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Spencer Private Hospitals Good

Inspection Summary


Overall summary & rating

Good

Updated 13 October 2015

Spencer Private Hospitals (Ashford) is a 4 bedded unit that was opened in 2008 within the local NHS trust and is one of two sites run by East Kent Medical Services Ltd.

In December 2012 the local NHS trust re-purchased the shares in Healthex (the holding company of East Kent Medical Services Ltd) that they originally purchased in 2008 and then sold in 2009 because of limits on private purchase income by Monitor.

The Board of East Kent Medical Services Ltd is made up of two executive directors and seven non-executive directors five of whom are local NHS trust directors. The Board is chaired by a retired orthopaedic consultant.

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.

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 unit provides for adult elective surgery, a small amount of medical in-patient care and children and young person’s services including minor surgery.

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 Hospitals (Ashford) was good.

Our key findings were as follows:

• CQC have 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 are in place with no 'Never Events' occurring within the last year.

• Serious incidents including anaesthetics, surgical site infections and all mortality and morbidities were monitored, reported and lessons 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 complete a 'Patient Experience' survey upon discharge and areas requiring improvement are fed back to the appropriate staff at departmental meetings.

• MRSA and C. Difficillle are 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 are systems for the effective management of staff which included an annual appraisal, including medical staff with practising privileges.

• East Kent Medical Services Ltd carry out a number of audits to monitor and improve services including collecting patient reported outcome measures (PROMS) hip and knee replacement surgery and infection control data.

• There is an organisational risk register for all risks including clinical, H&S, and financial risks.

• There is a business continuity plan is 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 exceed the national standard for harm free care.

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

The provider should:

• 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.

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

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Good

Updated 13 October 2015

The services at Spencer Private Hospitals (Ashford) were safe. There was a robust governance framework. Incidents were reported and there was evidence that learning from incidents took place. Themes and risks were regularly reviewed and actions taken to make improvements and minimize risks. Staff were familiar with safeguarding issues and knew how to raise any concerns. Adequate staffing levels were maintained.

Effective

Not sufficient evidence to rate

Updated 13 October 2015

Services provided by Spencer Private Hospitals (Ashford) were effective. Patients were assessed and cared for in accordance with professional guidance and standards. There were effective arrangements in place to facilitate good pain management. 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.

Caring

Good

Updated 13 October 2015

The services provided at The Spencer Private Hospital (Ashford) were caring. Staff were attentive and caring and made efforts to spend time with patients and treat them with dignity and respect. Reviews indicated that patients had positive experiences of care at Spencer Private Hospitals (Ashford). Staff took a holistic approach to patient care and supported any patient with anxieties or concerns.

Responsive

Good

Updated 13 October 2015

The services at Spencer Private Hospitals (Ashford) were responsive to the needs of patients. Patients were seen quickly and the booking process was efficient and effective. Services were planned and delivered in a way that met the needs of the people using the service. There was an effective complaints procedure to capture concerns and complaints. These were reviewed; action taken and lessons cascaded to all in the organisation. Lessons learned from complaints were used to improve the service to patients and their families. There were various means of monitoring patient experiences and actions implemented to continually improve this.

Well-led

Good

Updated 13 October 2015

The services provided at Spencer Private Hospital (Ashford) were well-led. 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. Staff felt well informed about the current service and about the challenges and plans for the future. Staff felt well supported and actively encouraged to develop and progress within the organisation. There were robust, integrated governance arrangements in place to minimise risks to patients, visitors and staff, and to ensure the quality of the services. There was an open culture and all staff in the organisation felt valued.

Checks on specific services

Outpatients and diagnostic imaging

Good

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.

Surgery

Good

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 were sufficient numbers of 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 hospital’s 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.