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Spencer Private Hospital Good

Inspection Summary

Overall summary & rating


Updated 13 October 2015

Spencer Private Hospital (Margate) is an independent hospital that is one of two sites run by East Kent Medical Services Ltd.

The Spencer Private Hospital (Margate) opened in 1998, and is built on the site of the local NHS trust to which it is physically linked via a corridor.

The Care Quality Commission (CQC) carried out a comprehensive inspection on 3rd and 4th February 2015 and undertook an unannounced inspection on 14th February 2015.

We inspected this hospital as part of our second wave independent hospital inspection programme, using the Care Quality Commission’s new inspection methodology.

This location has been given a shadow rating. Shadow ratings apply to inspections which are undertaken during the development of our approach and before our final methodology is confirmed and published.

The hospital has 22 ensuite private bedrooms on the first floor and five outpatient consulting rooms, two physiotherapy rooms and an endoscopy unit on the ground floor.

Services for Operating Theatres, Intensive Care, High Dependency, Coronary Care, Pathology, Medical Records, Estates and Maintenance, Supplies, X-ray and diagnostic imaging, Pharmacy and Medical Gases are procured by the hospital from the local NHS trust under a service level agreement (SLA).

Referrals are received from self-funding patients, patients with medical insurance and NHS patients through a contract with the local NHS trust. The majority of the hospital’s work is NHS-funded through Choose and Book, commissioned by the Clinical Commissioning Group (CCG).

The hospital provides a small amount of medical in-patient care and children and young person’s services including minor surgery.

75% of the hospitals case mix is adult elective surgery, predominantly orthopaedic.

For the purpose of the comprehensive inspection we undertook an on-site review of surgery and outpatient services and have included our findings of the small volume of medical care, children and young person’s services and end of life care within these core services. The hospital does not provide maternity or termination of pregnancy services.

The on-site element of the inspection involved a team of specialist clinical advisors (experienced healthcare professionals) and CQC inspectors.

Prior to the on-site inspection, the CQC considered a range of quality indicators and we sought the views of a range partners and stakeholders.

The inspection team make an evidence-based judgment to ascertain if services are:

• Safe

• Effective

• Caring

• Responsive

• Well-led.

Overall the rating for the Spencer Private Hospital (Margate) was good. The service was rated good in all five domains in both its inpatient and outpatient services.

Our key findings were as follows:

• CQC had received no complaints, safeguarding concerns or alerts or whistle-blower enquiries in the last 12 months.

• East Kent Medical Services Ltd had a robust process for appointing medical staff to the service under practicing privileges arrangements.

• Robust Clinical Governance processes were in place with no never events occurring within the last year.

• Serious incidents including anaesthetics, surgical site infections and all mortality and morbidities were being monitored and reported. These were low and lessons were learnt.

• There was a robust complaint management process that included Duty of Candour. East Kent Medical Services Ltd is a member of the Association of Independent Healthcare Organisations (AIHO) which gives access to the Independent Sector Complaints Adjudication Service (ISCAS) for Non-NHS patients and the provider liaises with the local Clinical Commissioning Group (CCG) for patients whose care is funded by the NHS.

• Patients completed a patient experience survey upon discharge. These showed a high level of satisfaction. Areas requiring improvement were fed back to the appropriate staff at departmental meetings and changes implemented.

• MRSA and C. Difficile is monitored and there have been no hospital- acquired cases in the last 12 months.

• East Kent Medical Services Ltd has an admission policy that sets out safe criteria for people using the service.

• There were systems for the effective management of staff that included an annual appraisal, including medical staff with practising privileges.

• East Kent Medical Services Ltd carried out a number of audits to monitor and improve services including collecting Patient Reported Outcome Measures (PROMS) for Hip and Knee replacement surgery and infection control data.

• There was an organisational risk register for all risks including Clinical, Health and Safety and financial risks.

• East Kent Medical Services Ltd uses an advance recovery programme for orthopaedic surgery. The NHS Institute for Improvement and Innovation introduce an enhanced recovery programme to improve patient outcomes and reduce the patient's recovery time after surgery. This is designed to reduce complications, improve the patient experience and reduce the time patients stay in hospital. Spencer Hospitals (Margate) were one of the top three Independent Providers for their Enhanced Quality and Enhanced Recovery in Kent, Surrey and Sussex.

• There is a Business Continuity Plan in place; this includes an agreement for the transfer of patients between the local NHS Trust and the hospital in the case of an emergency.

• East Kent Medical Services Ltd is accredited with ISO 14001 Environmental Standard and management systems.

• East Kent Medical Services Ltd is accredited to ISO9001 quality management systems.

• East Kent Medical Services Ltd is accredited as an Investor in People.

• East Kent Medical Services Ltd exceeds the national standard for Harm Free Care.

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

The provider should:

• Review the arrangements for the storage of all medicines and ensure they are stored securely and at the recommended temperatures to maintain their efficacy.

• Review the arrangements for delivering safeguarding training to staff against the intercollegiate framework for safeguarding children which recommends face to face training at level 3.

• Ensure that care pathway documentation be reviewed to include references to NICE or Royal College of Surgeons Guidelines.

• Be able to demonstrate that cosmetic surgery is carried out in line with the professional Standards of Cosmetic Practice, Royal College of Surgeons (RCS Professional Standards).

• Develop care pathway documentation that is made available for patients having cosmetic surgery.

• Audit DNA CPR forms to ensure these are meeting appropriate standards.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas



Updated 13 October 2015

The service was safe.

Systems were in place to manage risk, report incidents and monitor safety. Incidents were reported, investigated and lessons learned. There were robust infection prevention and control procedures in place and the hospital facilities were clean, tidy and appropriately equipped. Robust arrangements were in place to respond to a deteriorating patient or those who needed a higher level of care than planned. There were sufficient numbers of competent medical and nursing staff on duty to meet the needs of patients.

We found the medicines fridge was unlocked, which compromised the safety and security of medicines stored within it. The manager took immediate action to secure the fridge when this was raised with staff at the time. Staff did not record room temperatures which meant the hospital was unable to demonstrate that unrefrigerated medicines had been stored at the correct temperature to maintain their efficacy.

Staff were aware of the policies and procedures to protect children and vulnerable adults. All levels of safeguarding training were provided through electronic learning. This did not meet the requirements of the intercollegiate framework for safeguarding children, specifically at level three where face to face training was recommended.


Insufficient evidence to rate

Updated 13 October 2015

The service was effective.

Patients were assessed, treated and cared for in line with professional guidance. There were effective arrangements in place to facilitate good pain management and the monitoring of this. The nutritional needs of patients were assessed and patients were supported to eat and drink according to their needs.

Patient surgical outcomes were monitored and reviewed through formal national and local audit.

Staff caring for patients undertook training relevant to their roles and completed competence assessments to ensure safe and effective patient outcomes. Staff received feedback on their performance and had opportunities to discuss and identify learning and development needs.

Consultants led on patient care and there were arrangements in place to support the delivery of treatment and care through the multi-disciplinary team and specialists. Care and treatment was evidence based. However, there was variable practice between consultants with on going work on post-operative protocols being undertaken by the physiotherapy department.

There was multi-disciplinary working both internally and with the NHS trust in relation to the service level agreements.



Updated 13 October 2015

The service was caring.

Staff were attentive and made efforts to spend time with patients and treat them with dignity and respect. Patients spoke highly of the compassionate care they received at all times from staff. They told us that they felt cared for and were well informed about their treatment. Reviews indicated that patients had positive experiences of care at Spencer Private Hospital (Margate). The hospital’s Patient Experience surveys in 2013/14 found that 99.5% of patients would recommend Spencer Private Hospital (Margate) to friends and family. The survey runs from January to December.

During the inspection all patients’ privacy and dignity were protected. Staff took a holistic approach to patient care and supported any patient anxieties or concerns.



Updated 13 October 2015

The service was responsive.

Services were planned and delivered in a way that met the needs of the people using the service. Systems were in place to capture concerns and complaints raised within the department. These were reviewed; action taken and lessons cascaded to all in the organisation. We saw that the service used lessons learned from complaints received to improve the service to patients and their families. Patients were seen quickly in the outpatients department and the booking process was efficient and effective.



Updated 13 October 2015

The service was well-led.

Staff stated that all managers were visible, approachable and provided clear leadership.

The hospital’s management team was highly visible and the vision and mission statements for the service were well known and understood by all staff at all levels. There were robust, integrated governance arrangements in place to minimise risks to patients, visitors and staff, and to ensure the quality of the service. There was an open culture and all staff in the organisation felt valued. The departments were well-led. Staff were well informed about the current service and about the challenges and plans for the future. Staff were well supported and actively encouraged to develop and progress within the organisation. Staff were able to both raise concerns and put forward ideas for improvement and innovation.

Checks on specific services

Outpatients and diagnostic imaging


Updated 13 October 2015

Overall, the care and treatment received by patients using the outpatient department was safe, effective, caring, responsive and well-led.

Patients were very positive about the care they received and care and consideration given to them by staff.

Safety processes were in place and monitored. Staff were well trained and worked to protocols and pathways, however not all were linked to national guidance. Patients were provided with good information throughout their care and treatment. The booking arrangements were efficient and patients knew who to contact.

Patient feedback was encouraged and acted upon. Staff feedback was also encouraged and acted upon. Staff felt well qualified and able to develop and progress within the organisation. There was an open culture where staff were able to discuss both concerns and innovations with their manager and senior management who were visible and approachable.



Updated 13 October 2015

Surgical services were safe, caring, effective, responsive and well-led. Incidents were reported and dealt with appropriately and themes and outcomes were communicated to staff. Patient areas were clean, tidy and appropriately equipped.

There was sufficient competent medical and nursing staff on duty to meet the needs of patients.

Nursing, medical and other healthcare professionals were caring and patients were extremely positive about their care and experiences.

Patients were assessed, treated and cared for in line with professional guidance. There were effective arrangements in place to facilitate and monitor good pain management.

Patient surgical outcomes were monitored and reviewed through formal national and local audit.

Staff were attentive and caring and spent time with patients treating them with dignity and respect.

There were very few complaints arising from patient experiences in surgical services. Information about the hospitals complaints procedure was available for patients and their relatives and the service reviewed and acted on information about the quality of care that it received from complaints.

Staff were aware of the hospital’s vision and there were good arrangements for monitoring the quality of the service provided. There was strong leadership and an open culture where staff felt valued.