Spire Cambridge Lea Hospital

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that patients and communities had the best possible outcomes because their needs were assessed. We checked that patient’s care, support and treatment reflected these needs and any protected equality characteristics, ensuring patient were at the centre of their care. We also looked for evidence that leaders instilled a culture of improvement, where understanding current outcomes and exploring best practice was part of their everyday work.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant patient’s outcomes were consistently good, and patient’s feedback confirmed this.

We have not awarded this service a score for Effective.

Find out about when we will not publish a key question score and what we look at when we assess Effective.

We scored the service as 3. The evidence showed a good standard. The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Radiographers, radiologists and other professionals worked together as a team to benefit patients. They supported each other to provide good care. Vulnerable patients were discussed each morning by senior staff at the hospital safety meeting.

Staff reported healthy working relations across staff groups. We saw and heard examples of effective team working which was based on mutual respect and trust during one patient’s x-ray following surgery. Staff from both areas discussed how to reduce causing pain and best ways to move the patient into position.

Staff worked across health care disciplines and with other agencies when required to care for patients. For example, staff described referral to a NHS service when they identified a possible urgent medical issue and could not immediately contact the referring consultant. These actions were supported by the service’s information, policies, and guidelines for diagnostic imaging departments policy that guided staff when critical, urgent or unexpected issues were found.

Radiology staff worked closely with the referrers to enable patients to have a prompt diagnosis and treatment pathway. If they identified concerns from scans, they escalated them to the referrer. This ensured staff could share necessary information about the patients and provide holistic care.

We scored the service as 3. The evidence showed a good standard. The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduced their future needs for care and support.

The department had a range of information leaflets for different scans undertaken which included plain x-rays, CT and MRI scans. These detailed what patients should expect during the visit and how patients should prepare for their scan. We also saw advice in the department for smoking cessation.

The service had a range of health promotion information available via the provider website. This included promoting physical health, how to avoid injury during sports, alcohol awareness, women’s health and vision and skin awareness.

We scored the service as 3. The evidence showed a good standard. The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

Leaders monitored the effectiveness of care and treatment through hospital wide audit and benchmarking to compare with other services in the provider group. These included the number of clinical incidents, such as venous thromboembolism (VTE), falls, safeguarding, pressure injury, complaints and safeguarding incidents. The service used the findings to make improvements, if necessary, and achieved good outcomes for patients. Overall results showed the hospital ranked 5th out of 43 other hospitals across the group.

The radiology service monitored the number of incidents each quarter, against previous quarters and monitored levels of harm or if there was no harm. Radiology specific incidents were reported to external monitoring systems, such as notifications to us. Information provided showed there had been 8 no harm incidents in the 12 months prior to our inspection.

Patient satisfaction monitoring showed an average of 99% of responses with ‘good’ and ‘very good’ results for the 6 months before this assessment.

We scored the service as 3. The evidence showed a good standard. The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff gained consent from patients for their care and treatment in line with legislation and guidance. Consent for an MRI was sought by the referring clinician and included discussion about the benefits, potential complications, the risks and alternative options. Staff completed monthly consent audits, which showed staff completed 100% of radiology consent documentation.

We observed staff seeking verbal consent before providing care or treatment. Patients were involved in decision making at all levels. Patients told us they were involved in decisions about their care and treatment. They were able to describe the risks and benefits staff had discussed with them before procedures.

Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent. Staff knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health.

Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. Staff followed the services policies related to consent, mental capacity, deprivation of liberty and restrictive practice, as relevant.

Where specific requests had been made by patients, for a same gender health care professional, this was discussed and provided whenever possible. Chaperones were provided if requested.

Interpreters were used to support patients to give informed consent, including for British Sign Language (BSL) and face to face interpreting when necessary.

The service had a consent policy which was up-to-date and provided patients with written information about the consent process prior to attending for appointment. The policy also referenced how staff should seek consent from young people under the age of 18 years of age and those who lacked to capacity to consent.

Patients were sent an information leaflet explaining the MRI/CT procedure including what they needed to do prior to the appointment, when they arrived, the examination and results. We saw that patients had confirmed they had completed a safety questionnaire and had given their consent for the procedure they had attended for.

All staff received and kept up to date with training on the Mental Capacity Act and Deprivation of Liberty Safeguards and knew where to access the current polices. Staff could describe how to access the policy on Mental Capacity Act and Deprivation of Liberty Safeguards. Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. Staff knew how they would carry out and document a capacity assessment if required.