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Spire Wellesley Hospital Good

All reports

Inspection report

Date of Inspection: 13 October 2011
Date of Publication: 8 November 2011
Inspection Report published 8 November 2011 PDF

The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care (outcome 16)

Meeting this standard

We checked that people who use this service

  • Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.

How this check was done

Our judgement

The provider effectively assesses and monitors the quality of its service provision. Where changes are found to be required, they are implemented and reviewed accordingly, which improves the quality of service provided to people.

User experience

People with whom we spoke said they were made to feel comfortable about providing feedback about their stay in hospital.

Other evidence

Spire Wellesley monitors the quality of its service in a number of ways. Complaints information is publicised to people who use the service and complaints were seen to be fully recorded and investigated (whether or not they are received in respect of privately-funded treatment or NHS treatment). Examples of follow up work were seen, where changes had been implemented and the cases reviewed, and the impact assessed so as to avoid reoccurrence.

Adverse event reporting is now carried out on the new Datix database, which allows for the investigation and outcomes to tracked and collated. This is used for all incidents, such as serious untoward incidents, clinical incidents and incidents that lead to the cancellation of surgery after the person has been admitted, such as a chest infection. These are managed daily and reviewed by the hospital’s clinical governance lead, who collates various reports to inform the clinical effectiveness group. Any learning coming out of these incidents is passed on to staff at team meetings. This creates a safer service for people. Changes are monitored via routine audit trend analysis. The clinical governance lead is also responsible carrying out root cause analysis for most of the incidents that occur. Spire’s national governance lead receives details of all lessons learnt and outcomes. Alerts from the National Patient Safety Agency (NPSA) are reviewed by the hospital’s matron and clinical governance lead and they then put a work plan in place for implementation in the department for which the alert relates to.

Spire Wellesley has introduced a new risk management system, which flags up when each risk assessment in the hospital is due for renewal. Implementation of these is monitored via the health and safety committee. Annual patient and staff surveys are carried out and the results are analysed and published on the hospital’s website, along with any changes they have prompted.