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Archived: Spire Manchester Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 22 March 2017

Spire Manchester Hospital is operated by Spire Healthcare Plc. and originally opened in June 1981 as Bupa Manchester. The hospital was renamed in 2007 when the hospital arm of Bupa was sold to Spire Healthcare. The Spire Manchester Hospital treats both NHS funded patients and patients who wish to pay for their own treatment.

The Hospital is located in Whalley Range, Manchester and it has 49 patient bedrooms, four theatres (two of which are laminar flow), a separate endoscopy room and a CE (European conformity) accredited Sterile Services department.

There are imaging facilities on site, which include a 16 slice computed tomography (CT) scanner, 1.5T Magnetic resonance imaging (MRI) scanner, a Fluoroscopy room, ultrasound and mammography. There is also a physiotherapy department, a complete patient gym with rehabilitation equipment, including an anti-gravity treadmill. The outpatient department has 18 consulting rooms in the main hospital, minor treatment rooms and two specially adapted consulting areas for bariatric patients. The hospital is also an International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) accredited weight loss centre.

Specialities undertaken at the hospital include: Cardiology and Chest medicine, Cosmetic Surgery, Dermatology, ENT, Endocrinology, Gastroenterology, General Medicine, General Surgery, Gynaecology, Neurology, Ophthalmology, Oral and Maxillofacial surgery, Orthopaedics, Paediatric Medicine and Surgery, Pain Management, Plastic/Cosmetic Surgery, Psychiatry, Rheumatology, Urology and Weight Loss Surgery. The hospital also has a satellite clinic in Hale, with four consulting rooms and a minor treatment room.

Chris Chadwick became registered manager in November 2012 and the accountable officer for controlled drugs for the Spire Manchester Hospital is Dawn Davies.

The majority of the consultants are from local NHS trust and have all been given practice and privilege rights at the hospital. The hospitals main activity comes from general surgical procedures and outpatient diagnostics imaging services. The hospital reported 6,470 inpatient and day case episodes of care in the reporting period (April 2015 to March 2016); of these 33% were NHS funded and 67% were funded privately. The hospital operates Monday to Saturday, also offering evening appointments.

We inspected the hospital as part of our routine comprehensive inspection programme for independent healthcare services. We carried out an announced inspection visit on 13 and 14 September 2016 and an unannounced inspection on 26 September 2016.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs 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.

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

Spire Manchester Hospital has previously been inspected by the Care Quality Commission on 22 May 2014. The Care Quality Commission inspected against five core standards and found the hospital to be compliant.

Spire Manchester Hospital is operated by Spire Healthcare Limited, Spire Manchester Hospital is registered to provide the following regulated activities:

  • Diagnostic and screening.
  • Surgical procedures.
  • Treatment of disease, disorder or injury.

We inspected the core services of Surgery, Services for Children and Young People and the Outpatients and Diagnostics service.

We rated this hospital/service as requires Improvement overall. Our key findings were as follows:

  • Equipment was maintained and appropriately checked, but in some areas was not always visibly clean.
  • In theatres, there were inconsistencies in the recording of the administration and destruction of controlled drugs in all of the controlled drug registers we reviewed.
  • We found there were numerous missing signatures and times for administration of controlled drugs were not, or not accurately, recorded. Failures to record the amount of the medication administered or destroyed, indicated that these medications were unaccounted for.
  • Medications, including controlled drugs, were observed being drawn up prior to the operation and prior to the patient arriving in the anaesthetic room.
  • Staffing levels were sufficient to meet patients’ needs and staff assessed and responded to patient risks in theatres and the outpatients and imaging department. However, care and treatment was not always provided by suitably trained, competent staff. For example nurses caring for children did not have the appropriate paediatric competencies.
  • Patients did not always receive care and treatment according to national guidelines such as National Institute for Health and Care Excellence (NICE) and the Royal Colleges. Surgery services participated in national audits.
  • There were governance structures in place, which included a risk register. We saw that not all risks had been identified and actions were not always taken to mitigate the risks in a number of areas that included controlled drugs in theatres.

However 

  • The hospital had systems in place for reporting risk and safeguarding patients from abuse.
  • Medical equipment was checked and maintained by an independent company. We saw records to confirm that electrical equipment had been tested across all areas.
  • There was sufficient capacity in the ward and theatres, so patients could be seen promptly and receive the right level of care before and after surgery.
  • Patients were given information about how to make a complaint. Complaints about the services were resolved in a timely manner and information about complaints was shared with staff to aid learning.
  • Staff treated patients with dignity and respect and patients were kept involved in their care. Patients and their relatives we spoke with told us they were supported by staff. We observed staff deliver care in a caring, compassionate and supportive way.
  • All staff were dedicated to delivering good, compassionate care and were motivated to work at the hospital.
  • Patient records were stored securely at the hospital and access was limited to those individuals who needed to use them. This ensured that patient confidentiality was maintained at all times.
  • Patients had a choice of appointments available to them through the ‘Choose and Book’ service. This meant that patients were able to attend appointments at a time best suited to their needs.
  • Robust systems were in place to ensure that consultants holding practising privileges were valid to practice. We saw there were procedures in place to ensure all consultant requests to practice were reviewed by the Medical Advisory Committee (MAC).
  • Staff that worked at the hospital felt appreciated and valued, they discussed with us the different ways Spire recognised staff for their hard work.

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 a requirement notice that affected surgical services and children and young people services. Details are at the end of the report.

Ellen Armistead

Deputy Chief Inspector of Hospitals (North Region)

Inspection areas

Safe

Requires improvement

Updated 22 March 2017

We rated safe as requires improvement because:

  • In theatres, there was a widespread inconsistency in the recording of the administration and destruction of controlled drugs, in all of the controlled drug registers we reviewed.
  • We found there were numerous missing signatures in respect of the first practitioner’s signature and the second witness’ signature required for the appropriate administration and destruction of controlled drugs. Times for administration of controlled drugs were not, or not accurately, recorded. We also noted failures to record the amount of the medication administered or destroyed in the controlled drugs registers which meant that medications may be unaccounted for. Furthermore, we saw a number of other errors that included the absence of dates or recording of incorrect dates.
  • Medications, including controlled drugs, were observed being drawn up prior to the operation and prior to the patient arriving in the anaesthetic room and this practice was confirmed by theatre staff. When the order of the theatre list was changed, the entries in the controlled drugs register were crossed through and the name of the patient amended.
  • Staffing levels and skills mix was sufficient to meet patients’ needs in theatres and outpatient department. We raised concerns regarding the competencies of adult nurses caring for paediatric patients during the pre-assessment appointment. We found that paediatric nurses did not have the right skills to perform some of the pre-assessment tests, for example paediatric nurses had not been trained in scoliosis lung function tests, ECG reading or venepuncture.

However,

  • There were processes in place to report, investigate and monitor incidents. Staff had access to systems to keep people safe and knew what constituted as a clinical incident and safeguarding concern.
  • Surgical procedures were performed by a team of consultant surgeons and anaesthetists, who were mainly employed by other organisations, such as the NHS. Surgeons and anaesthetists were in substantive posts and had practising privileges.
  • All staff were aware of their responsibilities relating to the duty of candour legislation and were able to give us examples of when this had been implemented. The hospital had a duty of candour process in place to ensure that people had been appropriately informed of an incident and the actions that had been taken to prevent recurrence. The legislation was also incorporated in the complaints policy to ensure staff exercised their responsibility to inform patients of an incident.
  • Staff used assessment tools to examine patients; they routinely assessed and responded to patients’ risks.
  • Equipment was maintained, appropriately checked and visibly clean across areas inspected, except for the theatres. Medical equipment was checked and maintained by an independent company.
  • Patient records were stored securely and access was limited to those who needed to use them.
  • Resident registered medical officers [RMOs] were employed to provide medical cover when the named consultant was not available. We reviewed documentation that confirmed the hospital checked that doctors were able to practice within scope.

Effective

Good

Updated 22 March 2017

We rated effective as good because:

  • Staff delivered care and treatment according to national guidelines such as National Institute for Health and Care Excellence (NICE) and the Royal Colleges.
  • Spire corporate policies, based on National Institute for Health and Care Excellence (NICE) and national and royal college guidelines were available to all staff on the intranet.
  • Any new policies or amendments to existing policies were reviewed and signed off by the Medical Advisory Committee prior to implementation.
  • Patients were offered appropriate pain relief post operatively.
  • There was a system in place to review practising privileges. We saw there were procedures in place to ensure all consultant requests to practice were reviewed by the Medical Advisory Committee (MAC).
  • Appropriate systems were in place to obtain consent from patients. Consent was sought from patients prior to delivering care and treatment across all areas we visited.
  • Staff were aware of what actions to take if a patient lacked the capacity to make their own decisions.

However,

  • Patient outcomes were generally routinely monitored through audits to ensure that practice was in line with current guidelines.  

Caring

Good

Updated 22 March 2017

We rated caring as good because:

  • Patients and carers spoke positively about the care and treatment staff delivered. Staff treated patients with dignity and respect and kept them involved in their care plan.
  • Feedback from patients who used the service was consistently positive about the way they were treated and cared for. In the 2015 patient survey, 99% of patients said they were treated with dignity and respect.
  • All of the patients we spoke with during our visit told us that they had been treated exceptionally well by staff. This was also reported in the 2015 patient survey: 99% of patient said they received care and attention from nursing staff.
  • We observed that staff were sensitive and understanding of the emotional impact of care and treatment. Staff told us that they put the needs of patients first.
  • Patients we spoke with said that staff always introduced themselves and made them feel that they were involved.
  • NHS patients were asked to complete the friends and family test: 99% of patients between October 2015 – March 2016 said they would recommend the hospital. The hospital achieved a 57% response rate both results are above the national England average.

Responsive

Good

Updated 22 March 2017

We rated responsive as good because:

  • Patient needs were assessed to clearly identify the patient’s treatment pathway.
  • The service worked to clear inclusion and exclusion criteria and did not accept patients with certain underlying medical conditions. Daily planning by staff ensured patients were admitted and discharged in a timely manner.
  • Patients were able to access services in a timely manner and the service was performing within the recommended target timeframe.
  • If a patient had complex needs and was identified as high risk, they were referred to a local NHS trust to make sure all their needs were met appropriately.
  • There was sufficient capacity in theatres, so patients could be seen promptly and receive the right level of care before and after surgery.
  • Cultural needs of patients were taken into account when planning and delivering services. For example, patients attending the wards were asked about their religious beliefs and dietary requirements, in case these affected their treatment options or meal preferences.
  • Staff had access to translation services for those patients whose first language was not English and information was available to patients in differing formats if required.
  • Systems were in place to support vulnerable patients. Patients were given information about how to complain and raise concerns and the service responded to complaints. Complaints about the services were resolved in a timely manner and information about complaints was shared with staff to aid learning.

Well-led

Requires improvement

Updated 22 March 2017

We rated well-led as requires improvement because:

  • There was a corporate governance committee structure in place that captured and discussed identified risks. The framework also enabled the dissemination of learning and service improvements and a pathway for reporting and escalation to the Spire board.
  • The hospital’s vision and values had been cascaded across the services and staff had an understanding of what these involved.
  • All staff were dedicated to delivering good, compassionate care and were motivated to work at the hospital.
  • Staff across the departments spoke positively about the leaders and the culture within the services.
  • There was clearly visible leadership within the services; staff spoke positively about the culture and the level of support they received.
  • We observed well-defined leadership roles within the areas we visited; we noted that staff were supportive of each other and managers operated an open door policy. All the staff we spoke with spoke highly of the senior management team and colleagues.
  • The Medical Advisory Committee (MAC) was well attended and was monitored by the hospital. The MAC provided advice to the hospital director on any matter relating to the proper safe, efficient and ethical medical and dental use of the hospital. This included any satellite site where members of the medical society were undertaking or supervising the delivery of healthcare services.
  • There was a system in place to review practising privileges. We reviewed employee information that showed the service had followed the ‘fit and proper person’ regulations.
  • We observed NHS patients receive the same level of care as private, self-paying and insured patients.
  • Prior to admission, the hospital sent information packs with appointment letters to patients, which gave clear instruction about cost and payment. Patients received costing information to make sure that patients were fully aware of any costs involved.

However,

  • Although a quality assurance framework was in place, it failed to provide senior management with oversight of hospital activity. The hospital identified further refinements were required, for example with regards to drugs and therapeutic management.
  • The hospital strategic direction was well described by the senior management team and it was clear that the management team were committed to improving governance processes, but systems were not yet embedded and further work was still required.
  • The local governance arrangements did not ensure the identification, mitigation and monitoring of risks. We were not assured that the senior management team had a full understanding and grip of the potential risks within the service and the supporting clinical governance arrangements.
  • We were not assured that the senior management team took sufficient actions to address shortfalls identified through audit. For example, a corporate controlled drugs (CD) quarterly audit showed significant issues in the management of CD’s in the theatre areas for both quarter 1 and 2 of 2016. We found no evidence of action taken to address the gaps identified, despite a picture of worsening compliance in the theatre areas between quarter 1 and 2. We reviewed the governance meeting minutes held bimonthly and noted that the pharmacy manager did not attend this meeting for a number of months and there was no mention of the issues raised in the audits.
Checks on specific services

Services for children & young people

Requires improvement

Updated 22 March 2017

We gave the services for children and young people at Spire Manchester Hospital an overall rating of requires Improvement. This was because:

  • When incidents required more detailed investigation, which applied to 2/21 of the incidents that had occurred from September 2015 – August 2016, there was variability in the quality of the investigations. One case was appropriately investigated but the other did not identify all the issues that required addressing to ensure learning and prevention of further incidents.
  • Nurse staffing did not fully meet national guidance. We found there was only one children’s nurse on duty when children were taken to theatre, meaning that paediatric patients were left with adults’ nurses who did not have the appropriate paediatric competencies.
  • Not all theatre staff were trained in accordance with standards outlined in national guidance; 56.5% of theatre staff were not up to date with paediatric competencies and 33.3% of staff recovering children post-operatively had not completed their advanced paediatric life support (APLS) training.
  • Paediatric records completion was not consistently in accordance with best practice. Audits had recently been introduced in the hospital, but action plans to address findings from audits were not embedded at the time of our inspection. The service measured some patient outcomes using the paediatric scorecard, which had been recently introduced at the hospital. However, there was no standard dataset across Spire hospitals for effective benchmarking within the Spire group. The service told us this was being developed corporately, but no implementation date was provided. There were no child-friendly consulting rooms and limited provision for children in outpatients, for example toys and seating. In one of two pre-assessment clinics that were being undertaken, the patients were seen for their observations from the children’s playroom for inpatients.
  • Children waited alongside adults for their outpatient appointments and were nursed on adult wards.

  • Risks that affected the paediatric service were not all recorded on the provider’s risk register.
  • Whilst a gap analysis had gone some way to assist the provider in achieving its strategy, the analysis undertaken was not comprehensive and omitted immediate risks to patients’ safety.

However,

  • Systems and processes were in place to safeguard children and young people.
  • Duty of candour, a regulatory duty that relates to openness and transparency, was understood and correctly applied by staff.
  • Policies and procedures were in place that were in accordance with best practice and national guidance. For example staff applied the “Child day-case/overnight stay care pathways” for children and young people undergoing elective surgery.
  • The services available to children and young people were planned according to service demand. The hospital offered good access for children and young peoples’ routine operations. Outpatient clinics were available in the evening, as well as during the day.
  • Parents spoke very highly of the caring and compassionate nature of staff. Children and young people were involved in their care and were aware of their treatment options.
  • We found that consultants holding practising privileges for children had been assessed as holding the relevant skills and experience.

Outpatients and diagnostic imaging

Good

Updated 22 March 2017

We rated outpatients and diagnostic imaging good overall. This was because:

  • There were systems in place for reporting risk and safeguarding patients from abuse. Staff were aware of how to report incidents that took place in the departments and we saw evidence of incidents being investigated and learning being shared within the team.
  • From observations we saw that equipment was maintained, appropriately checked and visibly clean. Medical equipment was checked and maintained by an independent company.
  • Clinical areas and waiting rooms were all visibly clean and tidy. Patient records were stored securely and were only accessible by those authorised to do so. This ensured that patient confidentiality was maintained at all times.
  • The departments used evidence based guidance to inform their practice.
  • Patients and their relatives we spoke with told us they were supported by staff that were caring, empathetic and helpful to their needs. Patients were positive about how they were treated by staff. Staff maintained patient privacy and dignity across the departments and provided emotional support to patients.
  • Patients were kept well informed about the treatment they were receiving in the hospital.
  • Services were planned and delivered to meet the needs of patients. The hospital offered a wide range of services, which were planned and delivered in a way which met the needs of local people. Patients told us there was good access to appointments and flexibility to attend appointments at times that suited their needs.
  • All staff told us that managers of the service were available and supportive. Staff were positive about the culture within their departments and said the senior management team were visible and approachable.

However,

  • The hospital did not hold a full medical record for insured and self-paying patients using the outpatient department. Although it did have a process for requesting all records needed.

  • Not every non-emergency patient having a CT scan involving an iodinated contrast agent had their kidney function tested prior to their scan, which is a recommendation of Royal College of Radiologist guidelines.
  • On one occasion during the inspection we found patients standing in the waiting area as there were not enough seats in the outpatient department waiting area to always accommodate all of the patients waiting for appointments.

Surgery

Requires improvement

Updated 22 March 2017

We rated surgery as requires improvement in the safe and well-led domains, although effectiveness, caring and responsive was good.

  • Staff assessed and responded to patient risks and used recognised assessments. However the surgical safety checklist was not always fully completed.
  • Staff did not always cleanse their hands after touching patient surroundings. Equipment stored on corridors in theatres, such as trolleys, was dusty, whilst this equipment was labelled with an ‘“I am clean” sign. Oxygen cylinders had been stored outside and dirt from the base of the cylinders had been transferred onto patient trolleys.
  • Incidents in relation to recording controlled drugs and omissions or errors were under reported in theatres. There were widespread omissions and poor recording of controlled drugs in record books in theatre. Staff reported that there was consultant resistance to complete the controlled drug registers. We found no evidence of actions taken to address this prior to the inspection; action was only taken when the inspection team raised concerns. This issue had not been raised at the medical advisory committee.
  • Medications, including controlled drugs, were observed being drawn up prior to the operation and prior to the patient arriving in the anaesthetic room and this practice was confirmed by theatre staff; we observed an anaesthetist drawing up controlled drugs and documenting this in the controlled drugs register prior to the patient’s arrival in the anaesthetic room. However, when the order of the theatre list was changed, the entries in the controlled drugs register were crossed through and the name of the patient amended.
  • Audits to monitor patient safety did not always detail what actions were required to improve patient care and safety
  • The most recent audit of the surgical safety checklist showed 88% compliance with documentation and 73% compliance on the observational audit. The outcome of the audit did not identify appropriate actions or sufficient measures to address the shortfall in compliance. There had been no previous audit of compliance with this checklist.
  • We reviewed nine sets of records and saw that in all cases, documentation was incomplete and not in line with best practice for record keeping. In theatre records staff were identified by their first name only and there was no clear record of which staff member had undertaken what role during surgery.
  • There was no locally agreed policy or risk assessment in place to support the use of scrub staff carrying out a dual role in theatre.
  • Not all risks on the risk register had action due dates or details of who was responsible for completing the actions identified for wards and theatre departments. This meant that there was a risk of ineffective monitoring of actions taken to reduce risk.

However,

  • There were systems in place to keep people safe and staff were aware of how to ensure patients were safeguarded from abuse.
  • Staff were kind, caring and compassionate and high numbers of patients would recommend the hospital to their friends and family.
  • Patients had access to treatment in a timely way. Staff recognised and understood the importance of individual patients’ needs.
  • Staff responded to patient risk appropriately. Early warning scores and risk assessments were completed and escalated in line with guidance. Clear systems were in place to manage the care of deteriorating patients. Staff had access to resident medical officers and consultants, 24 hours a day.
  • Patients received care from sufficient numbers of well-trained staff. There were sufficient numbers of suitably qualified staff to care for patients and they worked well as part of a team.
  • Nursing staffing levels met the needs of patients. There was adequate access to a resident medical officer and access to consultant surgeons, physicians or intensivists if required.
  • Systems were in place to ensure the competence and compliance of consultants operating under practising privileges. .
  • Care and treatment was delivered in line with national guidance and best practice. Hospital policies and pathways reflected evidence based care and treatment.
  • The hospital participated in a number of national audits of patient outcomes including patient reported outcome measures.
  • Staff were supported to develop their skills through additional training. All clinical staff in surgical services had completed an annual appraisal.
  • There were systems in place to support vulnerable patients. Complaints about the services were resolved in a timely manner and information about complaints was shared with staff to aid learning.
  • The Medical Advisory Committee (MAC) provided clinical scrutiny in relation to evidence based care and treatment. If consultants wanted to introduce new treatment methods or procedures, the evidence and guidelines for these procedures were reviewed by the MAC and approved if this was appropriate. Minutes we reviewed showed that the MAC refused permission to carry out procedures where there was insufficient evidence to support the use of the procedures.
  • There was a positive, open and honest culture. Staff described leaders as approachable and they were happy to work at the hospital. Staff and the public were involved in developments and service improvement initiatives.
  • The hospital’s vision and values had been cascaded across the surgical services and staff had an understanding of what these involved. There was clearly visible leadership within the services.