Spire Cambridge Lea 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 good. At this assessment the rating remains good.

This meant people were safe and protected from avoidable harm.

We have not awarded this service a score for Safe.

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

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service managed patient safety incidents well. Staff recognised and reported incidents and near misses. Managers investigated incidents and shared lessons learned with the whole team and the wider service. Managers ensured actions from patient safety incidents were addressed and progress was monitored.

The service had a current incident reporting and reviewing policy, which reflected the provider and national guidance. Staff raised concerns and reported incidents and near misses in line with provider’s policy.

The service provided mandatory training in key skills to all staff. Managers monitored mandatory training and alerted staff when they needed to complete updates. Staff were given time to complete mandatory training.

The service had a target of 95% completion for 30 mandatory training modules. Modules included training on recognising and responding to patients with mental health and learning disabilities.

The data showed ward staff had met this target in all modules except 3, theatre staff had met this target in all modules except 8 and physiotherapy staff had met this target in all modules except 13. Leaders told us staff had until the 31 March each year to complete the training modules and reach the target compliance.

There had been no reported never events in the preceding year. Never Events are serious, preventable safety incidents which should not occur if the available preventative measures are followed. They include things like wrong site surgery or foreign objects left in a person’s body after an operation.

Staff told us they were able to identify and report risks. Where there was an immediate risk of harm to patients or others staff felt confident to intervene to prevent harm from occurring.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if and when things went wrong. The previous 12 months data showed duty of candour was completed when required.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Patients were assessed prior to surgery and findings were taken into account when planning care and treatment. This included cancelling or delaying the surgery when staff identified an underlying condition.

The service had admission criteria for both private and NHS patients. These criteria set out the service limitations and reduced risks by excluding some patients, such as those with high risk of needing additional support, including close physiological monitoring after major surgery. Data showed that no patients underwent surgery that did not meet the admission criteria in the previous 12 months.

Staff used systems and processes to ensure they treated the correct patients throughout the patient journey. We walked the patient journey and tracked patient care from admission to the wards to the operating theatre. We observed handover of patient information including all that related to identification checking processes. Once in theatre, the World Health Organisation (WHO) surgical safety check list was used to minimise the risk of harm. Data demonstrated that compliance with the WHO checklist was 100% for the previous 12 months.

Staff managed the transfer of patients from the operating theatre to recovery safely. Suitably skilled and qualified staff accompanied patients in all areas.

When overall responsibility for a patient’s care and treatment transferred to another service provider, such as the NHS, this was carried out under an established agreement with the local NHS provider. Whenever a patient required transfer, a review was undertaken to support ongoing learning and improvement. Data indicated that 16 patients required a transfer in the previous 12 months.

The service had several daily multidisciplinary team (MDT) safety huddles that included the head of clinical services. The team discussed serious incidents, equipment issues, patient risk, safeguarding, discharges and staffing levels.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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 understood how to protect patients from abuse. Staff received and completed adult and children's safeguarding level 3 training. There were current safeguarding policies, and these reflected the national guidance for adults and children, including visitors.

Staff knew how to make a safeguarding referral and who to inform if they had concerns. Expert safeguarding advice was available to support staff from the safeguarding lead. Staff knew how to contact them.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The service worked with patients to understand and manage risks. Treatment and care met patients' needs in a way which was safe and supportive and enabled them to do the things that mattered to them.

Staff understood how to identify and manage risks. They regularly reviewed risk assessments and discussed any changes with patients and their relatives or carers. Staff told us new or emerging safety risks were discussed during daily safety huddles and we observed this during our assessment.

We spoke with 6 patients during our assessment who told us they felt listened to, risks had been explained, and they were involved in decisions about their care and treatment.

Patients received a pre-operative assessment to identify key risks and their needs and preferences. Risk assessments were reviewed regularly or if there had been any change in a person’s condition. Where risks where identified, even on the day of surgery, this was thoroughly assessed and the procedure cancelled if assessed as unsafe.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The environment of the wards and other areas used for patient care reduced the risk of patient harm, and included features such as, safe flooring and handrails.

Fire safety equipment was available and had been serviced. Staff kept fire exits clear and free from obstruction, and they had completed a fire risk assessment.

Equipment was visibly clean and well maintained. Staff told us that all items of equipment were readily available and any faulty equipment was repaired or replaced in a timely manner. We observed documents that showed staff recorded and monitored equipment servicing repairs.

Staff carried out daily safety checks of specialist equipment. Emergency resuscitation equipment was available in all areas we inspected, and daily and weekly equipment check logs were complete and up to date. All the emergency resuscitation trolleys were tagged to minimise the risk of tampering.

Patients could easily access call bells. Staff positioned call bells by patient beds, and showed patients how to use them to summon help. We observed staff responding to call bells promptly.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The service employed sufficient clinical staff, including nursing and support staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide effective care and treatment. Staff received advanced notice of their shifts and could request changes where needed.

Managers provided temporary bank and agency workers with a local induction to the areas in which they worked.

Managers regularly reviewed the number and grade of clinical staff, healthcare assistants and other key roles, required for each shift using a safe staffing tool. Managers could adjust staffing levels daily according to the needs of patients. Managers planned theatre and recovery staffing in line with activity levels and the required skill mix.

Staff we spoke with said they felt the service was safe and that they were able to take breaks during their shifts.

Patients we spoke with said staff met their needs in a timely manner, and we observed staff responded quickly to call bells. We saw staff attend to patients in a kind and supportive way. Patients appeared comfortable and engaged in conversations, which reflected adequate staffing levels.

A pharmacist provided oversight of medicines optimisation and ward-based support for staff.

Doctors with appropriate seniority and specialty training carried out surgical procedures and made clinical decisions. Patients were clear which doctors were involved in their care.

The service provided adequate overnight and weekend cover, with access to the admitting consultant or a cross-covering peer for advice or attendance when required. The admitting consultant regularly reviewed their patients.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service managed infection risks well. It used systems to identify and prevent surgical site infections. Staff used equipment and control measures to protect patients, themselves, and others from infection. They kept equipment and the premises visibly clean.

Staff maintained theatre and ward areas in a clean and clutter-free condition. These areas had suitable furnishings that were clean and well-maintained.

The service caried out a programme of infection prevention and control audits, including audits against the National Standards for Hospital Cleanliness. Audit data showed the service achieved a 95% score in the most recent monthly audit, and we saw actions in were in place to further improve this score.

The service completed appropriate water quality testing, and the most recent audit showed good compliance.

Staff cleaned equipment after patient contact and labelled it to show when it was last cleaned.

We observed staff following infection prevention and control principles, including compliant handwashing and the correct use of personal protective equipment (PPE).

Staff supported infection prevention and control measures by following the uniform policy. They did not wear nail varnish or jewellery, and staff working in clinical areas were bare below their elbows to allow for full hand decontamination.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happen.

Staff administered medicines safely and in line with prescribed times.

Staff completed medicines reconciliation on admission by gathering gathering an accurate list of each patient’s medicines. They encouraged patients to bring their own medicines from home to support this process.

Staff completed medicines risk assessments, including assessments for venous thrombolytic embolism (VTE), and prescribed appropriate prophylaxis if needed.

Staff stored medicines, including controlled drugs, securely and checked them regularly.

Pharmacy staff visited the ward every day. They checked stock levels, supported ordering and answered prescribing questions.

Staff maintained medicines storage areas at the correct temperature, and pharmacy staff managed this daily using an electronic system. Any discrepancies were followed up straight away.

Staff checked medication expiry dates monthly, and maintained daily cleaning records.

Staff administered medicines at set times each day, which helped ensure doses were given on time.

Staff maintained emergency equipment, including anaphylaxis kits and the resuscitation trolleys, in date and checked them in line with policy. They completed daily safety checks of blood glucose machines and other equipment to ensure safe use.

Staff had access to medicines information resources, including Medicines Complete and Medusa.

Pharmacy staff also supported the service by reviewing discharge medicines and attending weekly multidisciplinary team (MDT) meetings to plan care for patients scheduled for surgery the following week. This ensured staff ordered and made medicines available for patients on admission.

The service used a paper prescribing system. Some prescriptions were difficult to read, which increased the risk of medicine errors.