Spencer Private Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination.

At our last assessment we rated this key question as good. At this assessment, the rating has stayed the same.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Managers and staff recorded accidents, incidents and complaints. Staff knew how to report incidents and understood the process. Staff used reflective accounts to learn from incidents. Managers investigated incidents and made changes. For example, wrong site surgery was narrowly avoided. However, managers found through an investigation that the presentation of theatre list documentation could improve so that the correct surgical site was clearer at the start of the theatre operating list. Existing safety audit checks were also considered in the theatre preparation list.

Incident data we reviewed also showed a theme with paperwork errors which managers found and started a learning programme with administration staff to improve performance. However, we could not see how this was checked following its implementation and therefore could not assess whether the intervention had been effective.

Outcomes from incident investigations were shared both internally and externally to ensure lessons learned were widely shared.

Staff received information on incident investigation outcomes during department meetings and by email.

Managers and staff followed duty of Candour processes when things went wrong and were open and honest with patients.

Risks to patient safety were mostly mitigated, however some risks for the transfer of patients between the NHS trust and the provider needed further strengthening However, they did make sure there was continuity of care, including when people moved between different services. Staff managed and monitored people’s safety.

The service supported their neighbouring NHS trust with added bed capacity for surgical patients. Managers attended a bed meeting daily with the NHS Trust to decide if patients from the NHS trust were suitable to be cared for at the hospital.

When people were transferred to the service from the neighbouring NHS trust, staff followed an admission process that supported the safe assessment and admission of people. Staff followed an admission criterion to ensure this. However, we found that there was not a policy that referenced this process. Staff showed us how they followed this process, but they said they were not always able to obtain up to date information.

For example, if a person came from the NHS trust their pre-assessment paperwork was not always available to be reviewed. This meant that information could be missed when staff considered if the patient was suitable for the service. This was escalated during our assessment, and managers responded to our concerns and provided evidence following our inspection that a new standard operating procedure had been drafted and was available to staff to support them and reinforce the admission policy. However, we were unable to review the effectiveness of this policy at the time of the assessment and therefore could not be fully assured that risks had been mitigated.

Staff from the bookings team provided information needed for the safe entry of people to the service. Information on procedures was explained and available to be reviewed at home.

People were given a pre-assessment prior to their surgery to ensure that they met the safety criteria for treatment at the hospital. A pre-assessment is an appointment that looks at a person’s suitability for surgery. This included a full medical, nursing and social history. This is conducted in a clinic environment led by a nurse and healthcare assistants.

Staff accessed information systems that provided information on patients which informed risk assessment processes. Managers completed integrated care pathway audits to ensure that patient care was consistent and met patient needs through multi-disciplinary services.

Staff worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people's lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff were trained at level 2 and 3 safeguarding for adults' dependant on the remit of their role. The staff completion rate for safeguarding adults at level 3 was 75%. The staff completion rate for safeguarding adults at level 2 was 96.8%. Staff were also trained in safeguarding children at level 2 which had a 100% completion rate.

The service had a designated safeguarding lead who was trained to level 4 safeguarding. This included advanced training for adult and child safeguarding considerations. The safeguarding lead met with the neighbouring NHS trust's safeguarding operational group for people collaboration and learning.

Staff could access the safeguarding policy and showed an understanding of safeguarding topics. Staff knew how to escalate safeguarding concerns and referenced the policy correctly.

The service did not provide regulated activities for children. However, managers followed up to date guidance for children and young people and staff had awareness of child safeguarding concerns.

Patients had access to safeguarding literature when needed and signs were seen at reception promoting safeguarding.

The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people's needs that were safe, supportive and enabled people to do the things that mattered to them.

People had opportunities during the pre-assessment process to discuss risks they were concerned about and understand any risks associated with their care.

Staff used risk escalation tools and completed suitable risk assessments for all people. Observational tools and measurements of vital signs, such as temperature or blood pressure, were used to recognise signs that a person may be unwell. Staff used a nationally recognised tool called the "New Early Warning Score" (NEWS) which was completed correctly for all patients. The NEWS tool improves the detection and response to clinical deterioration in adult patients.

Staff also completed patient risk assessments correctly for all patients included fall, nutritional, and clinical assessments.

Staff knew how to respond to a medical emergency and knew how to escalate the situation promptly. Staff could always access critical care outreach teams and a resident doctor. Staff received training in basic life support which was reviewed yearly.

The service did not always detect and control potential risks in the care environment. However,Staff did make sure equipment, facilities and technology supported the delivery of safe care.

Staff checked emergency equipment daily. However, some items on the ward emergency trolley were beyond their expiry date. Equipment for children was found despite children not being seen by the service. We raised these observations with managers on the day who removed the equipment. There was no evidence of harm being caused because of this, but it raised concerns that staff completing emergency trolley checks did not find this.

Some items in the ward store cupboard had passed their expiry date. This was raised with the management team and these items were removed from the storeroom. Staff explained the equipment was for training purposes only and not patient use. However, the expired items were not clearly labelled to reflect this. This meant that staff unfamiliar with the service could accidentally select this equipment for patient use.

Staff were aware of fire procedures and fire alarms were tested weekly. Staff knew what to do in an emergency and had suitable training. Fire equipment in the hospital was in date and had been checked regularly in line with recommended guidance. Fire safety audits were reviewed from the last three months, and no concerns were found.

Equipment was clean and ready to use, and electrical equipment was tested.

Managers performed Health and safety audits regularly. Health and safety environmental audits from the past 3 months found no concerns.

Patient Led Assessment of the Care Environment (PLACE) scores taken from 2023/2024 and 2024/2025 showed scores in all categories above the national average.

Managers also took part in external environmental audits by accredited organisations.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Staff worked together well to provide safe care that met people\u2019s individual needs.

Recruitment processes were managed safely and managers told us checks were made on a candidate\u2019s employment history, right to work, references and Disclosure and Barring Service (DBS) checks. DBS checks provide information about convictions and cautions held on the Police National Computer. This information helped employers make safer recruitment decisions.

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Staff followed a programme of mandatory training. The average completion rate for all training modules was 84.9%. This was in line with the expected completion rate of 85%

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Staff said training was effective and managers supported accessing more training if needed. Mandatory training subjects included, safeguarding, infection control, health and safety, moving and handling, information governance and equality, diversity and inclusion. Training was a mix of e-learning and face to face sessions. Nurses were trained in medication management, and their competencies were checked annually.

New staff had an induction process and managers encouraged continuous feedback on the process. Monthly orientation days were held to support the induction process.

Staff had a yearly appraisal. Managers reviewed every 6 months.

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Managers provided enough staff to meet people\u2019s needs and provide safe care. Managers used a dependency tool to calculate the number of staff needed at different skill levels. This was a flexible process that enabled the provider to increase or decrease staff numbers as needed. Agency staff were being used to fill gaps in the rotas.

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Managers confirmed the vacancy rate for all staff was 9% compared to 27% last year.

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Staff were invited to meetings where they felt listened to and were able to speak openly. Staff said managers at all levels were approachable and supportive. For example, staff were given opportunities to progress from non-clinical roles to clinical roles with support provided. Managers gave development opportunities which sometimes led to promotion.

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Medical staff worked under a practicing privileges agreement. This included bi-annual reviews and a good practice guide. The medical advisory committee (MAC) held responsibility to the approval and renewal of medical staff.

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Medical staff were reviewed through an appraisal process annually, which the MAC chair commented to us that performance management parameters were working well. Managers told us that consultants would be removed from practice if not performing procedures and oversight of these processes were managed by the MAC.

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Medical staff worked well with nursing staff and the wider team. Nursing staff said they felt comfortable to challenge medical staff and communication in all departments was seen as clear and kind when discussing patient needs.

The service assessed and managed the risk of infection.

Most areas of the service were clean, stickers had been placed on furnishings and equipment to state that they had been cleaned. However, there was evidence of significant dust on bed bumpers in some rooms despite housekeeping staff completing checklists that supported cleaning had taken place. This was concerning because housekeeping checklists were not reflective of the build-up of dust and raised concerns about the oversight of cleaning that took place. Following our assessment, managers completed a full review of the cleaning audit is complete as part of a due diligence process. All paperwork has been reviewed with the inclusion of specific audits for high and low dust areas.

External clinical waste storage bins and sharps containers were stored safely in a locked area outside the building, where an outsourced company would collect the full containers for disposal. However, we found that some clinical waste storage bins in the ward were not working correctly and reported this to staff. This concerned us as clinical waste storage bins held infection control risks if touched at the lid and the rooms were setup ready to receive patients.

Managers had an infection control policy that staff could access. An infection control lead and infection control link nurses were available to support staff with any infection concerns. Staff were aware of infection control techniques and had received the recommended training.

Managers completed hand washing audits and infection control audits regularly. Audits from the last three months for hand hygiene and sharps bins showed no action was needed.

Staff completed cleaning schedules, and these were checked by the managers. Corridors were free from obstructions in all departments.

Managers provided enough personal protective equipment (PPE) stations in patient facing areas. The PPE stations included hand sanitiser, gloves in all sizes and aprons for staff. Staff used PPE correctly. Each room had a clinical waste bin for disposal of PPE.

Cleaning products were kept in a locked cupboard and Control of Substances Hazardous to Health (COSHH) data sheets were available. COSHH audits were also completed and did not find concerns.

Staff were trained in preventing and managing surgical wounds and understood the risks of surgical site infections.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did involve people in planning.

Medicines that were in liquid form did not always have any record of the date opened on the bottles. This meant that staff could not guarantee the safety or efficacy of the medicine as they did not know how long it had been opened for. The provider should consult nationally recognised guidance and individual manufacturer’s instructions about the safe storage of medicines.

Managers audited drug charts to ensure medicines were safely prescribed, stored and administered. The audits found that staff did not always document height and weight of their patients, and this was raised in team meetings. This was important because some medications required the correct height and weight to be calculated correctly.

Medicine trolleys were locked and securely fixed to the wall. The trolleys were well organised and easy to navigate, with medicines distributed in specific sections. For example, antibiotics and analgesia were kept in separate areas. Medicines were administered by registered nurses and appropriately recorded in patients’ records.

Patients requesting to self-medicate, were able to do this following the completion of a risk assessment that ensured they had the mental capacity to make the decision, and they understood the need for safe drug storage.

Patients were not allowed to keep their own controlled drugs. Controlled drugs (CDs) are medication that are very strong and have a high risk of addiction. They should be locked in a secure location and the stock checked. If patients were admitted with their own CDs, these were stored in a separate CD cupboard, which also met the current storage guidance for these medicines.

Controlled drugs were stored following current guidance. CDs were counted twice a day by 2 nurses and the register signed to confirm they were all present and correct. Managers audited CDs monthly to make sure processes were followed correctly.

Pharmacists from the neighbouring NHS trust came every Tuesday to check stock and expiry dates of medication and place orders for any items low in stock. Pharmacists removed medication that had expired. Staff ordered CDs directly when they were needed for patients. Spare medicines were stored in a locked cupboard. Room and medicine fridge temperatures were recorded daily.

It was not possible to look at the storage of medical gases as part of this inspection as the cupboard was locked and the keys were not easily accessible by staff. Managers told us that the NHS Trust facilities team managed this area.