Archived: Spire Hull & East Riding Hospital

Spire Hull and East Riding Hospital is operated by Classic Hospitals Limited. Facilities at the hospital site include four operating theatres, a three bedded critical care unit and the hospital is registered with CQC for 56 beds. There are also x-ray, outpatient and diagnostic facilities. We inspected this hospital as part of our independent hospital inspection programme. The inspection was conducted using the Care Quality Commission’s comprehensive inspection methodology. It was a routine planned inspection. We inspected the following five core services at the hospital: medicine, surgery, critical care, children and young people and outpatient and diagnostic imaging. We carried out the announced part of the inspection on the 14, 15, 16 September 2015 along with an unannounced visit to the hospital on 23 September 2015.

Overall we rated children and young people's services, surgery and critical care as requires improvement and outpatient and diagnostic imaging services as good. We inspected but did not rate medical care. This was because: we did not have sufficient evidence, the small size of the service and, most evidence relating to medical inpatient services was included within the surgical report as these were co-located within the surgical ward area.

Are services safe at this hospital/service

The hospital was visibly clean but there were gaps in assessing and auditing of infection prevention and control procedures. Most staff were aware of the duty of candour. Incidents were reported however, the quality of root cause analysis (RCA) investigations was inadequate. Staff received mandatory training in the safeguarding of vulnerable adults and children and the nursing and medical staff we spoke to were aware of their responsibilities and of appropriate safeguarding pathways to use to protect vulnerable adults and children. The resident medical officer (RMO) was based in the hospital 24 hours. We reviewed RMO cover and found it to be sufficient. We reviewed five RMO records and found that three had no DBS check: there was a lack of evidence in the files to provide assurance that the checks required for each RMO, as part of the service level agreement with the employing organisation, had been recorded. Two RMOs had no evidence that safeguarding training had been completed. There was no effective tool used to assess staffing levels within the ward area. There was no specific patient acuity tool. A projected occupancy ratio was used by the hospital as a basis to plan the staffing levels required however this did not take into account dependency or acuity. Additionally there was high throughput of patients on a daily basis who required care from registered nurses. Mandatory training was in place for all employed staff. Spire healthcare used a 12 month training programme with target compliance of 95% at the end of December 2015. Data we reviewed during the inspection showed that some areas of training fell below Spire’s expected compliance levels for the current period of time. For the medical staff, with practice and privilege rights, the mandatory training records were not always completed or checked with substantive employers; there were only three, out of 10, which we checked that had training evidence logged. There was inclusion/exclusion criteria in place for accepting surgical patients. The hospital undertook the ‘five steps to safer surgery’ checks. During the inspection, we observed an episode of non-compliance with these checks. Additionally two ‘never events’ had been reported in 2014/2015, both were as a result of wrong site surgery following inappropriate patient marking. We informed the manager at the time of the inspection of our concerns and formally wrote to the provider requesting further information and actions to ensure patients were safe. The bed spaces and facilities in the critical care unit did not fully comply with current Department of Health building note 04-02.

Are services effective at this hospital/service

Patients mostly were cared for in accordance with evidence-based guidelines. However, not all documentation in critical care was updated to reflect current evidence based best practice.  Critical care staff did not have the appropriate postgraduate training but actions to address this in 2016 were in place.  Consent procedures were in place and training compliance rates for the Mental Capacity Act 2005 were good. Policies were mostly developed nationally. There were clinical indicators, which were monitored and compared across the Spire locations through the publication of a quarterly clinical scorecard. However, there was no evidence to show the children’s and young people’s service monitored specific patient outcomes for children. The hospital held meetings where mortality and morbidity was discussed. The hospital participated in a number of in-house and national audits for surgical patients, such as the National Joint Registry (NJR) and Health Protection Agency (HPA) post-operative surgical wound healing. There were 17 cases of unplanned readmission within 29 days of discharge in the reporting period (Apr 14 to Mar 15) which was ‘similar to expected’ compared to the other independent acute hospitals. Consultants working at the hospital were utilised under practising privileges (authority granted to a physician or dentist by a hospital governing board to provide patient care in the hospital); these, with appraisals were reviewed every year by the senior management team. However, there were gaps in this process identified at the inspection.

Are services caring at this hospital/service

Patients were cared for in a positive and compassionate way. Patients and relatives we spoke with all gave positive examples of caring. We observed positive interaction of staff with patients and staff appeared genuine, supportive and kind. There were high (scores above 85) for the Friends and Family Test (FFT), however the response rate fluctuated from high levels (above 61%) to low levels (less than 30%). Internal organisational patient surveys showed positive responses around care received, discharge information, and privacy and dignity. Patient records we reviewed took into account patient preferences and patients felt they were involved with information and decisions taken about them. There were psychological assessments prior to cosmetic surgery being undertaken and evidence of General Practitioner involvement pre surgery was noted.

Are services responsive at this hospital/service

The service had grown in demand from when the hospital was first developed with further anticipated growth. Plans were in place to build and expand the site. Referral to treatment times (RTT) data for the reporting period April 2014 to March 2015 showed that the provider had exceeded the target of 90% of admitted patients beginning treatment within 18 weeks every month. However, a small number of patients were cancelled on the day of surgery due to over booking of theatre lists, list overruns and staff or equipment not being available. Theatre utilisation was low: utilisation was noted as being 51.66% over a 12 month period for all four theatres. Patients’ individual needs were mostly met. An increased number of complaints had been received in 2014 for the hospital and these had been rated as an amber risk on the corporate scorecard. However, for quarters one and two of 2015 the percentage of complaints responded to within the policy timescales was at 93% and none had been escalated to stage two. Complaints trends were monitored and actioned. There was an active group of volunteers working within the hospital who supported patients through their patient journey.

Are services well-led at this hospital/service

There was a vision and strategy in place for the hospital. However there was a lack of vision and strategy for the smaller core services and staff could not articulate the strategy for these services. Whilst there were governance structures in place for the provider and locally within with the hospital these were not effectively implemented; there was a perceived high element of trust between staff and as a consequence a low formal assurance culture. There was a hospital clinical governance committee in place. This committee fed directly into the medical advisory committee (MAC); the MAC averaged 50% clinical attendance at each meeting. It also had direct links into the senior management team and the hospital l group governance arrangements. We reviewed the hospital business risk register and the hospital risk analysis register. Open risks were noted with the oldest of the risks being documented in 2010. The monitoring system to ensure the doctors’ safety to practice within the hospital, especially the RMOs, was not effective at the time of the inspection, for example, not all the DBS checks were up to date. There was a lack of effective oversight and action to ensure that incident investigations were of a high standard and root causes identified. Staff described leadership and culture of the hospital in a positive manner. Staff were encouraged to suggest ways to make departments run more effectively and efficiently and we saw examples of where staff had made small changes, which made a big difference to patients. The management team actively engaged in proactive recruitment and retention of staff including recent staff incentive packages. The development of a neighbouring site had been identified as necessary to address increasing space constraints within outpatients and also to improve and extend services in response to increased demand.

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

Importantly, the provider must:

1. Ensure compliance with the ‘five steps to safer surgery’ procedures and World health organisation audit, specifically for interventional radiology.
2. Ensure that infection prevention and control policies and procedures are in place and audited specifically in relation to observational audits for hand hygiene, and theatre dress codes.
3. Ensure that there is robust and effective root cause analysis following a serious incident and to share any learning across all services.
4. Take action to ensure that the appropriate checks and records as per HR policies are in place and recorded for the doctors working at the hospital including Disclosure and Barring Service (DBS) checks, mandatory training and appraisals.
5. Ensure that the bed spaces and facilities in the critical care unit fully comply with current Department of Health building note 04-02 for Critical Care Units published in March 2013 and Health Building Note 00-09: Infection control in the built environment (March 2013).
6. Ensure that care pathway documentation in critical care is updated to reflect current evidence research based best practice.
7. Ensure that Midazolam and oxygen are correctly prescribed on a medication chart and signed post administration and that that all CD entries into the CD medicine book are dated within the endoscopy unit.

In addition there were a number of areas where the provider should take action and these are listed at the end of the report.

Professor Sir Mike Richards

Chief Inspector of Hospitals