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Spire Leeds Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 3 July 2019

Spire Leeds Hospital is operated by Spire Healthcare Ltd. The hospital has 88 inpatient and day case beds. Facilities include four operating theatres, one endoscopy suite, one angiography suite, a chemotherapy unit, physiotherapy services, outpatients’ departments, and diagnostic and imaging facilities. There is an eight-bedded level two critical care unit, an eight-bedded children’s ward, a 10-bedded ambulatory care unit, six oncology day case chairs, and 56 inpatient and day case beds spread across two adult wards.

The hospital provides surgery - including cosmetic surgery, medical care - including chemotherapy, high dependency care for adults, services for children and young people, and outpatients and diagnostic imaging services.

We inspected this service using our focused inspection methodology. We carried out an unannounced responsive inspection on 11 December 2018. We focused on specific services which were highlighted as concerns to CQC from staff and members of the public, and we inspected surgery and services for children and young people. As concerns spanned multiple inspection domains, we looked at all key questions and asked if surgery and children’s and young people’s services were safe, effective, caring, responsive, and well-led.

Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate. As this was a focused inspection, new ratings were only awarded for the key questions that were inspected. The overall rating for surgery changed from good to requires improvement. The overall rating for and children’s and young people’s services changed from good to requires improvement. We amalgamated these ratings with ratings from our routine 2017 inspection of medical care, outpatients and diagnostic imaging, and critical care services. Our rating of this hospital went down. The rating for the hospital changed from good to requires improvement overall.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

The main service provided by this hospital was surgery. Where our findings about surgery services (for example, management arrangements) also apply to other services, we do not repeat the information but cross-refer to the surgery service level.

Services we rate

Our rating of this hospital went down. The rating for the hospital changed from good to Requires improvement overall.

We found the following areas of concern in surgery and children and young people’s services:

  • Key leaders in the service did not have the right skills and abilities to run a service providing high-quality sustainable care. Opportunities to prevent or minimise harm were missed.

  • Safety was not always a high priority, and the application of safety systems and processes required improvement. Levels of harm were inconsistently recorded against incident records. Investigation reports were of variable quality, and the completion and sign-off of action plans was inconsistent.

  • The application of governance arrangements and systems was not adequate. The hospital could not reliably determine how many serious incidents had occurred, and had not always notified CQC of serious incidents, or had not done so in a timely manner. At the time of inspection, the hospital had been without a governance lead for several months. We saw the frequency of key committees was not always in line with their terms of reference. There was little evidence senior leaders had worked to systematically improve service quality and safeguard good standards of care. Risk registers were not adequately managed and did not reflect key risks facing the service.

  • Senior leaders had not supported or promoted a culture of appropriately identifying, reporting, categorising, and learning from incidents. When concerns were raised, or things went wrong, the approach to reviewing and investigating causes was often insufficient or too slow. There was little evidence of learning from events or action taken to improve safety in key committee and group meeting minutes we reviewed.

  • Senior leaders had failed to meet their duty of candour obligations consistently well. The culture was not one of fairness, openness, transparency, honesty, challenge and candour. Senior leaders were reactive and defensive. When something went wrong, people were not always told in an open and honest way or in a timely manner.

  • The culture, policies and procedures had not provided adequate support for staff to raise concerns and have these adequately addressed at hospital level. From November 2017 to October 2018, CQC received five whistleblowing enquiries; and an internal whistleblowing investigation by Spire Healthcare (corporate) had been undertaken with respect to children’s and young people’s services.

  • The service had not sufficiently applied the systems available to identify risks and implement plans to eliminate or reduce them. Risks to patient safety had not been monitored or mitigated over time consistently well.We found senior managers had failed to sufficiently address fasting time compliance. Recent improvements had been made in venous thromboembolism (VTE) prophylaxis, daily and pre-discharge medical review of patients, and medical record keeping compliance; but deficiencies with compliance were observed throughout most of 2018. Where action plans had been implemented, we often found these were not sufficiently robust.

  • The hospital had systems to manage information. However, the information that was used to monitor performance or to make decisions was not always accurate, valid, reliable, or timely. We saw that clinical audit measures were not always collated or presented to committees and groups in a timely fashion; and we observed data inaccuracies between key hospital and service reports.

  • The service level agreement (SLA) for the transfer of critically ill children had expired in February 2018 and had not been renewed as of January 2019.

  • Staff did not always follow best practice when prescribing, giving, recording and storing medicines.

  • There was limited evidence of discussions about learning from concerns and complaints in key committee and group meeting minutes we reviewed.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with three requirement notices. Details are at the end of the report.

Ellen Armistead

Deputy Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 3 July 2019

Our rating of safe went down. We rated it as Requires improvement because:

  • Safety was not always a high priority, and the application of safety systems and processes required improvement. There was a deficit in the identification, classification, and management of patient safety incidents. Levels of harm were inconsistently recorded against incident records Investigation reports were of variable quality, and the completion and sign-off of action plans was inconsistent.

  • Staff did not always complete and update risk assessments for each patient. We saw that adult patients who had undergone surgery were not always reviewed daily, or prior to discharge, by a consultant. Despite compliance improvements in hospital audit data, venous thromboembolism (VTE) assessments we reviewed during our inspection showed not all patients were assessed fully. National early warning score (NEWS) audit results showed variable compliance with measures, which were under hospital target.

  • The children and young people’s (CYP) service had not risk-assessed the nursing and treatment of paediatric patients in adult areas consistently well. In addition, the service level agreement for transfer of critically ill children had expired in February 2018.

  • Medical staff in the surgery core service had not kept detailed daily records of patients’ care and treatment consistently well. We saw this was a reoccurring common theme in incident records and investigation reports we reviewed; and the service had identified this as an ongoing problem. Following our inspection, senior leaders reported they had implemented several methods to improve compliance, and we saw audit compliance had improved.

  • Staff did not always follow best practice when prescribing, giving, recording and storing medicines.

  • The service had suitable premises and equipment and looked after them well; however, we found emergency equipment checks were not completed consistently well.

  • Overall, we saw ward and theatre staff kept equipment and the premises visibly clean and used control measures to prevent the spread of infection. However, we were not assured laminar flow systems were compliant; and we were concerned about hip replacement surgical site infection rates.

However:

  • Staff were compliant with mandatory training requirements.

  • At the time of inspection, there were enough medical and nursing staff to keep patients safe and provide the right care and treatment.

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it.

  • We found nurse-led risk assessments, including for pressure damage acquisition, malnutrition, falls, bed rails, moving and handling, were completed on most occasions.

Effective

Requires improvement

Updated 3 July 2019

Our rating of effective went down. We rated it as Requires improvement because:

  • The service often provided care and treatment based on national guidance; however, the service had not adhered to national venous thromboembolism (VTE) prophylaxis guidance consistently well. In addition, we were not always assured of the accurate audit and reporting of CYP service performance indicators.

  • Staff gave patients enough food and drink to meet their needs and improve their health following surgery, and during inpatient stays. However, we saw adult patients were often fasted for excessive periods of time before surgery.

  • Staff understood how and when to assess whether a patient had the capacity to make decisions about their care; or who to approach to for support. However, we were not assured consent procedures had been followed consistently well.

However:

  • Staff monitored the effectiveness of care and treatment and benchmarked data against Spire peer group averages, and some national measures, to monitor performance.

  • Staff assessed and monitored patients regularly to see if they were in pain.

  • The service made sure staff were competent for their roles and staff of different kinds worked together as a team to benefit patients.

  • Services were available that supported care to be delivered seven days a week and patients were encouraged to be as fit as possible for surgery.

Caring

Good

Updated 3 July 2019

Our rating of caring went down. We rated it as Good because:

  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.

  • Staff provided emotional support to patients to minimise their distress.

  • Staff involved patients and those close to them in decisions about their care and treatment.

However:

  • Patient satisfaction scores across the 2018 period (quarter one to quarter four) were considered good and were broadly in line with peer group averages. However, some results (such as the proportion of patients who felt able to talk to staff about their worries or fears, and the proportion who felt they were told about medication side effects to watch for) were below peer group averages.

Responsive

Good

Updated 3 July 2019

Our rating of responsive stayed the same. We rated it as Good because:

  • The hospital planned and provided services in a way that met the needs of local people.

  • Services took account of patients’ individual needs.

  • People could access services when they needed them. Arrangements to admit and discharge patients were typically in line with good practice.

  • Overall, the hospital treated concerns and complaints seriously, and investigated them.

However:

  • We saw limited evidence of discussions about learning from concerns and complaints in meeting minutes we reviewed.

Well-led

Inadequate

Updated 3 July 2019

Our rating of well-led went down. We rated it as Inadequate because:

  • Key leaders in the service did not have the right skills and abilities to run a service providing high-quality sustainable care. Senior leaders could not reliably determine how many serious incidents had occurred, and had not always notified CQC of serious incidents, or had not done so in a timely manner. Senior leaders had not supported or promoted a culture of appropriately identifying, reporting, categorising, and learning from incidents. Opportunities to prevent or minimise harm were missed.

  • The culture was not one of fairness, openness, transparency, honesty, challenge and candour. Senior leaders were reactive and defensive. The leadership team had not always been open and honest with patients when things went wrong; and had failed to meet their duty of candour responsibilities consistently well.

  • The application of governance arrangements and systems was not adequate. At the time of inspection, the hospital had been without a governance lead for several months. We saw the frequency of key committees was not always in line with their agreed terms of reference and accurate key data was not always produced and subsequently reviewed by committees and groups in a timely manner. We were not assured that the process to report concerns to other external agencies had been followed in a timely manner.

  • The service had systems to manage information. However, appropriate and accurate information was not always effectively processed, challenged and acted upon. Risks to patient safety had not been monitored or mitigated over time consistently well. We observed recurrent trends in incidents and meeting minutes we reviewed. We found senior managers had failed to sufficiently address fasting time compliance at the time of inspection. We observed that recent improvements had been made in VTE prophylaxis, daily and pre-discharge medical review of patients, and medical record keeping compliance; but that compliance deficiencies were observed throughout most of 2018.

  • We found the hospital risk register and the paediatric risk register were not being appropriately managed. The service had not sufficiently applied the systems available to identify risks and implemented plans to eliminate or reduce them.

  • Leaders had not promoted and maintained a positive culture that supported and valued staff and created a sense of common purpose based on shared values. The culture, policies and procedures had not provided adequate support for staff to raise concerns and have these adequately addressed. From November 2017 to October 2018, CQC received five whistleblowing enquiries; and an internal whistleblowing investigation by Spire Healthcare (corporate) had been undertaken with respect to children’s and young people’s services.

However:

  • Ward and theatre staff said they felt supported by their line managers, who promoted a positive culture that valued staff.

  • There was a hospital strategy for what leaders wanted to achieve; however, there was no CYP specific mission statement or vision.

  • Senior managers engaged with patients, staff, and local organisations to plan and manage services.

  • We saw evidence of leaders promoting training, research and innovation.

Checks on specific services

Medical care (including older people’s care)

Outstanding

Updated 6 July 2017

Medical care services were a small proportion of hospital activity. The main service was oncology. Some of the services were delivered on the same wards as surgery. Where arrangements were the same, we have reported findings in the surgery section.

We rated this service as outstanding because it was outstanding in caring, responsive and well-led and good for safe and effective.

Services for children & young people

Requires improvement

Updated 3 July 2019

Children and young people’s services were a small proportion of hospital activity. The main service was surgery. Where arrangements were the same, we have reported findings in the surgery section.

We rated this service as requires improvement. We found the service was caring, effective and responsive. However, it requires improvement for being safe, and was deemed inadequate for being well-led.

Critical care

Good

Updated 6 July 2017

Critical care services were a small proportion of hospital activity. The hospital had an eight-bedded high dependency unit providing level 2 care. The main service was elective post-operative recovery. Where arrangements were the same, we have reported findings in the surgery section.

We rated this service as good because it was safe, effective, caring, responsive and well-led.

Outpatients and diagnostic imaging

Good

Updated 6 July 2017

Outpatients and diagnostic imaging was a large proportion of hospital activity.

We rated this service as good because it was safe, responsive and well-led. We rated caring as outstanding. We inspected the effectiveness of the service, but did not rate it.

Surgery

Requires improvement

Updated 3 July 2019

Surgery was the main activity of the hospital. Where our findings about surgery also apply to other services, we do not repeat the information but cross-refer to the surgery section.

We rated this service as requires improvement. We found the service was caring and responsive. However, it requires improvement for being safe and effective, and was deemed inadequate for being well-led.