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Spire Wellesley Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 19 December 2016

Spire Wellesley Hospital is part of Spire Healthcare Limited. Spire Wellesley Hospital offers comprehensive private hospital care to patients from Southend-on-Sea and the rest of Essex.

This includes patients with private medical insurance, those who self-pay and patients referred through NHS contracts. Hospital facilities include an outpatient service, diagnostic imaging service, a 30 bed inpatient ward, eight day case beds and three extended recovery unit beds. Theatre provision includes four theatres, two with laminar flow and a sterile services department. From January 2015 to December 2015 there were 7525 visits to theatre. Spire Wellesley Hospital also provides elective routine surgery for children aged three years to 18 years with consultation appointments within the outpatient and diagnostic imaging departments.

The hospital had a comprehensive inspection in November 2014 following an increased number of never event incidences in the previous year. The hospital was not rated following this inspection as it was conducted as part of our piloting of the independent sector methodology.

We inspected this hospital as part of our independent hospital inspection programme. This was the second comprehensive inspection of Spire Wellesley Hospital. The inspection followed the Care Quality Commission’s comprehensive inspection methodology. It was a routine planned inspection.

We carried out an announced inspection of Spire Wellesley Hospital on 16 and 17 May 2016. Following this inspection we also undertook an unannounced inspection on 31 May 2016, to follow up on some additional information.

The inspection team inspected the following core services:

• Medical care

• Surgery

• Services for children & young people

• Outpatients and diagnostic imaging

We rated Spire Wellesley hospital as requires improvement overall, with all services rated as requires improvement except medical care which was rated good overall.

Children’s and young people’s services were rated as inadequate for safety following significant concerns. Subsequent to the inspection we served the provider a warning notice on 30 June 2016 under Regulation 13 (Safeguarding service users from abuse and improvement) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and told the provider they must make improvements. We will follow this up and report on our findings.

Our key findings were as follows:

Are services safe at this hospital:

  • Incidents were not reported as required within the children’s service or diagnostic imaging service.
  • The resuscitation equipment for children was not standardised across the hospital.
  • There were no risk assessments in place to ensure the environment and access onto the ward was secure and provided safety for children. We raised this issue with senior hospital managers who responded and took immediate action.
  • Whilst there was reference to child abduction in two of the provider’s policies there was not a specific child abduction policy in place, and staff were not aware of the hospital’s policies and procedures in relation to child abduction, nor where they could access these.
  • Compliance with level three safeguarding training was poor across all staff levels and job roles.
  • Where incidents were investigated, root cause analysis (RCA) reports had limited recommendations or action plans.
  • There was a lack of hand hygiene practice observed in children & young people’s services.
  • The hospital did not achieve its target for grade two pressure ulcers, inpatient falls or incidents of venous thromboembolism events (VTE) in 2015.
  • Documentation was not robust. Consultant records were not always legible and were often brief and undetailed.
  • A small number of Consultants kept outpatient medical notes for patients, including the initial referral letters, off site. However, the hospital has a process in place in order to access these documents on request.
  • Security of patient information was not robust, notes were unattended and computer screens left unlocked. We raised this issue with senior hospital managers who responded and took immediate action.

Are services effective at this hospital:

  • Oncology services worked to recognised national guidelines. Local audits had been undertaken and improvement made as a result.
  • Pain management was appropriate to ensure adequate pain relief for patients. Oncology services worked with palliative care specialists to ensure end stage pain relief requirements were met.
  • Nutrition and hydration was appropriately assessed.
  • Patient Reported Outcome Measures (PROMs) data from April 2014 to March 2015 was above the England average following hip replacement and knee replacement.
  • There were good processes in place to obtain consent from patients in children & young people’s services and medical care.
  • Systems were in place to ensure safety checks and maintenance of equipment.
  • One-hundred per cent of staff had received an appraisal in 2014 and 2015.
  • Local service policies did not reference evidence based practice, relevant legislation and national guidance.
  • Staff knowledge about the Mental Capacity Act and Deprivation of Liberty Safeguards was not consistent.
  • We raised concerns during the inspection that written consent had not been undertaken in the outpatient department for a procedure involving injection into the joints. Senior staff took action following our concerns to improve practice.
  • Multidisciplinary team meetings did not occur for children & young people’s services.
  • There were no specific audits undertaken for children & young people’s service.

Are services caring at this hospital:

  • Patients provided consistently positive feedback about the care that they had received.
  • There were positive interactions between staff and patients in all areas.
  • Friends and Family Test data (FFT) showed that 100% of patients who responded in March 2016 were likely to recommend the hospital. The hospital had consistently scored above 98% since March 2015.
  • Within medical care services, each patient had a named nurse with overall responsibility for their individual care.
  • Children had a dedicated registered nurse (children’s branch) who oversaw their care throughout their admission.
  • “ISpire” children’s booklets explained information in a child friendly manner to help ensure children understood aspects of their care.

Are services responsive at this hospital:

  • Patients had access to care when they required it.
  • There was a resident medical officer (RMO) on site 24 hours a day, seven days a week, to provide medical care and advice.
  • Provision of support services such as physiotherapy, radiography, pharmacy and theatres out of hours was via an on call system.
  • In 2015 the clinical scorecard showed that 75% of patients felt prepared for discharge, which was above the Spire target of 71%.
  • Oncology patients were provided with unique individual patient folders and could choose an appointment time that suited them.
  • Staff were aware of equality and diversity and information was available for patients from varying cultures and religious beliefs.
  • Provision was available to allow relatives and parents to stay overnight when required.
  • There was evidence across services that feedback received from patients had been acted on and examples of this were displayed in waiting areas through “You said we did” posters.
  • The children & young people’s service did not robustly capture and monitor the number of cancelled operations.
  • There were no dedicated children’s play areas or waiting rooms throughout the hospital and a lack of toys and entertainment for children and young people.
  • The hospital had received an increase in complaints between 2014 and 2015 which was comparative to an increase in patient volumes. There was no formal system for monitoring patient satisfaction with the complaints process.

Are services well-led at this hospital:

  • There was a lack of effective governance and oversight at senior management level.
  • We found significant concerns with regards to children and young people’s services, particularly in relation to the governance arrangements in place to ensure children and young people accessing services were safeguarded from abuse and improper treatment. Furthermore, there was a lack of medical leadership for children and young people’s services, no multidisciplinary team meetings took place for the service and children and young people were not well represented at the medical advisory committee (MAC) meetings. This meant there was no platform at senior level for challenge or scrutiny into the running of children’s services at this hospital.
  • Policies and procedures were not reviewed regularly and there was a lack of oversight in relation to the management and development of policies and procedures. We raised this issue with senior hospital managers who responded and took immediate action.
  • Risk management systems were ineffective. There were no risks on this register, or any separate register, which related to children and young people’s services although during our inspection we identified many risks which required addressing.
  • Root cause analysis (RCAs) and subsequent actions plans were not always completed in detail. Root causes were not always identified which meant potential additional actions were missed.
  • There was a reluctance to accept the seriousness of the concerns we raised following our inspection, specifically with regard to security of records and aspects of consent. However subsequent actions were taken by the senior team to address issues.
  • The medical advisory committee (MAC) regularly reviewed consultant’s applicability, from a safety perspective, to continue treating patients under their practising privileges. We also saw evidence of clinical governance issues, including incidents that had been reported, being reviewed regularly at the MAC.
  • Staff were aware of the vision, values and strategy for the service.
  • Staff told us that they felt well supported by management, and members of the higher management were described as friendly and approachable. However, in the 2015 staff survey an average of only 64% of staff answered positively to questions about senior leadership and 58% of staff answered positively to questions about working together, although this was in line with the Spire average.
  • Staff described an open culture at this service and felt able to raise concerns.
  • The oncology service achieved MacMillan Cancer Support accreditation for being a good environment to be treated for cancer.

We also saw several areas of good practice which included:

  • The care provided by staff to patients and their relatives was seen to be compassionate, kind and dignified.
  • Feedback about the service from patients and relatives was consistently positive. The 2015 Friends and Family Test data demonstrated that between 99% and 100% of patients would recommend the hospital.
  • The service benefited from a committed and loyal workforce that understood the vision and strategy for the hospital.
  • There was strong local leadership within the oncology service.
  • Nursing documentation was clear and up to date with all necessary care plans and risk assessments having been completed.
  • Patients felt their pain was managed effectively.
  • There were clear and understood procedures in place to support people living with a learning disability when they accessed the service.

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

Importantly, the provider must:

  • The provider must ensure that a safeguarding children policy and an abduction policy are developed and implemented. These must reflect the requirements of the local children’s safeguarding board and other relevant local and national guidance.
  • The provider must ensure that processes are in place to ensure appropriate safeguarding risk assessments are undertaken for children and young people accessing services.
  • The provider must ensure that all staff working with or responsible for children and young people are trained to the appropriate level for safeguarding children and young people.
  • The provider must ensure that there is an effective governance system which yields sufficient management oversight of all the services provided at the hospital.
  • The provider must ensure there are effective systems which allow it to assess, monitor and improve the quality and safety of all services
  • The provider must ensure there is an effective risk management system to protect the health, safety, and welfare of service users and others who may be at risk.
  • The provider must ensure that records are stored securely at all times and that consultant entries are legible and contain all relevant information

In addition, the provider should:

  • The provider should consider the environment where children and young people are cared for so it meets their needs with a separate waiting area and age appropriate materials.
  • The provider should consider reviewing the arrangements in place to ensure the appropriate storage of medicines and blood products.
  • The provider should consider reviewing the prescription arrangements in oncology where there were two systems running.
  • The provider should consider reviewing infection control arrangements in relation to effective hand hygiene practices.

  • The provider should consider improving staff awareness of the needs of patients living with dementia and for patients whom may need a translation service because their first language is not English.
  • The provider should consider improving the level and quality of competency checks provided to staff to ensure they remain competent in their roles.
  • The provider should consider additional training for all staff to ensure understanding and practical application of the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards (2009

Professor Sir Mike RichardsChief Inspector of Hospitals

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 19 December 2016

Effective

Good

Updated 19 December 2016

Caring

Good

Updated 19 December 2016

Responsive

Good

Updated 19 December 2016

Well-led

Requires improvement

Updated 19 December 2016

Checks on specific services

Medical care (including older people’s care)

Good

Updated 19 December 2016

We rated the medical care service as good across all five domains: safe, effective, caring, responsive, and well-led.

Nursing staff knew how to report and escalate concerns and incidents. Identified lessons were shared back to staff. Nursing and medical staff were aware of their responsibilities under duty of candour.

Infection control practices were in place and the environment was visibly clean. Staff adhered to ‘bare below the elbow’ policy and good practices of hand washing and sanitation.

All equipment and medicines were stored correctly in line with the Nursing & Midwifery Council (NMC) standards for medicines management guidelines. Staffing was adequate and specialist knowledge provided by four oncology specialist nurses. They had sufficient training and were proactive in their professional development.

Oncology services were effective and provided a 24-hour advice line. Staff used the UK Oncology Nursing Society (UKONS) triage tool, allowing them to work to safe and clear guidelines. Staff were innovative and used internal audits to improve patient records and communication with other departments. Pain relief was well managed and patients’ nutrition and hydration needs were met.

Nursing staff provided compassionate and caring support. Additional support was available via a Macmillan counsellor and palliative care consultant when required. Patients were involved in their care and could attend coffee mornings or drop in sessions to provide feedback on the service, ask advice or discuss concerns.

The service was responsive to patients’ needs. Patients had no concerns regarding waiting times and could pick an appointment that suited them. Staff were aware of the vision and values of the service. Staff felt that the senior management were approachable and supportive. The department engaged with patients and actively sought feedback.

However:

Some medical records used were inconsistent, leading to confusion and potential risk of medication mistakes.

Staff had completed training in Mental Capacity Act and Deprivation of Liberty Safeguards, However, there was limited need to reflect this in practice and staff were unable to explain the practical application of Deprivation of Liberty Safeguards. This was escalated as a concern and staff were provided additional training.

Surgery

Good

Updated 19 December 2016

We rated surgical services as good overall. Safe, effective, caring and responsive were rated as good with well led rated as requires improvement.

Nursing documentation was complete and nursing assessments and monitoring of patients was appropriate. National Early Warning Scores (NEWS) were used to identify and respond to a deteriorating patient. The hospital was within Spire target for surgical site infections (SSI) for knee operations and had no SSI’s for hip operations during 2015.

There was an effective process in place for the servicing of equipment and all equipment checked was within its required service date.

Pain assessments were regularly undertaken and patients’ pain control was monitored and responded to efficiently. The latest Patient Reported Outcome Measures (PROMs) data was positive.

Staff provided compassionate, kind and dignified care. Patients felt involved in the decision-making processes around their care needs. The latest Friends and Family Test (FFT) results for NHS patients showed that throughout 2015, the hospital scored 99% to 100%. The hospital’s patient wide survey also showed that consistently over 99% of patients would recommend the hospital to friends and family.

Patients had timely access to assessments, diagnosis and urgent treatment and staff knowledge around additional support required by patients with a learning difficulty was good. The hospital had facilities to allow relatives to stay with patients to provide additional support if needed. The hospital met its target of 71% in 2015 for the way patients were prepared for discharge, scoring 75%.

The hospital had a vision and strategy in place and staff were positive about the local leadership.

However:

Storage and security of patients’ records, both electronic and paper based, was lacking. We raised this issue with senior hospital managers who responded and took immediate action.

Some orthopaedic surgeons did not follow infection control guidance within theatre.

Staff knowledge of safeguarding procedures, Mental Capacity Act 2005 (MCA), mental capacity assessments, and Deprivation of Liberty Safeguards was limited. We received inconsistent responses from nursing staff regarding the care needs of patients living with dementia

The annual average compliance score with pre-operative fasting guidelines had increased to 60% in the first 3 months of 2016. However this meant that some patients were at risk of having fasted for a prolonged period.

Not all senior staff were familiar with the contents of the risk register and the storage of several versions led to some confusion.

Root cause analysis (RCAs) and subsequent actions plans were not always completed in detail. Root causes were not always identified which meant potential additional actions were missed.

Services for children & young people

Inadequate

Updated 19 December 2016

Children’s and young people’s services at Spire Wellesley Hospital were rated as inadequate overall. The safety and well-led domain were rated as inadequate, the effectiveness domain as requires improvement, and responsive and caring received a rating of good.

There was poor compliance with safeguarding training across the service and the safeguarding policy in place was not fit for purpose. Subsequent to this we served the provider a warning notice on 30 June 2016 under Regulation 13 (Safeguarding service users from abuse and improvement) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and told the provider they must make improvements. We will follow this up and report on our findings.

In addition, hand hygiene was poor and the service did not carry out any observational hand hygiene audits. Incidents were not reported where required and environments where children and young people were cared for were not appropriately risk assessed. Some areas of the hospital were not secure and the hospital did not have an abduction policy in place. Resuscitation equipment was not standardised across the service.

Paediatric competencies were in place for nursing staff caring for children in the ward and in theatres, however, not for nursing staff within the outpatient department. Training compliance across the service was poor and not monitored effectively. Auditing did not take place to enable monitoring compliance against best practice and patient outcomes. There were no dedicated waiting or play areas for children and young people and there was a lack of toys and entertainment available. Governance, risk management and quality measurement was not robust. Our concerns were heightened given the safety issues found and throughout the service it was evident that the provider’s policy was not always followed. Furthermore, there was a lack of medical leadership for children and young people’s services, no multidisciplinary team meetings took place and children and young people were not well represented at the hospital’s medical advisory committee (MAC) meetings.

However:

Areas of good practice included a visibly clean and organised environment and the appropriate use of personal protective equipment. Staffing numbers were sufficient and children who were admitted were always cared for by a registered nurse, children’s branch (RCN). Whilst the service did not monitor access and flow routinely due to the small number of children and young people accessing the service, we found that the patient pathway was seamless. Pain relief was effective and given in a timely way and there were suitable patient feedback systems in place. The service had not received any complaints.

Feedback received from children and their parents was positive. Parents said that staff were kind and went above and beyond to support them and their child. Parents said they felt involved in their child’s care and treatment and understood the plan of care in place. The “Ispire” children’s booklet, which included child friendly information about the hospital and its service, was effective to support children to be involved in, and understand, their care. There was a clear service vision and strategy in place and feedback from staff about the culture within the service was very positive. Staff worked effectively as a team, were dedicated and very passionate about children and young people’s services.

Outpatients

Good

Updated 19 December 2016

Outpatient and diagnostic imaging services at Spire Wellesley Hospital were rated as good overall. We inspected, but did not rate, effective.

Areas of good practice included effective processes to ensure equipment was checked, serviced and ready for use and radiology and pathology reports and results were available to appropriate staff via secure electronic systems.

Data provided showed that 100% of outpatient and diagnostic staff and completed their annual appraisal for 2015

Patients were seen and treated within national guidance timeframes and were very happy with the level of care they received.

We saw that staff interactions with patients were polite, friendly, and helpful and the hospital was mindful of the needs of patients from various religions and backgrounds and translation services were available.

“You said, we did” notices were displayed in patient waiting areas, showing changes made as a result of complaints received.

However:

The procedures for monitoring medication fridge temperatures were not adhered to.

Patient records were not always fully complete or legible. The hospital did not hold a copy or summary of consultants’ records held off site however this was accessible on request.

Incident reporting was minimal within the diagnostic imaging department.

Incident information was provided to heads of department regularly but this data was across the hospital and not specific to individual departments.

There was a lack of oversight in relation to the management and development of hospital policies.