disciplinary approach to treatment. The classes were also open to patients without a referral.

However, there were also areas of where the provider needs to make improvements.

Importantly;

  • The hospital must ensure that all incidences of venous thrombo-embolism resulting in a pulmonary embolism are thoroughly investigated in line with Spire policy and national guidance. This is so that potential learning is identified and improvements are made when needed.
  • The hospital must have a robust system to determine the numbers of staff required at any given time on the inpatient ward.
  • The hospital must ensure that there are sufficient numbers of staff who are up to date with basic and immediate life support training.
  • The hospital must ensure that all staff have the necessary competencies for the tasks they are required to perform.

Termination of pregnancy service

  • Records by health professionals must be clear and easy to read.
  • Evidence of counselling offered must be included in patient records.
  • Medication charts must be clear, with all prescribed medication included and only one per patient.
  • The hospital must monitor the outcome of each termination of pregnancy.
  • The hospital needs to audit the uptake of Long Acting Reversible Contraception.
  • The hospital must evidence screening for sexually transmitted infections.
  • The hospital must evidence a discussion with patients about HSA4 form and evidence that this has been sent.

We issued a section 29 warning notice to the provider as we were not assured that all incidents were robustly investigated. A Section 29 warning notice tells a provider or registered manager that they are not complying with a condition of registration, requirement in the Health and Social Care Act 2008 or a regulation, or any other legal requirement the CQC view is relevant. Warning notices are issued in line with the CQC enforcement policy if there ‘appears to the commission’ to be a breach of relevant regulations. A warning notice can be served on any registered person.

In addition we identified areas where the provider should take action;

In Surgery

  • The hospital should consider how to become compliant with building note HBN 00-09.
  • The hospital should review equipment checking procedures, ensuring that resuscitation equipment on the ward is checked robustly and is in date.
  • The hospital should review processes to make sure that all cleaning agents are locked away in an appropriate storage area so that they are not accessible to members of the public.
  • The hospital should consider ways to ensure that all staff decontaminate their hands when required.
  • The hospital should consider storing emergency anaphylaxis medication in a more secure area so that it is not accessible to members of the public.
  • The hospital should consider ways to ensure that all staff are fully aware of female genital mutilation (FGM) and their legal obligation to report any identified incidences of it.
  • The hospital should improve compliance with overall mandatory training.
  • The hospital should make sure that consultants include their GMC number on all occasions when signing patient records.
  • The hospital should make sure that ‘stop before you block’ signage is used in all anaesthetic rooms and should consider monitoring compliance with ‘stop before you block’ during procedures.
  • The hospital should ensure that efficacy of administered pain relief is documented in line with Spire policy.
  • The hospital should ensure that written communication is provided on all occasions when Duty of Candour is being discharged.
  • The hospital should improve its performance in relation to compliance with fasting guidelines prior to patients undergoing surgery.
  • The hospital should consider using Q-PROMS to monitor cosmetic surgery outcomes and compare them nationally.
  • The hospital should ensure that they keep evidence of all achieved competencies for staff in their personal files so that these can be evidenced when required.
  • The hospital should find ways to share information about implants used during surgery to the patient’s GP on discharge.
  • The hospital should consider introducing guidance for staff about patients who suffer with delirium following an anaesthetic so that staff have consideration for this when managing patients.
  • The hospital should ensure that all policies take into account national guidance.

In the Termination of pregnancy service

  • The provider should consider ways to identify feedback from TOP patients to improve the service.
  • The provider should provide clear and accurate information in patient leaflets.
  • The provider should make it clear when complications should be recorded as incidents.
  • The provider should ensure that analgesia is prescribed in line with RCOG guidelines.
  • The provider should record evidence of all discussions about risk of complications including any increase in risk of complications.

In Outpatients and diagnostics

  • The hospital should ensure that all PGD’s are signed by an appropriate member of staff.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 7 April 2017

Effective

Good

Updated 7 April 2017

Caring

Good

Updated 7 April 2017

Responsive

Good

Updated 7 April 2017

Well-led

Requires improvement

Updated 7 April 2017

Checks on specific services

Termination of pregnancy

Not sufficient evidence to rate

Updated 7 April 2017

The service is available to self–funding patients from the age of 18 years and no later than 14 weeks gestation. The service offered both medical and surgical terminations of pregnancy. There were processes in place to protect patients from avoidable harm and abuse; however, hand–written records were difficult to read and provide clarity about discussions and treatment of patients, including prescription charts. Patients accessed the service in a timely manner with access to screening, counselling and contraception if required.

Surgery

Requires improvement

Updated 7 April 2017

The hospital did not use a dependency tool to determine the required staffing numbers or have formal guidance detailing how many staff were required on the inpatient ward. Health care assistants were completing risk assessments for patients on admission without having been assessed for competency. Additionally, we found incidences of risk assessments completed by health care assistants that had not been countersigned by a registered nurse as required. The hospital had policies for incident management and investigation but these were not always followed. The management team had not always followed duty of candour legislation when patients had suffered patient harm. However; the hospital followed and met the association for perioperative practice (AfPP) guidelines for staffing in theatre. Care pathways were evidence-based and had been developed in accordance with national guidelines such as those from NICE and the Royal College of Surgeons. Staff delivered care and treatment in a caring and compassionate way. Patients were treated with dignity and respect.

Outpatients

Good

Updated 7 April 2017

There was a culture of reporting investigating and learning from incidents. The departments were visibly clean and there were low levels of healthcare related infections. There were effective procedures to stabilise and transfer patients who became unwell. Evidence-based guidance and best practice was followed. There was effective multidisciplinary working, where different disciplines worked well together to provide a more holistic service to patients. Feedback from people who used the service was continuously positive, they said staff were compassionate and kind and were attentive to their needs. Patients were involved in decisions about their care and treatment. Care was planned and delivered in a pleasant and appropriate environment with the needs of patients and their relatives being taken into account. Complaints were dealt with appropriately. Leaders were visible, experienced, competent and enthusiastic. There were strategies and plans in place for the future of the hospital, in particular, the recent restructure of the outpatients department. There was effective governance, audits and internal measures of performance and quality. There was a positive staff culture.