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Inspection Summary


Overall summary & rating

Good

Updated 19 February 2016

Spire Leicester Hospital is run by Spire Healthcare Limited. The hospital is located in Oadby which is a residential area south of Leicester.

Healthcare is provided by the hospital to patients with private medical insurance, those who self-pay and through NHS contracts.

The service is registered to provide inpatient care to 54 patients at any time. Hospital facilities include a 30-bed inpatient ward, 14 bed day ward, five chemotherapy pods and five chemotherapy beds. Theatre provision includes: three theatres with laminar flow, a cardiac catheter laboratory and a minor procedures suite. From April 2014 to March 2015 there were 6,518 visits to theatre.

This was the first comprehensive inspection of Spire Leicester Hospital. We carried out an announced inspection of Spire Leicester Hospital between the 11 and 12 August 2015. Following this inspection an unannounced inspection took place on the 17 August 2015 between 12 and 3pm. The purpose of the unannounced inspection was to look at how the hospital operated at peak times and to follow-up on some additional information from the announced inspection.

The inspection team inspected the following core services:

  • Surgery
  • Medicine
  • Outpatients and Diagnostic Imaging
  • Children and Young People
  • Termination of Pregnancy.

The hospital provided a health screening service which was not inspected as part of our inspection.

We rated Spire Leicester Hospital as ‘Good’ overall but the outpatients and diagnostic imaging service required improvement.

Our key findings were as follows:

Are services safe at this hospital

  • There were information gaps in some children's and young people’s records. We reviewed 16 sets of records; four records did not have completed fluid charts and five records had no risk assessment.
  • We found gaps in some of the patient records we reviewed. We were told that some consultants used their own notes rather than Spire medical records in which to record the patient’s outpatient consultation and not all those notes were retained within the Spire medical record.
  • Medical notes were not always easy to read although the provider informed us notes were sometimes typed and staff could contact medical staff for an explanation if necessary.
  • The Spire Leicester Hospital weekly compliance report dated the 7 and 11 August 2015 showed shortfalls in the receipt of medical staff information on medical indemnity, disclosure and barring checks and General Medical Council registration expiry dates. The provider acknowledged that further work was required to ensure all consultants provided evidence of all the required documentation. A senior manager informed us of the actions in place to achieve compliance and mitigate risk. By 20 August 2015, 312 consultants had provided all the required documentation. The suspension of practising privileges for 34 consultants took place until all documentation was submitted to the hospital. Since 20 August 2015, the provider confirmed that compliance has remained at 100% at all times in relation to the collection of this information and that all medical staff were fully insured during the CQC inspection, despite shortfalls having been observed in the collection of this data.
  • Patients were protected from abuse and avoidable harm. Patients felt safe and staff had the skills, knowledge and tools to identify risks and knew how to escalate these if needed. Processes were in place to mitigate risks.
  • Incidents were investigated, actions taken and learning disseminated throughout the hospital.
  • All patient areas were visibly clean, infection prevention and control processes were in place and equipment had been checked regularly. Medicines were stored and administered safely.
  • Staffing was managed effectively to ensure patients received good care with access to medical care obtained in a timely manner. Staff were well trained and records were kept securely.

Are services effective at this hospital

  • The Spire Leicester Hospital weekly compliance report dated the 7 and 11 August 2015 showed shortfalls in the receipt of medical staff information on whole practice appraisals and biennial review dates.
  • The provider acknowledged that further work was required to ensure all consultants provided evidence of all the required documentation. We spoke with a senior manager who informed us of the actions in place to achieve compliance and mitigate risk. By 20 August 2015, 312 consultants had provided all the required documentation. The suspension of practising privileges for 34 consultants took place until all documentation was submitted to the hospital. Since 20 August 2015, the provider confirmed that compliance has remained at 100% at all times in relation to the collection of this information and that all medical staff were fully insured during the CQC inspection, despite shortfalls having been observed in the collection of this data.
  • No audits or monitoring of children’s and young people’s outcomes had taken place since this service had been set up in 2013. There was no audit system for ensuring that medical notes were fully completed within the children’s and young people’s service.
  • Patient’s pain was well managed.
  • Staff helped patients if they needed support to eat and drink and they had access to drinks.
  • Evidence based care and treatment was delivered to adult patients, which followed national guidance.

Are services caring at this hospital

  • Patients we spoke with confirmed that staff were kind, considerate and treated them with dignity and respect.
  • We observed staff being attentive and caring to patients during the inspection.
  • Patient experience was reported on through local patient surveys and the NHS Friends and Family Test (FFT). The FFT score for June 2015 was 99%.

Are services responsive at this hospital

  • Delays, cancellations and attendance rates had not always been monitored in an effective way. Data was collected but not audited or actioned further to prevent or reduce these events in future.
  • Waiting times in the outpatient department were not always monitored effectively.
  • Signage in all areas was small and only in English which could have proved a challenge for those with poor sight or whose first language was not English.
  • Planned admissions and multidisciplinary meetings took place to ensure effective admission, treatment and discharge planning. Processes were in place for transfers to other hospital if a patient required a higher level of care.
  • The hospital had a complaints policy and procedure in place and patients were given information about how to raise any concerns or make a complaint.

Are services well led at this hospital

  • The leadership, governance and culture at the hospital promoted the delivery of high quality person-centred care. Members of the management team were well respected amongst both staff and patients.
  • Staff felt valued and were positive about their roles.
  • There was a shared vision throughout the hospital and safe patient care was paramount.
  • Patient feedback was a valued tool and the hospital strived to improve following any negative comments from patients or relatives.

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

Importantly, the provider must:

  • Ensure that an accurate, complete and contemporaneous record is securely maintained in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided. There was no audit system for ensuring that medical notes were fully completed within the children’s and young people’s service.
  • Ensure arrangements are put in place to monitor outpatient appointment cancellations and delays.

In addition the provider should:

  • Ensure paediatric and adult drug boxes for resuscitation are not of a similar colour to aid quick identification in an emergency.
  • Ensure appropriate interpreting services following best practice are always available for those whose first language is not English.

  • Ensure auditing samples for compliance with the five steps to safer surgery checklists are more representative of the number of patients undergoing surgical procedures.
  • Ensure that there is an effective system in place for contacting a radiologist urgently.
  • Ensure that the minor operations room has a plan in place for ensuring patient safety and that treatment can be provided rapidly without delay.

  • Ensure that the privacy and dignity of patients using the imaging department is maintained.

  • Ensure that all staff working with oncology patients in the chemotherapy unit are aware of the gold standards framework.
  • Ensure practice is reviewed around the use of the malnutrition universal screening tool.
  • Ensure a protocol for children with learning difficulties is developed.
  • Ensure that staffing and workforce development plans are developed in parallel with the paediatric strategy.
  • Ensure the areas where children are cared for are appropriate for the needs of the child.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Good

Updated 19 February 2016

Effective

Good

Updated 19 February 2016

Caring

Good

Updated 19 February 2016

Responsive

Good

Updated 19 February 2016

Well-led

Good

Updated 19 February 2016

Checks on specific services

Medical care (including older people’s care)

Good

Updated 19 February 2016

The hospital had systems in place to protect patients and keep them from avoidable harm. Patients felt safe and staff had the skills, knowledge and tools to identify risks and knew how to escalate these if needed. Staff showed a good awareness of incident management showing that the system was embedded.

The use of professional guidance had ensured that patients’ safety was maintained. The local audit programme and the changes identified from specific audits were acted upon in a timely manner. We saw that 100% compliance had been achieved against some audits, for example, the sepsis audit and consent.

Staffing was managed effectively; staff were well trained, had received regular appraisals and professional qualifications were validated.

The Spire Leicester Hospital weekly compliance report dated the 7 and 11 August 2015 showed shortfalls in the receipt of medical staff information on medical indemnity, disclosure and barring checks, General Medical Council registration expiry dates, whole practice appraisals and biennial review dates.The provider acknowledged that further work was required to ensure all consultants provided evidence of all the required documentation. We spoke with a senior manager who informed us of the actions in place to achieve compliance and mitigate risk. By 20 August 2015, 312 consultants had provided all the required documentation. The suspension of practising privileges for thirty-four consultants took place until all documentation was submitted to the hospital. Since 20 August 2015, the provider confirmed that compliance has remained at 100% at all times in relation to the collection of this information and that all medical staff were fully insured during the CQC inspection, despite shortfalls having been observed in the collection of this data.

Patients received effective care and treatment that met their needs. Medical care was delivered by consultants who worked at local NHS hospitals.

Patients were supported, treated with dignity and respect and involved as partners in their care. Patients told us they felt cared for.

Patients with specific individual needs such as dementia were met. We saw effective systems in place to capture and act upon patient feedback.

Admissions were planned and multidisciplinary meetings had taken place to ensure effective admission, treatment and discharge planning. Processes were in place for transfers to other hospital if a patient required a higher level of care.

The leadership, governance and culture at the hospital promoted the delivery of high quality person-centred care.  Members of the management team were well respected amongst both staff and patients. Staff felt supported, spoke positively about the organisation and staff morale was high.

Services for children & young people

Good

Updated 19 February 2016

The children’s service had a good track record on safety. The hospital safeguarded children and young people through offering care tailored to their needs. If a child was admitted overnight, a paediatric consultant and a children’s nurse stayed on site to look after them. Staff working with children were qualified to ‘National Society of Prevention of Cruelty to Children’ safeguarding level three, in line with good practice. The children’s nurses had specialist training in paediatric life support and the lead nurse promoted skills in nursing children.

The hospital routinely conducted a range of risk assessments and there were procedures to treat children whose health was deteriorating after an operation. However, some of these risk assessments were not signed or fully completed.

The hospital lacked specific waiting areas and consulting rooms for children, but staff minimised the risk of mixing with adults.

The children’s services were relatively new and did not have a quality dashboard to monitor their performance over time. They had not developed systems to carry out benchmarking or clinical audits, which limited organisational learning.

Parents said their children received compassionate care. They said the hospital gave them good information and involved them in decisions about their child’s treatment and care. Child friendly information was available for children about their procedures, nurses and consultants encouraged them to ask questions about their care. Nursing staff offered children and parents emotional support when needed. The hospital planned care for children taking into account emotional, spiritual, social, mental and physical needs.

Children’s and young people’s services were responsive and provided access at times to suit children, young people and their parents.

Nurses encouraged children to keep in touch with friends and family and the hospital provided beds in children’s rooms and a meal if a parent wanted to say overnight. The service was sensitive to children who had been inpatients and introduced them to the environment through a visit and a pre-assessment appointment, so that everything would be familiar. Nurses and consultants ensured that children who had behavioural challenges also felt at home and were cared for well.

The service had a vision for expansion in the future.

There was a positive culture and staff showed clear motivation to do their best for children and young people.  There was a good risk management structure and children’s nurses worked well with consultants to develop policies and plan services.

Outpatients and diagnostic imaging

Requires improvement

Updated 19 February 2016

Emergency equipment was not immediately available within the department. Staff in outpatients department had limited knowledge in regards to decontamination following patients with suspected communicable diseases.

The Spire Leicester Hospital weekly compliance report dated the 7 and 11 August 2015 showed shortfalls in the receipt of medical staff information on medical indemnity, disclosure and barring checks, General Medical Council registration expiry dates, whole practice appraisals and biennial review dates. The provider acknowledged that further work was required to ensure all consultants provided evidence of all the required documentation. We spoke with a senior manager who informed us of the actions in place to achieve compliance and mitigate risk. By 20 August 2015, 312 consultants had provided all the required documentation. The suspension of practising privileges for thirty-four consultants took place until all documentation was submitted to the hospital. Since 20 August 2015, the provider confirmed that compliance has remained at 100% at all times in relation to the collection of this information and that all medical staff were fully insured during the CQC inspection, despite shortfalls having been observed in the collection of this data.

Safety concerns were identified and addressed in a timely manner. All staff were aware of responsibilities in relation to reporting incidents and the duty of candour.

There were effective systems in place to protect people from avoidable harm and lessons were learnt from any incidents within the department. We found that equipment was appropriately serviced and calibrated.

Staff received training in mandatory and role specific areas. Patient risk was assessed and responded to appropriately.

We saw that staff were caring towards patients and respected their privacy and dignity. Patients understood options available to them and were able to choose appointments to suit their needs.

Information was available for patients throughout the department and staff had the appropriate skills and knowledge to seek consent from patients throughout their care.

Waiting times and attendances were not always monitored and collated effectively; this was not recognised as an issue within the hospital.

Patient outcomes were not looked alongside cancelled clinics to ensure there was not a negative effect. People could access the right care at the right time and patient needs were taken into account.

Signage was not always clear to patients visiting the outpatient and imaging department. Consideration was not always given to those with cultural needs and staff said they would benefit from further training in this area.

Complaints were investigated and where necessary clinical and administrative practice had changed to prevent recurrence.

Radiation regulations were followed and staff received the necessary training and competency assessment to ensure patient safety.

Staff felt valued and were positive about their roles. There was a shared vision throughout the hospital and safe patient care was paramount. Innovation and improvement was encouraged in outpatient and imaging areas, with evidence to support this. Feedback was a valued tool and the department strived to improve following any negative comments from patients or relatives.

Surgery

Good

Updated 19 February 2016

The hospital had systems in place to keep patients safe. Processes were in place to report incidents and staff demonstrated a good awareness of the process for identifying and reporting any safety incidents showing the system was embedded. Investigations were robust and staff learned from actions taken. However, because of the small monthly sample size (less than 2%) for the auditing of the five steps to safer surgery checklists we could not be assured of overall compliance with safe practices in theatre.

All patient areas were visibly clean, infection prevention and control processes were in place and equipment had been checked regularly. Medicines were stored and administered safely.

Staffing was managed effectively to ensure patients received good care with access to medical care obtained in a timely manner. Staff were well trained and records were kept securely.

Evidence based care and treatment was delivered to patients following national guidance by competent staff. The hospital provided a seven-day week service with patients having good access to information.

All the patients and relatives we spoke with were overwhelmingly positive about the care they had received and the way staff treated them. Patients told us they were involved in their care and staff explained care and treatment in a way they understood.

Access to care and treatment was monitored and exceeded the national average. Staff acknowledged patients’ individual needs and responded to them in an appropriate way although we were not assured a suitable translator was always available for patients whose first language was not English.

Staff had a good understanding of the complaints process and the hospital learned from complaints, changing care practices if required.

Shortfalls were found in hospital wide consultants’ information; with the exception of consultant staff working with children and young people and termination of pregnancy services. The Spire Leicester Hospital weekly compliance report dated the 7 and 11 August 2015 showed shortfalls in the receipt of medical staff information on medical indemnity, disclosure and barring checks, General Medical Council registration expiry dates, whole practice appraisals and biennial review dates. The provider acknowledged that further work was required to ensure all consultants provided evidence of all the required documentation. We spoke with a senior manager who informed us of the actions in place to achieve compliance and mitigate risk. By 20 August 2015, 312 consultants had provided all the required documentation. The suspension of practising privileges for thirty-four consultants took place until all documentation was submitted to the hospital. Since 20 August 2015, the provider confirmed that compliance has remained at 100% at all times in relation to the collection of this information and that all medical staff were fully insured during the CQC inspection, despite shortfalls having been observed in the collection of this data.

The hospital had a governance system in place which included an audit system. Morale was excellent with staff talking positively about the organisation and their local management team. Staff felt listened to and supported in their role.

Termination of pregnancy

Good

Updated 19 February 2016

The termination of pregnancy service at Spire Leicester Hospital offered safe care to the patients.

There were sufficient numbers of suitably trained staff available to care for patients.

The environment and equipment was visibly clean and infection control procedures were followed.

Staff were aware of safeguarding procedures and had received training in safeguarding adults, the Mental Capacity Act (2005) and Deprivation of Liberties (DOLs.)

Medicines management was safe and there was a clear audit trail for the request and receipt of the medication.

There were appropriate procedures to provide effective care. Care was provided in line with national best practice guidance.

Arrangements were in place to ensure that staff had the necessary skills and competence to look after patients. Patients had access to Spire Leicester Hospital out of hour’s aftercare 24 hours a day, seven days a week.

Patients were cared for by a multidisciplinary team working in a coordinated way. Patients received compassionate care that respected their privacy and dignity. All the patients considering termination of pregnancy had access to pre-termination counselling.

Patient’s wishes were respected and their beliefs and faith were taken into consideration regarding the sensitive disposal arrangements for pregnancy remains.

The hospital was responsive to patient needs. Professional interpretation service was available to enable staff to communicate with patients for whom English was not their first language.

The service was compliant with the guidance from the Royal College of Obstetrics and Gynaecology (RCOG) Guidance in Relation to Requirements of the Abortion Act and the Department of Health guidelines Procedures for the Approval of Independent Sector Places for the Termination of Pregnancy Required Standard Operating Procedures (RSOP). The hospital monitored its performance against the RSOPs.

There were effective governance arrangements in place and staff felt supported by the senior management team.

The culture in the hospital was caring and supportive. Staff said that the leadership and visibility of the hospital director, matron and senior managers was good.

Staff spoke positively about the high quality care and services they provided for patients and were proud to work for Spire Leicester Hospital.