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Spire Murrayfield Hospital Requires improvement


Inspection carried out on 21 August 2017

During a routine inspection

Spire Murrayfield Hospital is operated by Spire Healthcare Limited. The hospital has 25 inpatient beds and 17 day-case beds. Facilities include three operating theatres, a pharmacy, a pathology laboratory, a physiotherapy treatment area, a sterile services department for the decontamination and sterilisation of theatre instruments, X-ray, outpatient and diagnostic facilities.

The hospital provides surgery, medical care and outpatients and diagnostic imaging. We inspected some aspects of surgical care services.

We inspected this service using our focussed inspection methodology. We carried out an unannounced visit to the hospital on 21 August 2017 as a follow-up to a warning notice that was issued following the last inspection in September 2016. This was issued due to concerns about the lack of assurance around the robustness of investigations of incidences of venous thrombo embolism’s (VTE). We also followed up concerns that had recently been raised with the CQC.

We found the following issues that the service provider needs to improve following the concerns recently raised with the CQC:

  • There were incidences of incorrect assessment of grading, according to the American Society of Anaesthesiologists (ASA) as part of patient preoperative assessments as part of NICE guideline NG45 (2016). This meant there was a risk that patients operations had either been cancelled or they should have been treated in a hospital with access to critical care facilities in case of any deterioration post surgery.
  • There was no evidence that the provider had reported incidents of patients who had an ASA level 3 who had undergone surgery. This meant there was a risk that potential learning had not been identified to improve services provided. During the inspection, there was no local policy or guidance for clarification for preoperative staff to classify the ASA level for patients to ensure that the hospital could provide the correct level of care post operatively. There were no audits of the accurate completion of preoperative assessments. There was no exclusion policy to assess the suitability of patients treated at the hospital, although the hospital had been working to put this in place.

  • There were staff employed in a surgical first assistant (SFA) role who had not received any theoretical training prior to assessment of practical competencies in line with recommended national guidance. Since the inspection the provider has told us that a tailored SFA module with a university has been commissioned to provide additional training.

However, we also found the following areas of good practice:

  • We were assured that the provider had addressed the concerns in the warning notice that included a review of the policy for the management of venous thromboembolism (VTE) and completion of root cause analysis (RCA) investigations to help improve practice.

  • Processes were now embedded for the management of investigations of venous thromboembolisms (VTE).
  • Staff, including health care assistants, were encouraged to develop their role, in theatres, whilst being supported and supervised.

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 two requirement notices that affected surgery. Details are at the end of the report.

Name of signatory

Ellen Armistead

Deputy Chief Inspector of Hospitals

Inspection carried out on 20 to 21 September 2016 and 29 September 2016

During a routine inspection

Spire Murrayfield Hospital is a private hospital which has been providing independent health care services on the Wirral since 1982. It is part of Spire Healthcare. Spire Murrayfield is registered to provide the following regulated activities:

  • Diagnostic and screening
  • Family planning
  • Services in slimming
  • Surgical procedures, including cosmetic surgical procedures
  • Termination of pregnancy
  • Treatment of disease

We carried out an announced inspection of Spire Murrayfield on 20 and 21 September 2016 and an unannounced inspection on 29 September 2016. We carried out this inspection as part of our comprehensive inspection programme of independent healthcare hospitals. Overall we have rated Spire Murrayfield Hospital as Requiring Improvement.

During our inspection we looked at three core service areas; surgery, outpatients and diagnostics and the termination of pregnancy service. We have not provided a rating for termination of pregnancy services because the service dealt with very small numbers of patients, meaning there was insufficient evidence to arrive at a rating.

There was a mobile computerised tomography (CT) service which visited the hospital on a weekly basis. This service was not registered at Spire Murrayfield and was therefore not inspected by the inspection team.

Are services safe at this hospital?

  • Staff were trained in the recording of incidents on the electronic incident system. When we spoke with staff, all staff knew how to record incidents and what type of events constituted an incident.
  • The hospital did not have any clear policies or use a dependency tool that indicated how many staff were needed to safely care for patients. A dependency tool is important as it determines the individual needs of patients which is then used to calculate the total number of staff required. Following the end of the inspection period, the management team provided information which indicated that they had recognised the need for implementing such a system.
  • All staffing levels complied with recommended guidelines; however we found instances when the number of qualified nurses were below the specified level identified by Spire Murrayfield in the data sent by the hospital to the CQC prior to inspection.
  • There was a duty of candour policy in place and all staff that we spoke with understood the principles of duty of candour. We saw an example of where harm had been caused and how the hospital had taken the appropriate steps to comply with the duty of candour legislation. However, the hospital had not taken all the required steps to inform patients when a cluster of venous thrombo-embolism (VTE) incidents had occurred.
  • There had been a cluster of eight cases of VTE which occurred at the hospital in the reporting period. From these eight cases, seven patients developed a pulmonary embolism. The senior management team and the medical advisory committee (MAC) were aware of the issue. Serious adverse event forms had been completed and had not identified any breach of policy or clinical protocols. However, a more detailed root cause analysis investigation had not been completed, which was required in the Spire Healthcare policy. This meant that potential opportunities to learn from them and prevent recurrence may have been missed.
  • Services were consultant led and there was a resident medical officer (RMO) on site 24 hours a day, seven days a week.
  • Compliance with mandatory training was low throughout the hospital. This included a low number of staff who were up to date with training for basic and immediate life support.
  • We found some instances where medication was prescribed on paper prescription charts that were not always clear and two occasions of more than one chart present in patient notes.
  • We found that health care assistants were completing VTE risk assessments, without the assurance of having their competency to do so assessed. The hospital addressed this immediately and put in place an action plan to introduce competency assessments for this task in the two weeks following the inspection.

Are services effective at this hospital?

  • Local policies, procedures and care pathways for all services were based on evidence and guidelines produced by Royal Colleges’ and National Institute for Health and Care Excellence (NICE).
  • The hospital had an annual audit timetable that was followed by all departments. The timetable was reviewed regularly by a number of committees, including the Clinical Governance and Medical Advisory Committees.
  • Outcomes data indicated that the hospital was performing at a comparable level with other independent hospitals for the services it provided.
  • Patients were assessed for fluid and nutrition requirements using formal tools. Fluid and nutrition intake was monitored and recorded in patient records. All records that we reviewed contained fluid balance charts. Patients were fasted for surgery in line with national guidelines.

Are services caring at this hospital?

  • We observed that patients were treated in a caring and compassionate way at all times. Staff addressed patients with respect and dignity and discussed the emotional needs of patients with inspectors.
  • We found that the senior management team placed great emphasis on considering patients’ emotional needs and treating patients with compassion. The hospital promoted the six C’s (care, compassion, courage, communication, commitment and competence) and encouraged a person –centred approach to care.
  • Patients told us that they were treated with kindness and respect at all times. We also received thirty comment cards related to our inspection, which reported that staff were kind, caring and that they were treated with respect.

Are services responsive at this hospital?

  • We found that the senior management team worked collaboratively to plan services for patients using the hospital. This team reviewed how services were delivered and considered the needs of patients when redeveloping services. An example of this is the recent redesign of outpatients services in line with patient needs.
  • The hospital had an admissions policy with detailed criteria for patients who could be safely treated at the hospital. We found this policy was being implemented.
  • The hospital was highly responsive in terms of access and flow for all services, particularly termination of pregnancy and outpatients. All patients were seen in a timely manner and referral to treatment times were being met.
  • The hospital considered the needs of patients with complex needs who used its services.

Are services well led at this hospital?

  • There was a clear vision and strategy for the hospital. The senior management team were able to articulate this vision and disseminated it throughout the hospital.
  • We found that there were robust governing structures in place, which included a number of groups with different functions and included clinical governance, combined health and safety/risk and senior management team.
  • The hospital had developed a set of standard operating procedures and working instructions to support the Spire corporate policies that already existed. However, we found that the provider’s policy for VTE was not in line with national NHS recommendations. This was because the provider’s policy stated that VTE incidents that occurred within 30 days post-surgery should be investigated. Guidelines from the national VTE prevention programme (2013) state that incidences of VTE can be attributable to surgery and should be investigated up to 90 days post-surgery.
  • The hospital did not provide sufficient management overview of the termination of pregnancy service.
  • The hospital did not have a formal staffing policy in place.
  • The Medical Advisory Committee (MAC) was well attended and had representation from each medical/surgical specialty. The MAC reviewed all applications for practising privileges. The MAC was well integrated into the clinical and corporate governance arrangements and reported a strong working relationship with the hospital management team.
  • There was a focus on safety and risk in the governance structures and this was reflected throughout the hospital.
  • There was strong leadership in evidence at the hospital. The hospital director working closely with a small senior management team to provide a focus on the quality and safety of services provided to patients.
  • Staff morale was extremely high, with all staff we met with reporting high levels of satisfaction within their roles and with the leadership and senior management team.

We saw one area of outstanding practice;

  • Two members of the physiotherapy team attended a six week pilates course approved by the Australian Physiotherapy and Pilates Institute (APPI) in order to offer a complimentary pain relief therapy for patients. Pilates is used as a preventative and multi-disciplinary approach to treatment. The classes were also open to patients without a referral.

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


  • The hospital must ensure that all incidences of venous thrombo-embolism resulting in a pulmonary embolism are thoroughly investigated in line with Spire policy and national guidance. This is so that potential learning is identified and improvements are made when needed.
  • The hospital must have a robust system to determine the numbers of staff required at any given time on the inpatient ward.
  • The hospital must ensure that there are sufficient numbers of staff who are up to date with basic and immediate life support training.
  • The hospital must ensure that all staff have the necessary competencies for the tasks they are required to perform.

Termination of pregnancy service

  • Records by health professionals must be clear and easy to read.
  • Evidence of counselling offered must be included in patient records.
  • Medication charts must be clear, with all prescribed medication included and only one per patient.
  • The hospital must monitor the outcome of each termination of pregnancy.
  • The hospital needs to audit the uptake of Long Acting Reversible Contraception.
  • The hospital must evidence screening for sexually transmitted infections.
  • The hospital must evidence a discussion with patients about HSA4 form and evidence that this has been sent.

We issued a section 29 warning notice to the provider as we were not assured that all incidents were robustly investigated. A Section 29 warning notice tells a provider or registered manager that they are not complying with a condition of registration, requirement in the Health and Social Care Act 2008 or a regulation, or any other legal requirement the CQC view is relevant. Warning notices are issued in line with the CQC enforcement policy if there ‘appears to the commission’ to be a breach of relevant regulations. A warning notice can be served on any registered person.

In addition we identified areas where the provider should take action;

In Surgery

  • The hospital should consider how to become compliant with building note HBN 00-09.
  • The hospital should review equipment checking procedures, ensuring that resuscitation equipment on the ward is checked robustly and is in date.
  • The hospital should review processes to make sure that all cleaning agents are locked away in an appropriate storage area so that they are not accessible to members of the public.
  • The hospital should consider ways to ensure that all staff decontaminate their hands when required.
  • The hospital should consider storing emergency anaphylaxis medication in a more secure area so that it is not accessible to members of the public.
  • The hospital should consider ways to ensure that all staff are fully aware of female genital mutilation (FGM) and their legal obligation to report any identified incidences of it.
  • The hospital should improve compliance with overall mandatory training.
  • The hospital should make sure that consultants include their GMC number on all occasions when signing patient records.
  • The hospital should make sure that ‘stop before you block’ signage is used in all anaesthetic rooms and should consider monitoring compliance with ‘stop before you block’ during procedures.
  • The hospital should ensure that efficacy of administered pain relief is documented in line with Spire policy.
  • The hospital should ensure that written communication is provided on all occasions when Duty of Candour is being discharged.
  • The hospital should improve its performance in relation to compliance with fasting guidelines prior to patients undergoing surgery.
  • The hospital should consider using Q-PROMS to monitor cosmetic surgery outcomes and compare them nationally.
  • The hospital should ensure that they keep evidence of all achieved competencies for staff in their personal files so that these can be evidenced when required.
  • The hospital should find ways to share information about implants used during surgery to the patient’s GP on discharge.
  • The hospital should consider introducing guidance for staff about patients who suffer with delirium following an anaesthetic so that staff have consideration for this when managing patients.
  • The hospital should ensure that all policies take into account national guidance.

In the Termination of pregnancy service

  • The provider should consider ways to identify feedback from TOP patients to improve the service.
  • The provider should provide clear and accurate information in patient leaflets.
  • The provider should make it clear when complications should be recorded as incidents.
  • The provider should ensure that analgesia is prescribed in line with RCOG guidelines.
  • The provider should record evidence of all discussions about risk of complications including any increase in risk of complications.

In Outpatients and diagnostics

  • The hospital should ensure that all PGD’s are signed by an appropriate member of staff.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 12 December 2013

During a routine inspection

We spoke with patients, relatives and staff during this inspection. We visited the ward, day care unit and the theatre department. Patients and their relatives spoke positively about their experience and the care they received. They provided comments such as:

�I can�t find anywhere better�.

�Very pleasant, I can�t speak high enough of them�.

We found that when patients were admitted their needs were assessed and a plan of care was put into place. We found that the assessments, care plans and pathways were standardised corporate documents that were fully completed. We found that people�s health, safety and welfare were protected when more than one provider was involved in their care and treatment.

We looked at staffing levels in the wards and theatres. We found that generally staffing levels were suitable and staff had the knowledge and skills relevant to their roles. In the theatre department we found that issues with recruitment and retention of staff had caused concerns for staff and had led to increased use of agency staff to ensure adequate staffing.

The provider had an effective governance framework in place that included systems and processes in place for monitoring the quality of services and risk management.

Inspection carried out on 23 August 2012

During a routine inspection

We spoke with four patients who were receiving treatment at the hospital on the day of the inspection visit. All said they felt the staff team respected and valued them as individuals. Some comments made were:

�I have found all the staff to be efficient and good at what they do. I would recommend Murrayfield to other people.�

�I feel I have been listened to and the staff team have explained every treatment and procedure to me.�

�I was given good information about my procedure including watching a slide show before I made a decision about whether I wanted to go ahead with it.�

We observed staff supporting patients in a professional and friendly manner. We spoke with four patients who told us they had been given detailed information about the procedures they were to have prior to consent being requested. Some comments made were;

�I was given a lot of written information by my consultant and told to go home and think about the procedure. Four weeks later I attended a second appointment and was able to ask any questions or raise concerns. It was at this point I gave my consent for the procedure."

�I had my first consultation six months ago my consultant gave me very detailed verbal and written information about the procedure I was considering. I did not feel pressurised at all and came back to him six weeks ago to arrange for the procedure to be done. It was at this point I signed to give my consent. On the day of the procedure the medical staff again checked with me and checked that I still wanted the procedure to go ahead.�

All four patients spoken with told us they were well looked after and felt their medical needs were being effectively met. Some comments made were;

�The staff always knock before they enter my room, they tell me who they are and what they need to do like take more bloods.�

�They have monitored me very closely since my operation I can�t fault them.�

Inspection carried out on 20 March 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

Reports under our old system of regulation (including those from before CQC was created)