Spire Southampton Hospital

Spire Southampton Hospital, part of Spire Healthcare, offers comprehensive private hospital treatments, procedures, tests and scans to patients from Hampshire, Dorset, Wiltshire, the Isle of Wight, the south coast of England and the Channel Islands.

The hospital offers a range of surgical procedures, cancer care, rapid access to assessment and investigation and a physiotherapy service for women's heath and pain management. Acupuncture, massage and hydrotherapy was also available.  Patients are admitted for elective surgery, day case or outpatient care.  There are no emergency admissions. Patients requiring an emergency admission are usually triaged through the high dependency unit (HDU) before a decision is taken to manage their care in HDU or if they are safe to move to a ward.

Facilities included 78 beds, of these 59 are en-suite patient bedrooms, 12 beds in day care, and seven in the intensive the care unit and high dependency unit.  There are five theatres, outpatient facilities, a cancer care suite (The Chalybeate Suite) and the Perform Centre for physiotherapy and pre-assessment.

Services were available to people who held private insurance  or to those paying for one-off private treatment. Fixed prices, agreed in advance, were available. The hospital also offered services to NHS patients on behalf of the NHS through local contractual agreements and 30% of its activity was NHS funded care  

Spire Southampton Hospital was selected for a comprehensive inspection as part of the first wave of independent  healthcare inspections. The inspection was conducted using the care quality commissions new inspection methodology.

The team of 20 included CQC inspectors and analysts, doctors, nurses, experts by experience and senior  managers. The inspection took place on 22 and 23 October 2014, with unannounced visit on 3 November 2014. 

The inspection team looked at the following core services: Medical care, surgery, critical care, services for children and young people, outpatient and diagnostic imaging services.   

Our key findings were as follows:

Are services safe?

• There was an open culture and learning environment for reporting incidents.  The staff reported incidents using an electronic reporting system.  Outcomes and learning from incidents was cascaded to staff. The numbers of serious incidents in the hospital compared to patient and bed numbers was low (better than expected).  However, the timeliness of investigations following incidents  needed to improve in some areas, for example, theatres.
• There were good infection control surveillance procedures to identify and manage infections.  However, procedures for infection prevention and control were not always followed, and the and fabric of the building and the design of some areas increased the risk of cross infection.
• Patients, other than those receiving critical care, were cared for in single rooms with ensuite facilities.  The critical care unit was adjacent to and open to the operating department theatre. The Critical Care Unit was built prior to the present building guidance. This meant the bed spaces and facilities did not meet current guidance. The space was smaller than expected but this did not have an adverse impact on patient outcomes.  Some daily equipment checks had not been done on the critical care unit.
• The hospital building was 30 years old and some areas required updating.  The outpatients department was undergoing renovation to increase the number of consulting rooms and improve facilities.  There was not enough storage space and equipment was in corridors.  We observed that this was kept as tidy as possible. 
• Most medicines were stored and managed in safe way. However, there was limited space in the critical care unit and the storage of intravenous infusion fluids did not reflect best practice.  The expiry date for liquid medicines was not being appropriately recorded, and intravenous fluids not recommended for use in children were stored on the paediatric resuscitation trolley.  
• The pharmacy department had good governance systems to monitor new drugs, off licence drugs, safety and drug alerts and incidents. There was a medicines reconciliation service on admission and audits on prescribing on the wards.  Local medicines policies were up to date and the medication error rate was low (0.28%, between January to March 2014).  There reporting of near misses was improving but the pharmacy department needed more time to verify medicines. The pharmacy department had limited capacity in terms of staffing levels, and stock control arrangements were limiting the amount of time available to provide a clinical service. 
• A single patient record was used by all professionals. These were mainly complete but consultant and nursing staff signatures and dated entries required improvement. The documentation for cardiac patients was incomplete and there was not an appropriate care pathway plan for neuro-surgical patients on the critical care unit. Outpatient records belonged to consultants and were not always consolidated with the hospital’s inpatient records.  The hospital was working to improve this. 
• The early warning score was used to identify and monitor patients whose condition might deteriorate, but there was not an age appropriate paediatric early warning score and this needed to be addressed
• Staff were aware of their responsibility to safeguard adults and children and the action to take if there was a concern. However, not all staff had completed appropriate training.  This had been identified as an area for action and there was on-going training. 
• Staff had been working flexibly to ensure that safe staffing levels were maintained while a recruitment campaign was underway.  To manage costs appropriately, staffing was matched to activity.  Many staff worked overtime and as part of a bank to cover vacancies or for example, if theatre lists overran; agency staff were not used.  Recruitment was on-going in the hospital but staff in all areas expressed some concern about the need to quickly improve recruitment processes as working long hours was becoming difficult.
• Staffing levels in pre-assessment meant that not all patients could be reviewed prior to admission and, staffing levels in the recovery area of the operating department did not always meet national guidelines.
• The children's service was small and was staffed in line with national guidance for surgical, medical and theatre staff and for nurses on duty for the number of children.  The service was not in line with national guidance, however, when only one registered paediatric nurse was on the day care unit and children were inpatients, and there needed to be a paediatric nurse on call. There were paediatric link nurses on the wards but some nursing staff did not feel they had the appropriate training to care for children.  Staff training for the care of older children was being developed. 
• Consultants were required to be available within 30 minutes when they had patients in the hospital and this on call procedure was adhered to. Intensivists were on call to support patients in the critical care unit.  There was a resident medical officer (RMO) in the hospital at all times.  In case of an unexpected emergency, the hospital had a resuscitation team consisting of the RMO, a critical care nurse, a senior nurse and an operating department practitioner.  Staff in the operating theatre and a general anaesthetist were also on call.  

Are services effective?

• Local policies and care pathways to treat patients followed national guidance.  Research and the introduction of and new technologies were introduced formally and through appropriate governance arrangements.  The policies and procedures in the critical care unit were out of date but these were being reviewed to ensure they were in line with current guidance.
• The hospital did not have an end of life care pathway but appropriate steps were taken for patients, for example, palliative care patients who had requested admission.  There were good procedures for when someone died, particularly in terms of responding to the needs of the family, spiritual needs and undertaking procedures for a coroner’s inquest.
• Patient's had appropriate pain relief but the critical care unit needed to develop pain assessments tools for all patients to ensure patient's pain relief was adequate. 
• Patients had appropriate nutrition and hydration. They were offered a choice of meals and alternative meals could be provided if required and special diets were catered for.  For those patients unable to take food orally  there was guidance for patients to receive nutrition though tube feeds or through an infusion. A dietician was available to offer support and guidance
• The hospital reported mortality rates were lower than national average for cardiac surgery, although audit needed to improve to demonstrate compliance with standards overall and patient outcomes.
• There was good multi-disciplinary team working to coordinate care for patients. 
• Services were supported by dedicated staff: For example, the weight loss service was supported by a dietician and a specialist nurse. The cancer service had a specialist breast care nurse and there was a cosmetic surgery nurse to support patients undergoing cosmetic procedures.
• Staff had annual appraisals which was linked to personal development plans.  The completion of mandatory training did not meet hospital targets in 2013, but the hospital was on track this year (2014).  However, the completion of other specialist training and staff supervision needed to improve. The competency assessments and reviews for staff on the critical care unit had not been maintained and this was identified as an area for action.  The majority (92.3%) of core staff had immediate life support training for adults but more staff overall needed to do basic and immediate life support training for adults and children. 
• Staff did not have an understanding of the Mental Capacity Act 2005 and the deprivation of liberty safeguards.  For example, staff did not recognise that sedation and the use of bed rails in the critical care unit were considered types of restraint. This had been identified as an area for action.

 Are services caring?

• Staff were caring and compassionate and treated patients with dignity and respect.  Patients were  positive about services and told us they felt well-cared for.
• Patients told us they were involved in their care plans and were able to make informed decisions and choices
• The hospital had recorded high Friends and Family Tests scores for both privately funded and NHS funded patients who had responded to the survey. 
• We received 22 comment cards from patients that were overwhelmingly positive about their experience of care and treatment.  Patients reported excellent, professional and caring staff and good information about their care and treatment.  Only one patient commented about the need for more support when having flat bed rest.
• The patient led assessment of the care environment (PLACE) conducted in June 2014 was positive. Although no comparative scores were provided, there were no actions identified for the hospital's environment and facilities, cleanliness, food, and privacy, dignity and well-being. 

 Are services responsive?

• Patient operations and procedures were rarely cancelled.
• The hospital undertakes 30% NHS funded care. There was no differentiation between NHS or private patients, although theatre staff noted that if cancellations were required this would more likely be for NHS patients.
• The majority of MRI and CT scans were not being reported within 48 hours.
• The hospital did not have dedicated facilities for children. When children were treated there was a paediatric nurse and the toys, and appropriate bed linen, were made available in the adult outpatient and inpatient areas”
• Children with a learning disability would be supported by a play specialist at pre-admission. There was no specialist support for adults with a learning disability, and staff had not received any dementia awareness training. The management team were actively addressing the concern about dementia awareness and an e-learning training package had been launched.
• Patients were positive about the information they received to help them in making decisions. Written information was available to support verbal information, however this was only available in standard English text.  There were some information leaflets about children's procedures but these had not been specifically written for children to understand.
• The hospital had received 88 complaints (1 April to 31 August 2014) and 52% were responded to within the hospital's target timescale of 20 days.  Patients were informed and kept up to date if their complaints took longer, and this was in line with the hospital's policy.  The hospital had not identified any themes in their analysis of complaints, but the number was increasing from previous years and showed higher levels involving clinical care from nurses and doctors. Complaints were taken seriously and investigated with the outcomes shared with the person making the complaint. The majority of complaints had been upheld and patients were reimbursed or compensated appropriately. The learning from complaints was cascaded to staff.  

 Are services well led?

• There were consultants from each speciality who represented their speciality at the hospital’s medical advisory committee (MAC).    There were regular meetings held with the hospital management team and there was liaison with other consultants via email, minutes, and meetings where necessary. 
• There were heads of departments, and ward and department managers.  There were medical leads for each service speciality represented on the hospital MAC.  
• Team and department meetings were used to discuss service and governance issues, such as complaints, incidents and audits. However, governance arrangements in the critical care unit and in the paediatric service needed to improve.
• Staff were positive about the hospital as a place of work. There was a supportive and open culture and staff felt that ward and department managers were approachable as were the hospital management team. The hospital was described and felt like a “friendly” place to work. The culture in the theatre department was said to be improving following previous concerns about management arrangements.
• Patient surveys and consultant surveys were conducted and these overall described a good or excellent service.  Action was being taken on areas identified for improvement. 
• Some nursing staff had specific subject matter lead roles for the hospitals, such as infection prevention and control and venous thromboembolism.  Some were working towards gaining national recognition for the service through national “exemplar status”  award schemes.  
• Staff had been involved in the design and development of services such as the Perform Centre and Chalybeate Suite.

  Was the hospital well led?

• The hospital's vision and strategy was that of Spire Healthcare group.  Its Compassion in Practice strategy was launched in 2012  and identified key organisational actions, values and behaviours (including the Spire Behaviours)  to support staff to deliver compassionate and high quality care, and improve patients outcomes and well-being. 
• There were six strategic objectives as part of its clinical strategy: clinical reliability, clinical safety, compliance, patient empowerment, clinical effectiveness and staff empowerment.  These were monitored quarterly through a clinical dashboard and defined targets. Hospitals that did not meet these targets were required to demonstrate what actions were being taken to improve. 

• Spire Healthcare produced the quality account as a company and the quality targets this year were to improve on the Friends and Family Test results, increase the number of telephone post-operative consultations, and embed the Compassion in Practice strategy.
• Spire Healthcare inspected the hospital as part of its quality assessment programme. The quality assessment report in February 2014 was positive overall.  There were areas to improve in medicines management, governance of consultant staff and staff training and development. The hospital had demonstrated some, but not complete progress towards these areas of action. The report in (May 2014) commended the hospital's strong incident reporting culture.
• In Spire Southampton Hospital, the Hospital Director and Matron were well thought of by staff.  Staff reported that they highly visible and took action in response to issues identified and staff concerns.  Staff were aware of the ‘Spire Behaviours’ guidelines.
• The hospital granted practising privileges to doctors who wished to practice and be employed by the hospital.  The process included pre-employment checks, induction, training and monitoring of appraisal. The information held by the hospital was not up to date, or was missing.  For example on Disclosure and Barring Scheme (DBS) re-checking, Hepatitis B screening, medical indemnity insurance and the approved practice profile of procedures that a consultant could undertake.   Approximately 13% of consultants could not demonstrate up to date medical indemnity cover and some had been out of date for several years.  There was evidence that these were being followed up, and evidence of suspension of practising privileges but action needed to be more timely.  
• The hospital undertook a review  of consultants annual appraisals and at the same time reviewed the information they held in relation to the consultants practice. This included review of complaints, incidents, adverse incidents and events and patient outcomes.  The hospital asked consultants to provide a copy of their annual NHS appraisal, and had copies from 93% of consultants.  There were arrangements to ensure that information on a consultant's private practice was included in their appraisal. The matron/ head of clinical services read all appraisals and followed up where  information was incomplete or absent.
• The hospital director and matron met with medical director of the local NHS trust quarterly and the deputy director monthly.  Information was shared, for example on clinical practice and incidents.  This was in line with national guidance for doctors and responsible officers (the medical director) on The Role of the Responsible Officer, Department of Health, 2013. There was a joint post with the local NHS trust of associate medical director for patient safety.
• There was a clinical committee structure to oversee and monitor the hospital’s services.  This included the monitoring arrangements for consultants under the MAC.  
• Governance arrangements needed to improve overall.  Some were effective and the hospital was focused on improvement. There was an open culture and learning environment for incident reporting; the hospital used the clinical dashboard and action was taken when targets were not met, for example, temperature checks had improved in theatre and a risk assessment introduced for falls prevention.  Adherence to hospital policies, procedures and care pathways was monitored. The hospital had weekly clinical effectiveness meeting to identify and manage risks.  Known risks had been identified as areas for action.
• Some  governance arrangements, however, needed to improve. There needed to be better assurance processes and escalation of priorities. Assurance processes, for example, to review practising privileges or to ensure changes following audits were embedded. There were quality governance reports that were comprehensive but were not timely.  The most recent report in October 2014, was for the period 1 January to 31 March 2014, and priorities were not analysed and defined so as to effectively be shared across all committees and staff groups.  Risks that were identified were appropriately managed but the focus of the risk register was on non–clinical risks and clinical risks were not highlighted and formally reviewed in the same way. 
• The hospital held meetings with patients where there had been moderate or severe harm following procedures. These meetings were documented and patients received information and details of action and/or necessary compensation.   A corporate policy on Duty of Candour was being developed in readiness for the new legislation in April 2015. 
• There were quarterly staff forum meetings that the hospital and matron held. The attendance target was for 80% of staff to attend.  Most staff were positive about these meetings and felt comfortable discussing issues and raising concerns. Some staff in lower pay grades, such as administration and clerical staff, cleaners and porters felt less engaged and identified that they needed different opportunities to be listened to and raise concerns. 
• Innovation and ideas from staff were actively encouraged.  We identified examples where staff were involved in service changes and developments and their achievements were recognised through awards.
• There was also a staff recognition award program. Staff could nominate other staff for awards. This peer recognition process was well received by staff.
• Patients were surveyed and asked about services, but other than this there was limited evidence of public engagement.   The hospital website included information about its services and staff, and was clear about fees and methods of payment.  
• Efficiency targets set by Spire Healthcare included reducing the length of stay, over-night conversion rates, non-clinical cancellations, and re-admission rates and minimizing hospital acquired infection and the use of agency staff.  The hospital recognised the need to have good working relationships with NHS commissioning groups and to have links with health and social care services, for example for effective discharge planning, if efficiency targets were to be met.  Agency staff were not used and staff were rostered to work to meet demand and costs were being reduced in administration.  The hospital was clear that clinical quality was the priority. There had not, however, been any quality impact assessments on the overall, approaches to meeting efficiency targets on patient care.

 We saw areas of outstanding practice: 

• The Chalybeate Suite for patients receiving chemotherapy and palliative care, was designed by nursing staff and patients. The environment was private, calm and relaxing.   The unit had received a Macmillan Quality Environmental Mark which indicates that the unit meets national standards to provide a welcoming private and comfortable environment for people with cancer to support and improve their wellbeing.  
• The hospital director and matron/head of clinical services met regularly with the Medical Director of the local NHS trust to share information on consultant's clinical practice, performance and services.  The hospital had a joint post with the local NHS trust of associate medical director for governance and patient safety.

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

Importantly, the provider must ensure that:

• Procedures for infection prevention and control are followed.
• The environment is in line with recommend guidance to reduce the risk of cross infection.  Particular attention needs to be placed on the fabric of the building, and keeping dirty and clean equipment for cleaning and sterilisation processes separate.
• Single use gowns are used appropriately.
• Access and security arrangements are effective and  reduce risks to staff and patients.
• Medicines are managed appropriately, so that liquid medicines are stored and labelled correctly and there is adequate storage for intravenous infusions, dialysis and irrigation solutions in the critical care unit. Intravenous fluids not recommended for use in children are not stored on the paediatric resuscitation trolley.
• Cleaning fluids covered by the Control of Substances Hazardous to Health (COSHH) regulations, 2002 are stored securely. 
• All equipment in the critical care unit is checked daily where this is required.
• Staffing levels improve in theatre recovery to meet national guidance and improve to ensure appropriate pre-assessment prior to admission.
• Nurse on call arrangements for children in the day care unit are in accordance with national guidance.
• An age appropriate paediatric early warning score system, to identify children whose condition might deteriorate, is introduced in line with current national guidance.
• Staff working in the critical care unit have their competencies reassessed on an annual basis.
• All staff have appropriate safeguarding training and staff who have regular contact with children should complete safeguarding children training at a level suitable to their role.
• Staff attend basic and immediate life support training according to hospital targets.
• Nursing staff have appropriate training to care for medical patients and children.
• Staff must have an understanding, and follow guidance, to ensure they adhere to the Mental Capacity Act 2005 and deprivation of liberty safeguards.  
• Imaging reporting times meet service standards of within 48 hours.
• Appropriate information for consultant's practising privileges are reviewed and kept up to date, and there is evidence that suspension is timely, where required.

In addition the provider should ensure that:

• Improve the timeliness of investigation following an incident in areas where this remains outstanding.
• Recruitment continues to alleviate the pressure of long working hours on staff.
• Information is available in a format other than English and that information is available that is specific for children and young people.  
• Clinical staff have an understanding of the needs of people living with dementia and those with a learning disability.
• Care plans are appropriately completed for cardiac patients in critical care and there is appropriate documentation for patients on a neurosurgical pathway.
• The capacity within pharmacy is reviewed to ensure more time is spent on providing a clinical pharmacy service.
• A policy on Duty of Candour is implemented with respect to forthcoming legislation.
• There are better systems to audit and monitor compliance with guidelines and patient outcomes
• Quality impact assessments are undertaken for actions taken to meet efficiency targets, and the annual operating plan.

Professor Sir Mike Richards

Chief Inspector of Hospitals