The Care Quality Commission
  • Hospital
  • Independent hospital

Spire Regency Hospital

Overall: Good read more about inspection ratings

West Street, Macclesfield, Cheshire, SK11 8DW (01625) 501150

Provided and run by:
Spire Healthcare Limited

Important: The provider of this service changed. See old profile

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Spire Regency Hospital on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Spire Regency Hospital, you can give feedback on this service.

23 to 24 November 2021 and 29 November 2021

During a routine inspection

Our rating of this service stayed the same. We rated it as good because:

  • The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. Most people could access the service when they needed it and did not have to wait too long for treatment.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

In Surgery;

  • The surgical services did not achieve national standards for waiting times from referral to treatment. However, they had undertaken actions to improve this.
  • The service had suspended some quality monitoring and audit activities due to COVID-19 pressures.
  • The environment across the surgical wards and theatre areas was not always dementia friendly.

In Medical Care;

  • The service had not installed a double sink for the process of endoscope decontamination. Although this was a temporary measure it was not in line with their own endoscopy policy.
  • The new endoscopy pathway recording booklet was completed inconsistently.
  • Chemical substances were not always stored in a lockable storage cupboard or sink in the decontamination room.

In Outpatients;

  • The process for monitoring maintenance of equipment was not embedded and one of the fridges was not included in daily routine checks. The service level agreement for the ophthalmic laser was past the date for review, at time of inspection, however; renewed when highlighted.
  • The service did not capture re-booking information following a cancellation or when a patient did not attend (DNA).The service had not embedded care for all patients with a protected characteristic such as a mental health need.

11 to 12 October 2016 and 19 October 2016

During a routine inspection

Spire Regency is operated by Spire Healthcare Limited. The hospital has 31 beds for inpatients and day cases. Facilities include two operating theatres, the Byron suite which has 18 en-suite bedrooms, the Coleridge suite with either single en-suite rooms or a room that can accommodate two people, and outpatient and diagnostic facilities. There is also an endoscopy unit.

The hospital provides surgery, a very small medical care service and outpatients and diagnostic imaging. We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 11 and 12 October 2016, along with an unannounced visit to the hospital on 19 October 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 legislation

The main service provided by this hospital was surgery. Where our findings on surgery, for example, management arrangements, which also apply to other services, we do not repeat the information but cross-refer to the surgery core service.

Services we rate

We rated this hospital as ‘Good’ overall. This is because;

  • There were adequate systems in place to protect people from avoidable harm and learn from incidents.
  • The hospital was visibly clean and well maintained. There were systems in place to prevent the spread of infection.
  • There were effective systems in place to ensure the safe storage, use and administration of medicines.
  • There were adequate numbers of suitably qualified, skilled and experienced staff to meet patients’ needs. There were effective arrangements in place to ensure staff had, and maintained the skills required to do their jobs.
  • People received nutrition and hydration that met their preferences and needs.
  • Care was delivered in line with national guidance and outcomes for patients were good.
  • There were arrangements for obtaining consent ensuring legal requirements and national guidance was met.
  • The individual needs of patients were met including those in vulnerable circumstances such as those living with a learning disability or dementia.
  • Patients could access care when they needed it and were treated with compassion. Their privacy and dignity was maintained at all times.
  • The hospital management team had the confidence of patients and their team. Staff felt motivated and supported by the management team.
  • There was appropriate management of quality and governance at a local level and managers were aware of the risks and challenges they needed to address.

However, we found areas of practice that required improvement across the hospital;

  • Duty of candour processes were not always being followed as outlined in the hospital policy.
  • Some of the root cause analysis investigation reports reviewed did not always adequately record the learning to improve standards of care.
  • There was no process in place at the hospital to risk assess or check areas of non-compliance with all National Institute of Health and Care Excellence (NICE) guidance.
  • There was still work to do in terms of agreeing target risk ratings and identifying actions to mitigate all risks identified on the risk register.
  • Written information to patients, such as discharge letters and leaflets, was available in other languages or formats on request.
  • Although there was a clear committee structure to support governance and risk management, we saw that the quality of the committee minutes and attendance was variable.

In surgery:

  • The theatre and the wards did not have entrances that were locked to prevent access by unauthorised personnel.
  • The hospital did not use the Q-PROM’s recognised tool to collect data for patients undergoing cosmetic procedures such as breast augmentations.
  • A new competency toolkit designed to support the development of staff undertaking the role of a surgical first assistant was still in the draft phase and none of the staff had started or completed an accredited qualification. However, they had been signed off by a consultant as competent to undertake the role and had a mentor.

In medical care:

  • The hospital policy regarding the destruction of controlled drugs did not meet all the standards in the Safer Management of Controlled Drugs and Royal Pharmaceutical Society Guidance and the practice within the hospital was not consistent. Some areas were following hospital policy and some were following the national guidance.
  • The hospital were not auditing patient outcomes undergoing medical procedures.

In outpatient and diagnostic imaging:

  • The turnover rate of nurses was high at nearly 40% in the outpatient department but this figure represents three staff who left in the 12 month period as a proportion of 7 outpatient staff. The turnover for healthcare assistants was low.
  • The hospital did not use the World Health Organization (WHO) surgical safety checklist when undertaking minor procedures. However, as the hospital was beginning to undertake more complex procedures they were considering introducing it. The WHO checklist was designed for use in an operating theatre as a safety checklist to reduce the number of potential incidents during surgery.

Following this inspection, we told the provider that it should make other improvements, even though a regulation had not been breached, to help the service improve. Details are at the end of the report.

Ellen Armistead

Deputy Chief Inspector of Hospitals (North)