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Archived: Spire Liverpool Hospital Good

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Inspection Summary


Overall summary & rating

Good

Updated 17 June 2015

Spire Liverpool Hospital is run by Classic Hospitals Limited which is part of Spire Healthcare Group Plc. Spire Liverpool Hospital, previously known as Lourdes Hospital, is located in a residential area of south Liverpool which provides care and treatment for private (self-funding and insured) and NHS patients referred under the Standard NHS Acute Contract.

The hospital offers a variety of services including surgery and outpatients and diagnostics. There were 3 outpatient areas, 2 wards with a total of 32 single rooms, a six bedded day-case unit, 3 operating theatres (one of which is a mobile and 2 laminar flow), physiotherapy department, radiology department, a MRI scanner and a mobile CT scanner.

Day surgery and inpatient treatment is provided for patients across a range of specialties, including urology, ophthalmology, orthopaedics, pain injection, minor hand surgery, minor neurosurgery, ear, nose and throat (ENT), gynaecology, endoscopies, general surgery (such as upper and lower gastrointestinal surgery) and cosmetic surgery. There were 1,251 overnight patients and 7,458 day case patients admitted to the hospital between October 2013 and September 2014. There were also 8,513 visits to theatre recorded in that time. The majority of procedures were for non-complex orthopaedic surgery; however, the hospital does also carry out some complex procedures including arthroplasty and shoulder surgery.

The hospital has a policy which outlines the inclusion/exclusion criteria for patients based on acuity and the services available on site. As part of the pre-operative assessment process, patients with certain medical conditions are excluded from receiving treatment at the hospital. For example, patients with an American Society of Anaesthesiologists (ASA) physical status score of 4 are excluded. The majority of patients admitted to the hospital have an ASA score of 1 or 2. These patients are generally healthy or suffer from mild systemic disease.

The hospital previously provided surgical services for children from the age of three upwards. Due to the Independent Healthcare Advisory Services (IHAS) guidance on the care of children in the independent healthcare sector, the hospital ceased providing surgical services for children on 16 February 2015. At the time of our inspection the hospital only provided adult inpatient services (18 years and over). The outpatient services remained unchanged and any children identified as needing treatment through an outpatient appointment would be referred to an alternative healthcare provider.

The outpatients and diagnostic imaging services provided by the hospital cover a wide range of specialties including neurology, orthopaedics, ear nose and throat (ENT), general medicine, physiotherapy, urology, cosmetic surgery and general surgery. The diagnostic and imaging department carries out routine x-rays as well as more complex tests such as MRI scans, CT scans and ultrasound scans. The service is open from 8am to 8pm Monday to Friday with some additional clinics on Saturdays. The hospital recorded 78,692 patient attendances between January 2014 and end of February 2015. The busiest clinics were the orthopaedic clinics with around 16,000 attendances; ear, nose and throat (ENT) clinics at 6,000 attendances and the general surgery clinics with around 5,000 attendances.

Spire Liverpool Hospital was selected for a comprehensive inspection as part of the second wave of independent healthcare inspections. The inspection was conducted using our new methodology.

We carried out an announced inspection of Spire Liverpool Hospital between 18 and 19 March 2015. We also carried out an unannounced inspection of the hospital between 7:15pm and 8.30pm on 26 March 2015. The purpose of the unannounced inspection was to look at how the hospital operated at off-peak times.

The inspection team inspected the following core services:

  • Surgery
  • Outpatients and diagnostic imaging

The hospital do provide fertility treatment services; however, these were not inspected as part of our inspection because these services are regulated by the Human Fertilisation and Embryology Authority (HFEA).

We rated Spire Liverpool Hospital as “Good” overall.

This location has been awarded 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.

Our key findings were as follows:

Overall Service Leadership

  • The hospital was led by the senior management team comprising of the medically trained Hospital Director, the Matron/Head of Clinical Services, the Operations Manager, the Finance and Commercial Manager and Business Development Manager.
  • The Hospital Director had only been in post for approximately 8 weeks at the time of our inspection and the application for that person to become the registered manager with CQC was still being processed.
  • Staff were positive about the leadership of the hospital and described significant improvements since the appointment of the new Hospital Director.
  • Staff were engaged and described an open culture where they felt they could raise issues or concerns and positively influence the services they were providing.
  • Clinical governance meetings were held to discuss issues such as patient safety, clinical reliability and clinical effectiveness; however, they were infrequent, with only three meetings being held in the past 12 months.
  • Medical oversight of hospital practices was undertaken via the Medical Advisory Committee (MAC) and meetings were held three times in the past year but the policy was that these should be held four times a year. The purpose and desired outcomes of these meetings were not clear. We were told by the MAC chair that this was an advisory committee for clinical issues; however, there was no requirement for the hospital to act upon the advice of the committee.
  • Health & Safety/Risk meetings were held to discuss hospital risks. Meetings were due to be held four times a year. We saw evidence that there was a meeting in March 2015 with the next one to be planned for quarter 2 but that the previous meeting was in March 2014. At these meetings, the risk register was reviewed along with the clinical scorecard. The risk register consisted of mainly health and safety issues and the clinical scorecard was a tool to monitor clinical performance against targets (such as readmission rates and surgical site infections). Whilst we saw evidence of local risk assessments within the departments, we did not see a hospital risk register (or other mechanism) that captured all of this information to show the hospital wide risks; how risks were graded, reviewed and escalated or de-escalated on an ongoing basis. We raised this with hospital management at the time of our inspection and were told that a new post of risk manager had recently been appointed at Spire (corporate level) and that the risk management policy was planned for review in March 2015. Risk management processes would be reviewed at the same time.
  • An audit of incidents at the hospital showed that whilst thorough investigations were conducted and actions were taken to address them, heads of department were slow to close incidents down. Some actions had been taken to address this and there was an action plan in place to monitor improvements going forward.
  • All of the issues highlighted had been recognised by the senior management team and plans were being developed to address them.

Cleanliness and infection control

  • All areas that we inspected were visibly clean and well maintained. Cleaning schedules were in place and roles and responsibilities were well defined.
  • In all clinical areas we observed staff to be complying with best practice with regard to infection prevention and control policies. Staff followed hand hygiene and ‘bare below the elbow’ guidance and wore personal protective equipment, such as gloves and aprons, while delivering care.
  • There were processes in place for the handling, storage and disposal of clinical waste, including sharps and the prevention of healthcare acquired infection. We observed staff adhering to these processes.
  • There had been no cases of Methicillin-Resistant Staphylococcus Aureus (MRSA) bacteraemia infections, Methicillin-Sensitive Staphylococcus Aureus (MSSA) bacteraemia infections or Clostridium difficile (C. diff) infections at the hospital between October 2013 and February 2015. MRSA, MSSA and C.difficile are infections that can cause harm to patients. MRSA is a type of bacterial infection that is resistant to many antibiotics. MSSA is a type of bacteria in the same family as MRSA but it can be more easily treated. C.difficile is a bacterium that can affect the digestive system; it often affects people who have been given antibiotics.

Staffing Levels

  • Nurse staffing levels had previously been set based on a trial of the Shelford ‘Safer Nursing Care Tool’ but this was no longer used because the majority of patients were only admitted to the hospital for a short period of time. Staffing levels were set based on planned activity on a weekly basis.
  • Daily meetings were held to review staffing and there were escalation arrangements in place so that additional staff could be brought into an area should there be unexpected absences or if a patient’s level of dependency increased.
  • When additional nursing or support staff where required, the hospital used their own staff to cover additional shifts where possible but on occasions agency staff were used and the hospital tried to secure agency staff that were familiar with the hospital. There was a robust system in place to ensure agency staff were appropriately inducted to the service. We spoke with one agency member of staff who was very positive about the induction process and told us that they felt well supported by their colleagues.
  • We reviewed recent duty rotas and noted that all areas had a sufficient number of trained nursing and support staff with the appropriate skill mix to ensure that patients were received the right level of care based on their needs..
  • There was a Resident Medical Officer (RMO) based on site who reported any changes in a patient’s condition to the responsible consultant, and together with the nursing team provided 24 hour medical support to patients. The RMO's utilised by this hospital were appropriately trained in Immediate Life Support (ILS), Advanced Life Support (ALS) and Advanced Paediatric Life Support (APLS) and they provided cover 24 hours a day for that week before rotating with the other RMO.
  • Consultants and anaesthetists who were mainly employed by other organisations (usually in the NHS) in substantive posts and had practising privileges (the right to practice in a hospital) with Spire Liverpool Hospital. The consultant handbook provided by Spire outlined that consultants and anaesthetists were responsible for their individual patients during their hospital stay. The RMO and ward staff had a list of contacts for all the consultants and anaesthetists for each patient and told us they could be easily contacted when needed; however, there was no formalised on-call rota (or other mechanism) to show who was responsible for the care and treatment of patients if their consultant or anaesthetist was not available.
  • Throughout our inspection both patients and staff told us that the hospital had sufficient staff.

Mortality rates and outcomes for patients

  • The hospital had reported no instances of inpatient mortality in the reporting period October 2013 to September 2014.
  • There had been no unexpected patient deaths from October 2013 to September 2014. However, one had been reported to the CQC in December 2014. A full root cause analysis investigation had been undertaken by the senior management team. Learning and actions had been identified and implemented. The case had been appropriately referred to the coroner.
  • The national joint registry (NJR) data showed that hip and knee mortality rates at the hospital were in line with the national average.
  • Performance reported outcomes measures (PROMs) data between April 2013 and March 2014 showed that the percentage of patients with improved outcomes following hip replacement and knee replacement procedures was similar to the England average.
  • The hospital had a performance target for at least 70% of NHS funded patients aged over 70 years to undergo hip replacements with cemented prosthesis. This target was achieved for all patients over the past six months.
  • The rate of emergency readmissions to the hospital within 30 days of discharge was similar to the England average between June 2013 and May 2014.
  • The number of unplanned patient transfers to another hospital was better than the England average between July and September 2014.
  • The diagnostic imaging department had a yearly audit schedule in place and ensured all staff participated in these. Dose audits were conducted in line with Ionising Radiation (Medical Exposure) regulations (2000) (IR(ME)R) regarding protecting patients from the risks of unnecessary exposure to x-rays. The department was also audited externally from its commissioners, such as BUPA, to ensure the quality standards were being met. The reports were all positive.

Care and Compassion

  • All the patients we spoke with were positive about the care and treatment they had received. We observed friendly staff treating patients with dignity and respect.
  • Patients were kept involved in their care and treatment and staff were clear at explaining their treatment to them in a way they could understand.
  • We were told of some good examples in surgery of how the hospital had shown a person centred approach to patient care and involved family or relatives even if that required a longer stay in the hospital.
  • Patient feedback from the NHS Friends and Family Test (FFT) was consistently positive. Response rates for August, September and October 2014 were between 40% - 46%. Of those that responded, all respondents in August 2014 would recommend the hospital to friends and family, whilst 98% of respondents in September and October would.

  • A Spire satisfaction survey conducted by the hospital for 2014 showed that 95% of respondents rated the care and attention from nurses as excellent (84%) or very good (11%). The results of the survey had consistently improved since 2012.

  • Staff were caring and compassionate. Patients reported very high levels of satisfaction with the care they received and we observed many positive interactions between staff and patients.
  • We saw people being treated as individuals and staff spoke to patients in a kind and sensitive manner.

Complaints

  • Information on how to raise complaints was displayed in the areas we inspected.
  • We reviewed a sample of complaints across the hospital, which showed that complaints were investigated in a timely way, appropriate responses were given to patients and lessons were learned as a result.
  • Staff had a good understanding of the complaints process and feedback was given to staff individually if required. Learning from complaints was cascaded to all relevant staff during team meetings to raise awareness and improve patient experience.

The services we inspected were good overall; however, there were some areas of poor practice where the provider needs to make improvements.

The provider should:

  • Review the terms of reference and frequency for hospital wide meetings to ensure they are effective in achieving their objectives.
  • Review the hospital’s risk management processes to ensure that all risks are captured, monitored and reviewed on a regular basis.
  • Ensure controlled drugs in the theatre recovery area are appropriately stored at all times.
  • Ensure that action is taken to properly record the disposal of part vials of controlled drugs and improve compliance in medicine audits.
  • Improve performance relating to patient fasting times whilst awaiting surgery to ensure current clinical guidelines are met.
  • Implement a formalised system that shows which consultant or anaesthetist is responsible for a particular patient. This should include a nominated deputy for occasions when the responsible person is unavailable.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Good

Updated 17 June 2015

The hospital had good systems and processes in place to prevent avoidable patient harm.

Patients received their care in a visibly clean and suitably maintained environment. There was a high standard of cleanliness throughout the hospital. Staff had been trained in and were aware of current infection prevention and control guidelines. Facilities and equipment were appropriate to manage infection risks.

There had been no cases of Methicillin-Resistant Staphylococcus Aureus (MRSA) bacteraemia infections, Methicillin-Sensitive Staphylococcus Aureus (MSSA) bacteraemia infections or Clostridium difficile (C. diff) infections at the hospital between October 2013 and February 2015.

Staff were aware of the process for reporting incidents. All incidents, accidents and near misses were recorded and investigated. Any lessons learnt from the investigation were shared with staff to prevent recurrence. 

Nurse staffing levels were calculated in advance and reviewed on a daily basis. There were sufficient numbers of skilled and suitably qualified nurses to meet the needs of patients. There were escalation arrangements in place so that additional staff could be brought into an area should there be either a gap in the planned staffing or if the level of dependency of the patients had increased.

There was a Resident Medical Officer (RMO) based on site who reported any changes in a patient’s condition to the consultant responsible for their care, and together with the nursing team provided 24 hour medical support to patients.

Medicines were stored safely and we observed good practice where staff followed a safe medicines administration procedure.

Mandatory training was undertaken on a calendar year basis and the majority of staff had completed their required training in 2014. In addition, a high proportion of staff had undertaken their training for the 2015 calendar year at the time of our inspection. Staff were aware of safeguarding procedures and had received training in safeguarding children and vulnerable adults.

Patient records that we checked were accurate, complete, legible and up to date. The hospital stored records and patient identifiable information securely.

Effective

Not sufficient evidence to rate

Updated 17 June 2015

We are not confident that we gathered sufficient evidence to be able to rate the effectiveness of surgery or outpatients and diagnostic imaging on this inspection.

Evidence based assessment, care and treatment was delivered in line with national guidance and quality standards by appropriately qualified staff. Pain management was effective and patients received suitable pain relief in a timely manner.

Surgical outcomes for patients were similar to the national average. The hospital had reported no instances of inpatient mortality in the reporting period October 2013 to September 2014; however, the hospital had reported one unexpected patient death in the reporting period October 2013 to December 2014. A full root cause analysis investigation was undertaken by the senior management team. Learning and actions had been identified and implemented. The case was appropriately referred to the coroner.

The number of unplanned patient transfers to another hospital was better than the England average between July and September 2014.

The hospital fell short of their performance target for at least 75% of patients to have fasted within current clinical guidelines whilst awaiting surgery, which meant that patients sometimes starved longer than they were clinically required to. An action plan had been created to address this issue.

A multi-disciplinary team approach was evident across the hospital. We observed good multi-disciplinary working in all the areas we inspected.

The majority of staff had completed the appraisal process for the 2014 calendar year, with the exception of theatre staff. However, all theatre staff had undergone an initial review during February and March 2015 and had set objectives and a personal development plan in place.

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). Practising privileges were reviewed every two years by the hospital’s senior management team. This included a review of appraisals, training, scope of practice and checks for any reported incidents related to the individual consultant. The hospital also participated in the re-validation process for doctors and monitored this to ensure appropriate re-validation had taken place.

Caring

Outstanding

Updated 17 June 2015

Staff across the hospital were polite and friendly to patients and visitors without exception.

We rated caring in the surgical division as "outstanding" and we rated outpatients and diagnostic imaging as "good".

Staff were caring and compassionate. Patients reported very high levels of satisfaction with the care they received and we observed many positive interactions between staff and patients.

Staff treated patients with dignity and respect. Patients were kept involved in their care and treatment and staff were clear at explaining their treatment to them in a way they could understand.

We saw people being treated as individuals and staff spoke to patients in a kind and sensitive manner.

We were told of some positive examples in surgery of how the hospital had shown a person centred approach to patient care and involved family or relatives even if that required a longer stay in the hospital.

Patient feedback from the NHS Friends and Family Test (FFT) was consistently positive. Response rates for August, September and October 2014 were between 40% - 46%. Of those that responded, all respondents in August 2014 would recommend the hospital to friends and family, whilst 98% of respondents in September and October would.

A separate Spire satisfaction survey conducted by the hospital for 2014 showed that 95% of respondents rated the care and attention from nurses as excellent (84%) or very good (11%). The results of the survey had consistently improved since 2012.

Responsive

Good

Updated 17 June 2015

Overall we found the responsiveness across both services to be good.

Waiting times for outpatient appointments were short and within the national guidelines. Waiting times ranged from zero days for general surgery and gynaecology to the longest wait being 24 days for a nephrology consultant.Patients were offered a choice of appointment times to fit around their personal and work lives.

Hospital data showed that at least 90% of surgical patients were discharged prior to 11am over the last six months and this exceeded the hospital’s performance target of at least 40%.

Referral to treatment (RTT) data for March 2015 showed that no patients waited longer than 18 weeks for treatment.

Information leaflets about the services were readily available in all the areas we visited. They were also available in the most commonly requested languages: Mandarin, Somali, Polish, Farsi and Arabic. Leaflets could be provided in braille if requested. Patients whose first language was not English could access an interpreter and these were identified and booked in advance if required.

Complaints were investigated, appropriate responses were given to patients and lessons were learned as a result. The outcomes were discussed during team meetings to raise staff awareness and aid future learning.

Well-led

Good

Updated 17 June 2015

The surgery and outpatients and diagnostic services were well led locally.

The hospital vision was embedded in the departments and staff embraced the values in the work they undertook. The ethos was centred on the quality of care patients received and morale was high.

There were clearly defined and visible local leadership roles across both services. Theatres had recently appointed a new manager and whilst the appointment had been relatively recent, there was evidence this was having a positive impact.

Senior hospital staff provided visible leadership and motivation to their teams. The services were appropriately represented at senior management level and there was appropriate management of quality, governance and risks at a local level.

At the time of our inspection, the Hospital Director had only been in post for approximately 8 weeks and the application to become the registered manager with CQC was still being processed.

Staff were positive about the leadership of the hospital and described significant improvements since the appointment of the new Hospital Director. Senior staff were visible and approachable and it was clear that they were having a positive impact.

Staff were engaged and described an open culture where they felt they could raise issues or concerns and positively influence the services they were providing.

The hospital undertook a range of patient surveys and participated in the NHS Friends and Family Test; the results of which were all positive.

Since the appointment of the new hospital director, there was evidence that decisive action had been taken where governance issues had been highlighted; however, we found that some areas of risk management and governance required further development.

We saw good evidence that risk assessments had been carried out locally in areas of concern; however, there was no hospital wide risk register that captured or monitored these risks. In addition, when incidents had been investigated, the hospital was sometimes slow to close the incident.

The purpose of hospital wide meetings was not always clear and some were infrequent. These should be reviewed to ensure they are effective and timely in achieving their aims.

All of the issues highlighted had been recognised by the senior management team and plans were being developed to address them.

Checks on specific services

Outpatients and diagnostic imaging

Good

Updated 17 June 2015

Incidents were reported and learning was shared across the departments. The environment was visibly clean, well maintained and in a good state of repair. Patient areas were comfortable and staff were aware of infection prevention and control guidelines. Equipment was appropriately serviced and the calibration tested prior to use (where required). Staff received training in mandatory and role specific areas. Patient risk was assessed and responded to appropriately. Staff worked to policies and procedures in line with local and national guidance. Clinical care pathways had been developed. Staff received regular one to one supervisions and yearly appraisals. We observed close, cohesive and collaborative working amongst all the teams in the hospital. Information was available for patients throughout the hospital. Staff had the appropriate skills and knowledge to seek consent from patients and explained how they sought verbal and implied informed consent during consultations. Patients received caring and supportive services in an environment that afforded them privacy, dignity and confidentiality. Staff were enthusiastic and respectful whilst providing care. We observed positive interactions between staff and patients. Patients could be referred to the hospital in a number of ways and had many options to book appointments that suited them. Waiting times for outpatient appointments were within the national guidelines. Interpreters could be booked for patients whose first language was not English, if required. Staff had access to telephone interpreter services and patient information leaflets which were translated into the most commonly requested languages. Wheelchair access was available but not in all areas. Information on how to raise compliments and complaints was displayed in the waiting areas and available in a number of languages. The vision was embedded in the departments and staff ethos was centred on the quality of care patients received. There were clearly defined and visible local leadership roles in each speciality within the outpatients and diagnostic imaging areas. Senior staff provided visible leadership and motivation to their teams. Staff and public satisfaction was positive. The diagnostic and imaging department were trialling an initiative to conduct scans on the same day for patients who had attended clinics. This reduced waiting times in the long term and meant patients didn’t have to return another day. The mammography service was under review.

Surgery

Good

Updated 17 June 2015

There were good systems and processes in place to prevent avoidable patient harm. Patient safety was monitored and incidents were investigated to assist learning and improve care. Patients received care in visibly clean and suitably maintained premises and were supported with the right equipment. Medicines were stored safely and given to patients in a timely manner. The patient records we reviewed were completed appropriately. The staffing levels and skills mix was sufficient to meet patients’ needs and staff assessed and responded to patient risks; however, there was no formalised on-call rota (or other mechanism) to show who was responsible for the care and treatment of patients if their consultant or anaesthetist was not available. Patients generally received care according to national guidelines such as National Institute for Health and Clinical Excellence (NICE) and Royal Colleges' guidelines. The hospital fell short of their performance target for at least 75% of patients to have fasted within current clinical guidelines whilst awaiting surgery, which meant that patients sometimes fasted longer than clinically necessary. An action plan had been created to address this issue. The majority of patients had a positive outcome following their care and treatment. Patients received pain relief suitable to them in a timely manner. The number of patients that had surgery and were readmitted to hospital within 30 days of discharge was similar to the England average. Patients received care and treatment by trained, competent staff that worked well as part of a multidisciplinary team. Staff sought consent from patients prior to delivering care and treatment and understood what actions to take if a patient lacked the capacity to make an informed decision. All the patients we spoke with were positive about the care and treatment they had received. We observed friendly staff treating patients with dignity and respect. Patients were kept involved in their care and treatment and staff were clear at explaining their treatment to them in a way they could understand. We were told of some good examples of how the hospital had shown a person centred approach to patient care and involved family or relatives even if that required a longer stay in the hospital. Patient feedback from the NHS Friends and Family Test (FFT) and a separate Spire satisfaction survey were consistently positive and indicated that most patients would recommend the hospital’s wards to friends and family. Patient needs were assessed prior to undergoing surgery. There was daily planning by staff and sufficient capacity in the wards and theatres to ensure patients were admitted, operated on and discharged in a timely manner. There were systems in place to support vulnerable patients, such as patients living with dementia. Complaints about the service were shared with staff to aid learning. The ‘Spire’ values and hospital vision was visible in the wards and theatres and staff had a good understanding of these. There was a clear governance structure in place with committees such as clinical governance, infection control, health and safety and medicines management feeding into the medical advisory committee (MAC) and hospital management team; however, these areas required further development. There was effective teamwork and visible leadership within the surgical services. Staff were positive about the culture and the support they received from the managers and the matron. The hospital director regularly engaged with staff through staff forums and staff spoke positively about the level of engagement by senior managers.