spire leicester hospital newapproachcomprehensive report ... ·...

This report describes our judgement of the quality of care at this location. It is based on a combination of what wefound when we inspected and a review of all information available to CQC including information given to us frompatients, the public and other organisations

Ratings

Overall rating for this location Good –––

Are services safe? Good –––

Are services effective? Good –––

Are services caring? Good –––

Are services responsive? Good –––

Are services well-led? Good –––

SpirSpiree LLeiceicestesterer HospitHospitalalQuality Report

Gartree Road,Oadby,Leicestershire,LE2 2FFTel: 0116 272 0888Website: www.spirehealthcare.com

Date of inspection visit: 11, 12 and 17 August 2015Date of publication: 19/02/2016

1 Spire Leicester Hospital Quality Report 19/02/2016

Letter from the Chief Inspector of Hospitals

Spire Leicester Hospital is run by Spire Healthcare Limited. The hospital is located in Oadby which is a residential areasouth of Leicester.

Healthcare is provided by the hospital to patients with private medical insurance, those who self-pay and through NHScontracts.

The service is registered to provide inpatient care to 54 patients at any time. Hospital facilities include a 30-bed inpatientward, 14 bed day ward, five chemotherapy pods and five chemotherapy beds. Theatre provision includes: three theatreswith laminar flow, a cardiac catheter laboratory and a minor procedures suite. From April 2014 to March 2015 there were6,518 visits to theatre.

This was the first comprehensive inspection of Spire Leicester Hospital. We carried out an announced inspection ofSpire Leicester Hospital between the 11 and 12 August 2015. Following this inspection an unannounced inspection tookplace on the 17 August 2015 between 12 and 3pm. The purpose of the unannounced inspection was to look at how thehospital operated at peak times and to follow-up on some additional information from the announced inspection.

The inspection team inspected the following core services:

• Surgery• Medicine• Outpatients and Diagnostic Imaging• Children and Young People• Termination of Pregnancy.

The hospital provided a health screening service which was not inspected as part of our inspection.

We rated Spire Leicester Hospital as ‘Good’ overall but the outpatients and diagnostic imaging service requiredimprovement.

Our key findings were as follows:

Are services safe at this hospital

• There were information gaps in some children's and young people’s records. We reviewed 16 sets of records; fourrecords did not have completed fluid charts and five records had no risk assessment.

• We found gaps in some of the patient records we reviewed. We were told that some consultants used their own notesrather than Spire medical records in which to record the patient’s outpatient consultation and not all those noteswere retained within the Spire medical record.

• Medical notes were not always easy to read although the provider informed us notes were sometimes typed and staffcould contact medical staff for an explanation if necessary.

• The Spire Leicester Hospital weekly compliance report dated the 7 and 11 August 2015 showed shortfalls in thereceipt of medical staff information on medical indemnity, disclosure and barring checks and General MedicalCouncil registration expiry dates. The provider acknowledged that further work was required to ensure allconsultants provided evidence of all the required documentation. A senior manager informed us of the actions inplace to achieve compliance and mitigate risk. By 20 August 2015, 312 consultants had provided all the requireddocumentation. The suspension of practising privileges for 34 consultants took place until all documentation wassubmitted to the hospital. Since 20 August 2015, the provider confirmed that compliance has remained at 100% at alltimes in relation to the collection of this information and that all medical staff were fully insured during the CQCinspection, despite shortfalls having been observed in the collection of this data.

Summary of findings


• Patients were protected from abuse and avoidable harm. Patients felt safe and staff had the skills, knowledge andtools to identify risks and knew how to escalate these if needed. Processes were in place to mitigate risks.

• Incidents were investigated, actions taken and learning disseminated throughout the hospital.• All patient areas were visibly clean, infection prevention and control processes were in place and equipment had

been checked regularly. Medicines were stored and administered safely.• Staffing was managed effectively to ensure patients received good care with access to medical care obtained in a

timely manner. Staff were well trained and records were kept securely.

Are services effective at this hospital

• The Spire Leicester Hospital weekly compliance report dated the 7 and 11 August 2015 showed shortfalls in thereceipt of medical staff information on whole practice appraisals and biennial review dates.

• The provider acknowledged that further work was required to ensure all consultants provided evidence of all therequired documentation. We spoke with a senior manager who informed us of the actions in place to achievecompliance and mitigate risk. By 20 August 2015, 312 consultants had provided all the required documentation. Thesuspension of practising privileges for 34 consultants took place until all documentation was submitted to thehospital. Since 20 August 2015, the provider confirmed that compliance has remained at 100% at all times in relationto the collection of this information and that all medical staff were fully insured during the CQC inspection, despiteshortfalls having been observed in the collection of this data.

• No audits or monitoring of children’s and young people’s outcomes had taken place since this service had been setup in 2013. There was no audit system for ensuring that medical notes were fully completed within the children’s andyoung people’s service.

• Patient’s pain was well managed.• Staff helped patients if they needed support to eat and drink and they had access to drinks.• Evidence based care and treatment was delivered to adult patients, which followed national guidance.

Are services caring at this hospital

• Patients we spoke with confirmed that staff were kind, considerate and treated them with dignity and respect.• We observed staff being attentive and caring to patients during the inspection.• Patient experience was reported on through local patient surveys and the NHS Friends and Family Test (FFT). The FFT

score for June 2015 was 99%.

Are services responsive at this hospital

• Delays, cancellations and attendance rates had not always been monitored in an effective way. Data was collectedbut not audited or actioned further to prevent or reduce these events in future.

• Waiting times in the outpatient department were not always monitored effectively.• Signage in all areas was small and only in English which could have proved a challenge for those with poor sight or

whose first language was not English.• Planned admissions and multidisciplinary meetings took place to ensure effective admission, treatment and

discharge planning. Processes were in place for transfers to other hospital if a patient required a higher level of care.• The hospital had a complaints policy and procedure in place and patients were given information about how to raise

any concerns or make a complaint.

Are services well led at this hospital

• The leadership, governance and culture at the hospital promoted the delivery of high quality person-centred care.Members of the management team were well respected amongst both staff and patients.

• Staff felt valued and were positive about their roles.• There was a shared vision throughout the hospital and safe patient care was paramount.

Summary of findings


• Patient feedback was a valued tool and the hospital strived to improve following any negative comments frompatients or relatives.

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

Importantly, the provider must:

• Ensure that an accurate, complete and contemporaneous record is securely maintained in respect of each serviceuser, including a record of the care and treatment provided to the service user and of decisions taken in relation tothe care and treatment provided. There was no audit system for ensuring that medical notes were fully completedwithin the children’s and young people’s service.

• Ensure arrangements are put in place to monitor outpatient appointment cancellations and delays.

In addition the provider should:

• Ensure paediatric and adult drug boxes for resuscitation are not of a similar colour to aid quick identification in anemergency.

• Ensure appropriate interpreting services following best practice are always available for those whose first language isnot English.

• Ensure auditing samples for compliance with the five steps to safer surgery checklists are more representative of thenumber of patients undergoing surgical procedures.

• Ensure that there is an effective system in place for contacting a radiologist urgently.• Ensure that the minor operations room has a plan in place for ensuring patient safety and that treatment can be

provided rapidly without delay.

• Ensure that the privacy and dignity of patients using the imaging department is maintained.

• Ensure that all staff working with oncology patients in the chemotherapy unit are aware of the gold standardsframework.

• Ensure practice is reviewed around the use of the malnutrition universal screening tool.• Ensure a protocol for children with learning difficulties is developed.• Ensure that staffing and workforce development plans are developed in parallel with the paediatric strategy.• Ensure the areas where children are cared for are appropriate for the needs of the child.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Summary of findings


Our judgements about each of the main services

Service Rating Summary of each main service

Medical care

Good –––

The hospital had systems in place to protectpatients and keep them from avoidable harm.Patients felt safe and staff had the skills,knowledge and tools to identify risks and knewhow to escalate these if needed. Staff showed agood awareness of incident management showingthat the system was embedded.The use of professional guidance had ensured thatpatients’ safety was maintained. The local auditprogramme and the changes identified fromspecific audits were acted upon in a timelymanner. We saw that 100% compliance had beenachieved against some audits, for example, thesepsis audit and consent.Staffing was managed effectively; staff were welltrained, had received regular appraisals andprofessional qualifications were validated.The Spire Leicester Hospital weekly compliancereport dated the 7 and 11 August 2015 showedshortfalls in the receipt of medical staffinformation on medical indemnity, disclosure andbarring checks, General Medical Councilregistration expiry dates, whole practice appraisalsand biennial review dates.The provideracknowledged that further work was required toensure all consultants provided evidence of all therequired documentation. We spoke with a seniormanager who informed us of the actions in placeto achieve compliance and mitigate risk. By 20August 2015, 312 consultants had provided all therequired documentation. The suspension ofpractising privileges for thirty-four consultantstook place until all documentation was submittedto the hospital. Since 20 August 2015, the providerconfirmed that compliance has remained at 100%at all times in relation to the collection of thisinformation and that all medical staff were fullyinsured during the CQC inspection, despiteshortfalls having been observed in the collection ofthis data.

Summary of findings


Patients received effective care and treatment thatmet their needs. Medical care was delivered byconsultants who worked at local NHS hospitals.Patients were supported, treated with dignity andrespect and involved as partners in their care.Patients told us they felt cared for.Patients with specific individual needs such asdementia were met. We saw effective systems inplace to capture and act upon patient feedback.Admissions were planned and multidisciplinarymeetings had taken place to ensure effectiveadmission, treatment and discharge planning.Processes were in place for transfers to otherhospital if a patient required a higher level of care.The leadership, governance and culture at thehospital promoted the delivery of high qualityperson-centred care. Members of themanagement team were well respected amongstboth staff and patients. Staff felt supported, spokepositively about the organisation and staff moralewas high.

Surgery

Good –––

The hospital had systems in place to keep patientssafe. Processes were in place to report incidentsand staff demonstrated a good awareness of theprocess for identifying and reporting any safetyincidents showing the system was embedded.Investigations were robust and staff learned fromactions taken. However, because of the smallmonthly sample size (less than 2%) for the auditingof the five steps to safer surgery checklists wecould not be assured of overall compliance withsafe practices in theatre.All patient areas were visibly clean, infectionprevention and control processes were in placeand equipment had been checked regularly.Medicines were stored and administered safely.Staffing was managed effectively to ensurepatients received good care with access to medicalcare obtained in a timely manner. Staff were welltrained and records were kept securely.Evidence based care and treatment was deliveredto patients following national guidance bycompetent staff. The hospital provided a seven-dayweek service with patients having good access toinformation.

Summary of findings


All the patients and relatives we spoke with wereoverwhelmingly positive about the care they hadreceived and the way staff treated them. Patientstold us they were involved in their care and staffexplained care and treatment in a way theyunderstood.Access to care and treatment was monitored andexceeded the national average. Staffacknowledged patients’ individual needs andresponded to them in an appropriate wayalthough we were not assured a suitable translatorwas always available for patients whose firstlanguage was not English.Staff had a good understanding of the complaintsprocess and the hospital learned from complaints,changing care practices if required.Shortfalls were found in hospital wide consultants’information; with the exception of consultant staffworking with children and young people andtermination of pregnancy services. The SpireLeicester Hospital weekly compliance report datedthe 7 and 11 August 2015 showed shortfalls in thereceipt of medical staff information on medicalindemnity, disclosure and barring checks, GeneralMedical Council registration expiry dates, wholepractice appraisals and biennial review dates. Theprovider acknowledged that further work wasrequired to ensure all consultants providedevidence of all the required documentation. Wespoke with a senior manager who informed us ofthe actions in place to achieve compliance andmitigate risk. By 20 August 2015, 312 consultantshad provided all the required documentation. Thesuspension of practising privileges for thirty-fourconsultants took place until all documentationwas submitted to the hospital. Since 20 August2015, the provider confirmed that compliance hasremained at 100% at all times in relation to thecollection of this information and that all medicalstaff were fully insured during the CQC inspection,despite shortfalls having been observed in thecollection of this data.The hospital had a governance system in placewhich included an audit system. Morale wasexcellent with staff talking positively about theorganisation and their local management team.Staff felt listened to and supported in their role.

Summary of findings


Services forchildren andyoungpeople

Good –––

The children’s service had a good track record onsafety. The hospital safeguarded children andyoung people through offering care tailored totheir needs. If a child was admitted overnight, apaediatric consultant and a children’s nurse stayedon site to look after them. Staff working withchildren were qualified to ‘National Society ofPrevention of Cruelty to Children’ safeguardinglevel three, in line with good practice. Thechildren’s nurses had specialist training inpaediatric life support and the lead nursepromoted skills in nursing children.The hospital routinely conducted a range of riskassessments and there were procedures to treatchildren whose health was deteriorating after anoperation. However, some of these riskassessments were not signed or fully completed.The hospital lacked specific waiting areas andconsulting rooms for children, but staff minimisedthe risk of mixing with adults.The children’s services were relatively new and didnot have a quality dashboard to monitor theirperformance over time. They had not developedsystems to carry out benchmarking or clinicalaudits, which limited organisational learning.Parents said their children received compassionatecare. They said the hospital gave them goodinformation and involved them in decisions abouttheir child’s treatment and care. Child friendlyinformation was available for children about theirprocedures, nurses and consultants encouragedthem to ask questions about their care. Nursingstaff offered children and parents emotionalsupport when needed. The hospital planned carefor children taking into account emotional,spiritual, social, mental and physical needs.Children’s and young people’s services wereresponsive and provided access at times to suitchildren, young people and their parents.Nurses encouraged children to keep in touch withfriends and family and the hospital provided bedsin children’s rooms and a meal if a parent wantedto say overnight. The service was sensitive tochildren who had been inpatients and introducedthem to the environment through a visit and a

Summary of findings


pre-assessment appointment, so that everythingwould be familiar. Nurses and consultants ensuredthat children who had behavioural challenges alsofelt at home and were cared for well.The service had a vision for expansion in thefuture.There was a positive culture and staff showed clearmotivation to do their best for children and youngpeople. There was a good risk managementstructure and children’s nurses worked well withconsultants to develop policies and plan services.

Outpatientsanddiagnosticimaging

Requires improvement –––

Emergency equipment was not immediatelyavailable within the department. Staff inoutpatients department had limited knowledge inregards to decontamination following patientswith suspected communicable diseases.The Spire Leicester Hospital weekly compliancereport dated the 7 and 11 August 2015 showedshortfalls in the receipt of medical staffinformation on medical indemnity, disclosure andbarring checks, General Medical Councilregistration expiry dates, whole practice appraisalsand biennial review dates. The provideracknowledged that further work was required toensure all consultants provided evidence of all therequired documentation. We spoke with a seniormanager who informed us of the actions in placeto achieve compliance and mitigate risk. By 20August 2015, 312 consultants had provided all therequired documentation. The suspension ofpractising privileges for thirty-four consultantstook place until all documentation was submittedto the hospital. Since 20 August 2015, the providerconfirmed that compliance has remained at 100%at all times in relation to the collection of thisinformation and that all medical staff were fullyinsured during the CQC inspection, despiteshortfalls having been observed in the collection ofthis data.Safety concerns were identified and addressed in atimely manner. All staff were aware ofresponsibilities in relation to reporting incidentsand the duty of candour.

Summary of findings


There were effective systems in place to protectpeople from avoidable harm and lessons werelearnt from any incidents within the department.We found that equipment was appropriatelyserviced and calibrated.Staff received training in mandatory and rolespecific areas. Patient risk was assessed andresponded to appropriately.We saw that staff were caring towards patients andrespected their privacy and dignity. Patientsunderstood options available to them and wereable to choose appointments to suit their needs.Information was available for patients throughoutthe department and staff had the appropriateskills and knowledge to seek consent from patientsthroughout their care.Waiting times and attendances were not alwaysmonitored and collated effectively; this was notrecognised as an issue within the hospital.Patient outcomes were not looked alongsidecancelled clinics to ensure there was not anegative effect. People could access the right careat the right time and patient needs were taken intoaccount.Signage was not always clear to patients visitingthe outpatient and imaging department.Consideration was not always given to those withcultural needs and staff said they would benefitfrom further training in this area.Complaints were investigated and wherenecessary clinical and administrative practice hadchanged to prevent recurrence.Radiation regulations were followed and staffreceived the necessary training and competencyassessment to ensure patient safety.Staff felt valued and were positive about theirroles. There was a shared vision throughout thehospital and safe patient care was paramount.Innovation and improvement was encouraged inoutpatient and imaging areas, with evidence tosupport this. Feedback was a valued tool and thedepartment strived to improve following anynegative comments from patients or relatives.

Terminationof pregnancy Good ––– The termination of pregnancy service at Spire

Leicester Hospital offered safe care to the patients.

Summary of findings


There were sufficient numbers of suitably trainedstaff available to care for patients.The environment and equipment was visibly cleanand infection control procedures were followed.Staff were aware of safeguarding procedures andhad received training in safeguarding adults, theMental Capacity Act (2005) and Deprivation ofLiberties (DOLs.)Medicines management was safe and there was aclear audit trail for the request and receipt of themedication.There were appropriate procedures to provideeffective care. Care was provided in line withnational best practice guidance.Arrangements were in place to ensure that staffhad the necessary skills and competence to lookafter patients. Patients had access to SpireLeicester Hospital out of hour’s aftercare 24 hoursa day, seven days a week.Patients were cared for by a multidisciplinary teamworking in a coordinated way. Patients receivedcompassionate care that respected their privacyand dignity. All the patients consideringtermination of pregnancy had access topre-termination counselling.Patient’s wishes were respected and their beliefsand faith were taken into consideration regardingthe sensitive disposal arrangements for pregnancyremains.The hospital was responsive to patient needs.Professional interpretation service was available toenable staff to communicate with patients forwhom English was not their first language.The service was compliant with the guidance fromthe Royal College of Obstetrics and Gynaecology(RCOG) Guidance in Relation to Requirements ofthe Abortion Act and the Department of Healthguidelines Procedures for the Approval ofIndependent Sector Places for the Termination ofPregnancy Required Standard OperatingProcedures (RSOP). The hospital monitored itsperformance against the RSOPs.There were effective governance arrangements inplace and staff felt supported by the seniormanagement team.

Summary of findings


The culture in the hospital was caring andsupportive. Staff said that the leadership andvisibility of the hospital director, matron andsenior managers was good.Staff spoke positively about the high quality careand services they provided for patients and wereproud to work for Spire Leicester Hospital.

Summary of findings


Contents

PageSummary of this inspectionBackground to Spire Leicester Hospital 15

Our inspection team 15

How we carried out this inspection 15

Information about Spire Leicester Hospital 16

Detailed findings from this inspectionOverview of ratings 17

Outstanding practice 88

Areas for improvement 88

Action we have told the provider to take 89

Summary of findings


Spire Leicester Hospital

Services we looked at

Medical care (including older people’s care); Surgery; Services for children and young people; Outpatients &diagnostic imaging; Termination of pregnancy;

SpireLeicesterHospital

Good –––


Background to Spire Leicester Hospital

Spire Leicester Hospital is run by Spire Healthcare Limitedand is located in Oadby a residential area south ofLeicester. Healthcare is provided by the hospital privatelyand through an NHS contract. The registered managerregistered with the CQC on the 1 October 2010.

The service is registered to provide inpatient care to 54patients at any time. Hospital facilities include a 30-bedinpatient ward, 14 bed day ward, five chemotherapy podsand seven chemotherapy beds. Inpatient and outpatientservices include: children’s services, orthopaedics,cosmetic and plastic surgery, weight loss surgery,oncology and chemotherapy. Outpatient services operatefrom 8.30am to 9pm Monday to Friday Saturdaymornings. Diagnostics include MRI, CT scans, ultrasoundscans, fluoroscopy, mammograms and X-rays.

In addition, a private GP service and a number of rapidaccess and one-stop clinics such as the One Stop CardiacClinic and a Bupa-accredited Breast Cancer Service, forthe rapid diagnosis, onward referral and treatment ofbreast disease are offered.

Spire Leicester Hospital was selected for acomprehensive inspection as part of the programme ofcomprehensive independent healthcare inspections. Theinspection was conducted using the new methodology.

We carried out an announced inspection of SpireLeicester Hospital between the 11 and 12 August 2015.Following this inspection an unannounced inspectiontook place on the 17 August 2015 between 12 and 3pm.The purpose of the unannounced inspection was to lookat how the hospital operated at peak times and tofollow-up on some additional information from theannounced inspection. The areas inspected included,surgery, medicine, outpatients and diagnostic imaging,children and young people and termination ofpregnancy.

Our inspection team

Our inspection team was led by:

Head of Hospital Inspection: Carolyn Jenkinson

Inspection Lead: Sue Stanton, Care Quality Commission

The team included eight CQC inspectors, an expert byexperience and a variety of specialists including aconsultant surgeon, a consultant anaesthetist, anoncology nurse, an outpatients nurse and aradiographer.

How we carried out this inspection

To get to the heart of patients’ experiences of care wealways ask the following five questions of every serviceand provider:

• Is it safe?

• Is it effective?

• Is it caring

• Is it responsive to people’s needs

• Is it well led?

Before visiting the hospital, we reviewed a range ofinformation we held about the hospital and spoke to thelocal clinical commissioning group. Patients were invitedto contact CQC with their feedback. We carried out anannounced inspection between 11 and 12 August 2015and an unannounced inspection on 17 August 2015. Weheld focus groups with a range of staff in the hospitalincluding nurses and medical staff. We also spoke withstaff individually. We talked with patients and relativesand observed how people were being cared for andreviewed patients’ records of their care and treatment.

Summaryofthisinspection

Summary of this inspection


We would like to thank all staff, patients, carers and otherstakeholders for sharing their balanced views andexperiences of the quality of care and treatment at theSpire Leicester Hospital.

Information about Spire Leicester Hospital

Spire Leicester Hospital is registered to provide thefollowing activities:

• Diagnostic and screening procedures• Surgical procedures• Treatment of disease, disorder or injury• Family Planning• Management of supply of blood and blood derived

products• Termination of pregnancies

The hospital provides treatment and care for patientsreferred under the Standard NHS Acute Contract, insuredand self-pay referrals and provides outpatient, inpatient,diagnostic and therapeutic services.

The types of services offered at the hospital includeurology, ophthalmology, orthopaedics, pain injection.

The accountable CD officer is the Registered Manager.

Summaryofthisinspection

Summary of this inspection


Detailed findings from this inspection


Overview of ratings

Our ratings for this location are:

Safe Effective Caring Responsive Well-led Overall

Medical care Good Good Good Good Good Good

Surgery Good Good Good Good Requiresimprovement Good

Services for childrenand young people Good Requires

improvement Good Good Good Good

Outpatients anddiagnostic imaging

Requiresimprovement N/A Good Requires

improvement Good Requiresimprovement

Termination ofpregnancy Good Good Good Good Good Good

Overall trust Good Good Good Good Good Good

Detailed findings from this inspection


Safe Good –––

Effective Good –––

Caring Good –––

Responsive Good –––

Well-led Good –––

Information about the serviceSpire Leicester hospital has one inpatient ward, Ward 2,made up of thirty individual patient rooms. The wardcatered for medical and surgical patients.

Medical services offered at the hospital were mainly incancer care. Some medical procedures were carried out inthe cardiac catheter laboratory and some medicalendoscopies were performed. Some medical services wereprovided in the outpatients department, these will becovered in the outpatient section of this report.

At the time of the inspection there were no medicalinpatients. We spoke to medical patients receiving day caretreatment in the chemotherapy suite.

We visited Ward 2, the chemotherapy unit, endoscopy unitand the cardiac catheter laboratory. We spoke withendoscopy staff. We spoke with a total of ten patientswhich included a patient forum, and patients in thechemotherapy suite.

All areas we visited had adequate staffing ratios and werewell supported by the housekeeping team.

Summary of findingsThe hospital had systems in place to protect patientsand keep them from avoidable harm. Patients felt safeand staff had the skills, knowledge and tools to identifyrisks and knew how to escalate these if needed. Staffshowed a good awareness of incident managementshowing that the system was embedded.

The use of professional guidance had ensured thatpatients’ safety was maintained. The local auditprogramme and the changes identified from specificaudits were acted upon in a timely manner. We saw that100% compliance had been achieved against someaudits, for example, the sepsis audit and consent.

Staffing was managed effectively; staff were well trained,had received regular appraisals and professionalqualifications were validated. The Spire LeicesterHospital weekly compliance report dated the 7 and 11August 2015 showed shortfalls in the receipt of medicalstaff information on medical indemnity, disclosure andbarring checks, General Medical Council registrationexpiry dates, whole practice appraisals and biennialreview dates. The provider acknowledged that furtherwork was required to ensure all consultants providedevidence of all the required documentation. We spokewith a senior manager who informed us of the actions inplace to achieve compliance and mitigate risk. By 20August 2015, 312 consultants had provided all therequired documentation. The suspension of practicingprivileges for thirty-four consultants took place until alldocumentation was submitted to the hospital. Since 20August 2015, the provider confirmed that compliancehas remained at 100% at all times in relation to the

Medicalcare

Medical care

Good –––


collection of this information and that all medical staffwere fully insured during the CQC inspection, despiteshortfalls having been observed in the collection of thisdata.

Patients received effective care and treatment that mettheir needs. Medical care was delivered by consultantswho worked at local NHS hospitals. Patients weresupported, treated with dignity and respect andinvolved as partners in their care. Patients told us theyfelt cared for.

Patients with specific individual needs such as dementiawere met. We saw effective systems in place to captureand act upon patient feedback.

Admissions were planned and multidisciplinarymeetings had taken place to ensure effective admission,treatment and discharge planning. Processes were inplace for transfers to other hospital if a patient requireda higher level of care.

The leadership, governance and culture at the hospitalpromoted the delivery of high quality person-centredcare. Members of the management team were wellrespected amongst both staff and patients. Staff feltsupported, spoke positively about the organisation andstaff morale was high.

Are medical care services safe?

Good –––

Patients were protected from abuse and avoidable harm.

When something went wrong, people received a sincereand timely apology and were told about any actions takento improve hospital processes to prevent the same eventreoccurring. Openness and transparency about safety wasencouraged. Staff understood and fulfilled theirresponsibilities to raise concerns and report incidents andnear misses; they said they had been fully supported whenthey did so. Monitoring and reviewing activities enabledstaff to understand risks and gave a clear, accurate andcurrent picture of safety

There were clearly defined and embedded systems,processes and standard operating procedures to keeppeople safe and safeguarded from abuse. Safeguardingvulnerable adults, children and young people was givensufficient priority. Staff took a proactive approach tosafeguarding and focused on early identification.

Shortfalls were found in hospital wide consultants’information; with the exception of consultant staff workingwith children and young people and termination ofpregnancy services. These shortfalls related to currentmedical indemnity insurance and Disclosure and BarringService (DBS) checks.

The Spire Leicester Hospital weekly compliance reportdated the 7 and 11 August 2015 showed shortfalls in thereceipt of medical staff information on medical indemnity,disclosure and barring checks and General Medical Councilregistration expiry dates. The provider acknowledged thatfurther work was required to ensure all consultantsprovided evidence of all the required documentation. Wespoke with a senior manager who informed us of theactions in place to achieve compliance and mitigate risk.By 20 August 2015, 312 consultants had provided all therequired documentation. The suspension of practicingprivileges for thirty-four consultants took place until alldocumentation was submitted to the hospital. Since 20August 2015, the provider confirmed that compliance has

Medicalcare

Medical care

Good –––


remained at 100% at all times in relation to the collectionof this information and that all medical staff were fullyinsured during the CQC inspection, despite shortfallshaving been observed in the collection of this data.

Staffing levels and skill mix were planned, implementedand reviewed to keep people safe at all times. Any staffshortages were responded to quickly and adequately.There were effective handovers and shift changes to ensurestaff could manage risks to people who used services.

We saw that risks to people who used services had beenassessed, monitored and managed on a day-to-day basis.These included signs of deteriorating health, medicalemergencies or behavior that challenged. People wereinvolved in managing risks and risk assessments wereperson-centered, proportionate and reviewed regularly.

Incidents

• Staff told us they knew how to report an incidentthrough the electronic incident management system.Two staff described the incident reporting process anddemonstrated this to us through the electronicreporting system.

• Between April 2014 and March 2015 the hospitalreported 578 clinical incidents of which 19 were seriousincidents. Of the 19 serious incidents five involvedmedical patients. We saw evidence of the investigationprocess, identification of lessons learnt and actions tobe taken. For example, one incident involved atreatment delay to a patient who had developed aninfection. One of the actions from the investigationincluded clinical staff’s use of a sepsis flowchart toenable a rapid assessment of symptoms. Nursing staff inthe chemotherapy suite showed us the United KingdomOncology Nursing Society (UKONS) triage tool whichincluded assessment of fever.

• Staff had received an annual refresher session on theelectronic incident reporting and management system.This was included on the clinical training day timetableand a rolling programme was in place.

• Staff told us a weekly Rapid Response Meeting tookplace to discuss incidents or complaints which occurredfor that week. This allowed immediate dissemination ofinformation to the rest of the hospital in relation to anyrequired changes in practice. We saw on the agenda ofthe mandatory clinical training days that trends inincidents and complaints were discussed at themandatory clinical training days.

Safety Thermometer

• The NHS Safety Thermometer report for July 2015showed that all patients including medical patientsreceived harm free care. The NHS Safety thermometer isan improvement tool for measuring, monitoring andanalysing patient harms and harm free care. Areascovered were pressure ulcers, falls, catheters, urinarytract infections, deep vein thrombosis, pulmonaryembolism and venous thromboembolism risk. We sawthe quality report dated June 2015, which reported onecase of pulmonary embolism. The report included asummary of the investigation, root cause analysis andlearning points.

• The VTE screening for all patients was consistently 100%in the reporting period between April 2014 and March2015: 95% is the targeted rate for NHS patients. CQC hadassessed the proportion of patients risk assessed forVTE to be ‘much better than expected’ compared toother acute independent hospitals we hold this data for.

• The number of patients acquiring hospital provoked VTEor pulmonary embolus (PE) in the period between April2014 and March 2015 was 13. A PE is a blockage of anartery in the lungs. The most common cause of theblockage is a blood clot.

Cleanliness, infection control and hygiene

• Minutes of the latest infection control Meeting dated 3August 2015 identified actions and responsible persons.For example, an action identified the use of Clinelstickers in the outpatient department. When weinspected the department, Clinel stickers were in useand were applied to equipment to indicate it has beencleaned and ready for use.

• The hospitals annual patient led assessment of the careenvironment carried out on the 6 May 2015; scored 99%for cleanliness against a national average of just over97%.

• Staff told us following the patient led assessment of theclinical environment catering staff had changed theirheadwear to a washable cap.

• Following an audit dated 26 March 2015 sterile servicesachieved accreditation by an inspection verification andtesting company. We saw the documented audit report.

• Staff used personal protective equipment and weobserved the safe use of spillage kit guidance andguidelines for dealing with blood and bodily fluids ontextiles and carpets.

Medicalcare

Medical care

Good –––


• Sanitising hand gel was available and was used by staffbefore entering clinical areas. Patients told us theyobserved nurses and consultants using hand washingfacilities before and after administering care.

• The use of hand sanitiser gel had been audited monthly.The July 2015 rating was scored a green rating whichmeant that the use of hand sanitiser gel was on, orbetter than, target.

• Patient rooms were visibly clean and patients told usthat their rooms had been cleaned daily. The hospitalwas aware that the carpets and sinks in patient roomswere not in line with best practice infection preventionand control guidance. To achieve compliance in theseareas a refurbishment plan had started in July 2015.

• Carpets and sinks in some of the individual patientrooms did not comply with national best practiceguidance, however a refurbishment plan was underway.Carpets were visibly clean and housekeeping staff toldus they were deep cleaned six monthly. We looked at aroom that had been refurbished and found that it wascompliant with national infection prevention andcontrol guidance.

Environment and equipment

• Patient accommodation was in individual rooms.• We were told by facilities staff that emergency

generators were tested regularly and if needed wereable to back up essential power supply.

• We saw that there was sufficient equipment to care forbariatric patients.

• We inspected five infusion pumps in the day care unit.The infusion pumps were visibly clean and clearlymarked with service check dates, and all were within thescheduled date for the next service.

• We checked the resuscitation trolley. The trolley wasvisibly clean, well-stocked and all items within expirydate. The daily check log was signed and up to date.

Medicines

• Drugs and intravenous fluids were stored securely andwere within expiry date. ‘Short Dated’ stickers were inuse to identify clearly those drugs nearing expiry.

• The drug fridge was locked and only contained relevantitems. The fridge temperature had been recorded dailyand was within the recommended range.

• Controlled drug records were complete. The hospitalcarried out audits of controlled drugs and we saw areport on the review of the management of ControlledDrugs dated April 2014 which showed that all actionshad been implemented and closed.

• We reviewed the medication charts of six patients andfound that records were completed accurately, writingwas legible, and all risk assessments completed andcharts signed and dated.

• Pharmacy updates were part of the annual clinicaltraining day. The hospital reported that by July 2015,47% of staff had attended the training day and were ontarget to achieve 95% compliance by the end of 2015.

Chemotherapy Suite

• The chemotherapy suite used prescription andmedication administration records specific to the needsof their patients, which facilitated the safeadministration of medicines. Medicines interventions bya pharmacist were recorded on the prescription chartsto help guide staff in the safe administration ofmedicines.

• We looked at the prescription and medicineadministration records for two patients on the unit. Wesaw appropriate arrangements were in place forrecording the administration of medicines. Theserecords were clear and fully completed .The recordsshowed people were getting their medicines when theyneeded them. This meant people were receiving theirmedicines as prescribed.

• Medicines, including those requiring cool storage, werestored appropriately. We saw controlled drugs werestored appropriately.

• The pharmacy team visited the unit daily. We saw thatpharmacy staff checked that the medicines patientswere taking when they were admitted were correct, thatrecords were up to date and the medicines wereprescribed safely and effectively

• There was access to spill kits extravasation packs andSavene. Savene is a drug used when chemotherapydrugs have leaked into surrounding skin tissues. TheSavene had clear and detailed instructions with it onhow to use it. A copy of the policy for the managementof cytotoxic chemotherapy extravasation was seen, anda copy was available with the kits on the unit.

• Chemotherapy was manufactured on site in a sterileaseptic room next to the chemotherapy suite. Thechemotherapy suite does not hold a manufacturing

Medicalcare

Medical care

Good –––


licence so only produced items in response to a patientprescription. Standard operating procedures were inplace for all aspects of prescribing and dispensing ofcytotoxic preparations. The isolators (sterile units for thesafe preparation of medications) were audited by anexternal pharmacist and action plans produced as aresult of their reports. We saw that the latest report hadvery minor issues identified which had all been actedon. All staff working in the aseptic unit had receivedtraining through an accredited provider and we sawevidence to confirm this. The hospital had acquiredmembership of the ‘British Oncology PharmacyAssociation.’

• Patients said that they are told about any newmedicines prescribed and what they were for in a waythat they understood; and that they continued to gettheir medicines at home where appropriate. Onepatient said, “Staff tell you what they are doing” “Sideeffects are explained so there are no surprises”

• Patients said that their pain was well managed; as wastheir nausea.

• Staff described access to medicines as adequate, theyknew how to access medicines out of hours, and couldaccess medicines to take home so that there had notbeen delays in patient discharge.

• A pharmacist visited the unit regularly throughout theday to see patients and work with the doctors to ensurethat medicines were prescribed safely and effectively.

• Role specific controlled drug training is availablethrough an e learning course. Staff could also accessmedical gases training. Training in the administration ofEntonox, a pain relieving medical gas, was being rolledout to registered nurses.

• Staff said that they knew how to record and report drugerrors and that learning was shared via clinicalgovernance meetings.

Records

• Patients had paper medical records and electronicpatient records. Paper medical records were storedsecurely and work stations, with access to electronicpatient records, were password protected.

• We looked at six sets of medical records and found thedocumentation to be clear and fully completedincluding clinical risk assessments and whereappropriate do not attempt resuscitation instructions.

Nursing and medical reviews and observations werecorrectly recorded. We concluded that patient carerecords were completed accurately, timely andcontributed to good patient care.

• The hospital training record showed that for the yearApril 2014 – March 2015 the hospital had achieved itstarget of 95% of all staff attending informationgovernance training. Between April 2015 and July 2015,47% of staff had attended information governancetraining. This showed that the hospital was workingtowards its 95% target, which was to be reached by theend of March 2016.

Safeguarding

• All staff had completed training on the protection ofvulnerable adults at induction. Staff told us about thepolicy and the referral process.

• The Leicestershire safeguarding teams contact namesand numbers were available for staff to access.

• The safeguarding training strategy dated April 2014identified that level two training was mandatory for allclinically qualified staff working in day care, ward 2 andchemotherapy. It was difficult to ascertain from thetraining records what the compliance was for thistraining. However, the overall mandatory training ratesfor the hospital were 95%, which would indicate thattraining had been undertaken.

• The hospital weekly compliance report showed that onthe 11 August 2015 84% of consultant staff had suppliedevidence of their medical indemnity insurance whilst87% of consultant staff had provided evidence of aDisclosure and Barring Service (DBS) check.

Mandatory training

• The hospital mandatory training could be accessedthrough the Access Academy. Mandatory trainingcovered eighteen different topics including, incidentreporting, mental capacity act, protection of vulnerableadults, manual handling, child protection and infectioncontrol. The training target for mandatory training was95%. The hospital had achieved this for the year endingDecember 2014. Resident medical officers had receivedtraining in advanced life support.

Assessing and responding to patient risk

Medicalcare

Medical care

Good –––


• The hospital did not accept urgent or unplannedmedical admissions and we saw the admissions criteriapolicy, which clearly listed conditions requiring furtherrisk assessment by nurse, consultant or anaesthetistdepending on their severity.

• The national early warning score (NEWS) was used todetect if a patient’s condition is deteriorating.

• Consultant medical staff could be contacted at all timesand could attend the hospital within 30 minutes of thecall if necessary. If a consultant was found to be notattending within the required time a clinical incidentwould be reported and investigated.

• Patients were reviewed daily by their consultant.• The resident medical officer (RMO) rota was covered by

two RMO’s who worked on a one week on – one week offrota which meant there was continuous RMO cover torespond to nursing concerns or deteriorating patients.

• We observed a handover between nursing staff. It waseffective and relevant safety information was passedbetween staff members.

Nursing staffing

• Spire Leicester told us they used an adapted version of arecognised safer nursing care tool. This is an acuity anddependency tool, which helps determine optimalstaffing levels for inpatient wards. The tool wascompleted daily. The ratio of nursing staff to patientswas one to four. This was reflected in the number of staffwe observed on duty at the time of the inspection. Thiswould increase if the dependency of the patientrequired additional staff.

• We reviewed the personal files of five nursing staff andfound that appraisals, professional registrationvalidation and disclosure and barring service checkswere all up to date.

Medical staffing

• Resident medical officers (RMOs) were sourced througha healthcare medical recruitment agency. We saw thepersonal files of the three RMOs, which containedreferences, and a comprehensive list of self-declaredcompetencies.

• At the time of inspection, 347 consultants withpractising privileges worked at Spire Leicester.

Major incident awareness and training

• We asked staff if they were aware of the hospitals role inmajor incident planning. Senior nurses told us that the

on call senior manager held the procedure for majorincidents and would invoke this when required. Stafftold us that regular simulations are carried out in orderthat they remain familiar with their role in the event of amajor incident; however they seemed unclear aboutwhat constituted a major incident and talked about apatient with a major blood loss.

• Post inspection we were provided with information toshow that major incident plans were currently beingdiscussed with the head of emergency preparedness,resilience and response for the Central Midlands. Thematron informed us that once plans had beendeveloped further then staff would receive informationand training.

Endoscopy Unit

• We were unable to inspect the endoscopy unit as it wasbeing used for other procedures at the time of our visit.We spoke with endoscopy staff. We were told patientsrelatives were able to go into the endoscopy room withpatients during the procedure. Patients requiringsedation were transferred to the recovery suite followingendoscopy procedure.

• Endoscopy took place in one of the operation theatreswhere the ventilation and cooling systems wereregularly tested and maintained. The number of airchanges in the endoscopy area is important in reducingthe risk of airborne infection.

• The endoscopy unit was working towards Joint AdvisoryGroup (JAG) accreditation.

• The endoscopy unit employed a nurse who specialisedin endoscopy. A JAG registered consultant from aneighbouring hospital supported her.

• There was a clear admission pathway for patientattending endoscopy, patients were admitted andprepared for their procedure the same way as a patientundergoing surgery, and they would then be transferredto the theatre department.

• People were offered the option of having medication tomake them sedated during the procedure if theywished.

• A recovery area was near the theatres, which meantpatients recovering from high levels of sedation weregiven a period of higher observation prior to transferback to the ward.

Medicalcare

Medical care

Good –––


• We were told patients relatives were able to go into theendoscopy room with patients during the procedures ifthey were anxious or had additional support needs forexample a patient living with dementia.

• Chaperoning was offered to all patients attending forendoscopy.

• Systems, processes and standard operating proceduresin infection control, medicines management, patientrecords and, the monitoring and maintenance ofequipment were available in the department.

• There was sufficient numbers of probes available for useand we saw that equipment was stored and checksmade to ensure that it was visibly clean and fit forpurpose. We saw a standard operating procedure for thedecontamination of the endoscopy probes after eachuse.

Cardiac Catheter Laboratory

• The Cardiac Catheter Laboratory operated on a patientneed basis and had the facilities to undertakeimplantation of pacemakers and other complex devicesprocedures. Coronary angiography, cardioversions andtrans-oesophageal echocardiography were also carriedout. The laboratory was staffed by a catheter laboratorytrained nurse, radiographer, cardiac physiologist andcardiology consultant when in use.

• We were told that patients were given information priorto the procedure and kept informed of progress duringand after the procedure.

• The ‘World Health Organisation’ checklist was in place inthe catheter laboratory however, at the time of our visit,no patients were scheduled to have procedures and sowe were unable to observe its implementation.

Are medical care services effective?

Good –––

People received effective care and treatment that met theirneeds. Participation in clinical audits and other monitoringactivities demonstrated positive outcomes. Patients’dietary needs were met and their pain managed effectively.

We saw evidence of multi-disciplinary working whichincluded discussions about the patient’s progress andwhere relevant their discharge needs.

Staff were well trained; high levels of staff appraisalachieved.

The Spire Leicester Hospital weekly compliance reportdated the 7 and 11 August 2015 showed shortfalls in thereceipt of medical staff information on whole practiceappraisals and biennial review dates. The provideracknowledged that further work was required to ensure allconsultants provided evidence of all the requireddocumentation. We spoke with a senior manager whoinformed us of the actions in place to achieve complianceand mitigate risk. By 20 August 2015, 312 consultants hadprovided all the required documentation. The suspensionof practising privileges for thirty-four consultants took placeuntil all documentation was submitted to the hospital.Since 20 August 2015, the provider confirmed thatcompliance has remained at 100% at all times in relation tothe collection of this information and that all medical staffwere fully insured during the CQC inspection, despiteshortfalls having been observed in the collection of thisdata.

Evidence-based care and treatment

• The UK oncology nursing society (UKON) triage tool isused by ward staff and the chemotherapy team. Thistool ensured patient safety in that oncology patientsreceived robust reliable assessment over the phone,which had resulted in the appropriate prioritisation ofcare.

Pain relief

• We reviewed six sets of patient records; all includeddocumentation on pain control. Pain was scored using anationally recognised pain scoring tool and wasrecorded on the NEWS chart.

• Pain management training was included in the annualclinical training day.

• Patients told us that they felt pain was taken seriouslyby staff and the call buttons were answered promptly.

Nutrition and hydration

• We witnessed patients’ dietary needs being discussed atthe bed management meeting and staff handovers. Thewhiteboard in the Ward 2 kitchen clearly highlightedpatients on special diets.

• We reviewed six sets of patient notes and all hadMalnutrition Universal Screening Tool (MUST)assessments completed. The MUST assessment

Medicalcare

Medical care

Good –––


identified adults who were malnourished, at risk ofmalnutrition or obese. Staff told us that if the MUSTscore was three or higher they referred the patient to thehead chef for a tailored diet. MUST recommends that ascore of two or higher should be referred to a dietician,nutritional support team or to implement local policy.

• The hospital had a contract in place with a neighbouringNHS trust for dietetics support.

• Patients told us that snacks were always available and ifthey wanted something that was not on the menu thehead chef would prepare this for them. They told us thatdrinking water was changed regularly and relatives andcarers could order and pay for meals if they wanted toeat at the hospital.

• We observed a patient in the chemotherapy suite makevery specific requests for meal times. These requestswere all met.

• We met with catering staff who told us that if patientsstayed in hospital for longer than four days the headchef would visit them to ask if they had any specialrequests for a particular food.

• The ward hostess told us that they made sure patientscan reach and eat their food. If they noticed patientsleaving their meals they would report this to the nursingstaff.

Patient Outcomes

• The deputy matron was responsible for clinical auditand monitoring processes. We saw the hospitals annualaudit plan, which had listed audits already completedand audits planned for the rest of the year. Seniornurses told us they had been involved in recent auditssuch as the care pathway.

• The chemotherapy suite showed us their recent auditwork. These included a Portacath audit (0% infection),sepsis audit and consent audit (100% compliance). Aportocath is an implantable venous access system thatallows easy access to veins for the administration offluids, medication or to take blood. The audits werecompleted continuously and reviewed at the teammeeting.

• The hospital had four cases of unplanned readmissionfor the period July to September 2014; CQC hasassessed the proportion of unplanned readmissions tobe ‘Similar to expected’ compared to the otherindependent acute hospitals we hold this type of datafor.

Competent Staff

• Shortfalls were found in hospital wide consultants’information; with the exception of consultant staffworking with children and young people andtermination of pregnancy services. Information from theweekly compliance report identified the requireddocumentation for hospital wide consultants. Theinformation showed that on 11 August 2015 84% ofconsultants had received a practice appraisal and 71%had received a biennial review.

• Although the percentages of compliance had increasedsince 15 April 2015, the provider acknowledged thatfurther work was required to ensure all consultantsprovided evidence of all the required documentation.We spoke with a senior manager who informed us ofactions that would be put in place immediately toachieve compliance and mitigate risk. The Consultant’sHandbook stated that consultants were at risk ofsuspension if they did not provide up-to-datedocuments.

• On 20 August 2015, we were informed that 84% ofconsultants had provided all the requireddocumentation. Thirty-four consultants practisingprivileges were suspended until the documents weresubmitted to the hospital. Staff were made aware ofwhom the consultants were. Since 20 August 2015, theprovider confirmed that compliance has remained at100% at all times in relation to the collection of thisinformation and that all medical staff were fully insuredduring the CQC inspection, despite shortfalls havingbeen observed in the collection of this data.

• The hospital reported appraisal rates of 94% for all staffin 2014. Nurses told us there were opportunities fortemporary promotions and they were encouraged toconsider succession planning for future promotionopportunities.

• The housekeeping and catering staff told us they hadmany opportunities for personal development. Cateringand housekeeping staff all had the food hygiene NVQ tolevel three.

• The provider was reviewing requirements for carecertification for health care assistants. At the time of ourinspection, no National Vocational Qualification trainingwas offered to care assistants new into the role. Formaldocumented assessments on their competencies wereundertaken following induction and a mentor wasassigned to all new care assistants.

Medicalcare

Medical care

Good –––


• Nurses told us there were good opportunities forattending training courses. Eight out of the twelvenurses were attending the ‘Management fundamentals’training course.

• One recently appointed member of staff described herinduction. This included being supernumerary for threeweeks and a meet and greet with heads of departments.In addition, they had a guided tour of the hospital,introduction to key staff and allocation of a personalmentor. She also received an induction pack whichincluded information about policies, procedures andmandatory training.

• Nurses told us about the twice monthly clinical trainingdays, which all clinical staff attended. We saw thetimetable for the training days and we saw evidence onstaff rotas of planned dates.

• Medical staff also completed an induction programmeand a mandatory training checklist.

Multidisciplinary working

• Senior nurses told us that every day at 8.30am there wasa multi-disciplinary meeting, which included the nursein charge, physiotherapy, pharmacy, Resident MedicalOfficer and deputy matron. The purpose of the meetingwas to discuss individual patient’s progress and plan fordischarge.

• The senior oncology nurse told us that an audit hadbeen carried out on the numbers of patients who had amultidisciplinary team meeting prior to commencementof treatment. Compliance was good at 94% attendance.

• Patients told us they felt that all staff worked as a team,that communication between consultants and nursingstaff was excellent.

Seven-day services

• The resident medical officer was available 24hours aday, seven days a week.

• Consultants could be called at any time and can reachthe hospital within 30 minutes if required. Consultantsperformed daily ward rounds, outcomes of which weredocumented in patient’s notes.

• The chemotherapy unit did not open weekends but thetwo senior nurses offered an on call provision out ofhours until 20.00hrs.

• Physiotherapists provided a seven day service from08.00 – 20.00hrs.

• Twenty four hour on call services were provided by asenior nurse, pharmacist, pathologist and radiologist.

Access to information

• Staff told us that referral notes from GPs were availablefor patients, which enabled consultants to carry out fullyinformed assessments of all new patients.

• There were systems in place for the transfer of medicalinformation between neighbouring hospitals. Thismeant that consultants treating oncology patients couldreview their full medical history and previous test resultsin order to ensure the correct treatment was prescribed.

Consent, Mental Capacity Act and Deprivation ofLiberty Safeguards

• We reviewed six sets of patient notes. Two sets of patientnotes contained ‘Do Not Attempt Resuscitation’ (DNAR)forms, which were accurately completed.

The hospital reported all nursing staff had attended MentalCapacity Act training. Mental Capacity Act training was onceonly training for all clinical staff in Ward 2 and the day careunit. Staff told us they were aware of the act and knewwhat to do if they suspected someone of lacking capacityto consent.

Are medical care services caring?

Good –––

People were supported, treated with dignity and respect,and had been involved as partners in their care. Feedbackfrom people who used the service, those who were close tothem and stakeholders about their experiences waspositive. We saw people were treated with dignity, respectand kindness during all interactions with staff and thatrelationship’s with staff were positive. People said they feltsupported and said that staff cared about them.

People were involved, encouraged to be partners in theircare and were supported in making decisions. Staff spendtime talking to people, or those close to them. Theycommunicated with and received information in a way thatpatients understood.

Staff responded compassionately when people neededhelp and support them to meet their basic personal needs.They anticipated people’s needs and people’s privacy andconfidentiality are respected at all times.

Compassionate care

Medicalcare

Medical care

Good –––


• Friends and Family Test (FFT) results consistently scoredabove 98% for the reporting period October 2014 toMarch 2015 which is above the national average.Response rates were low in 2014 (29.9%) but haveimproved in 2015 and latest available data (to the end ofJune), shows the response rate was 58.5%, again higherthan the national average of 26.1% in the same period

• The results of the latest patient survey were clearlydisplayed on notice boards.

• Chemotherapy staff told us they contacted patients sixto eight weeks after they had finished their course ofchemotherapy to check how they were. We sawevidence of this on a documented sheet.

• We saw people were treated with dignity, respect andkindness during all interactions with staff and thatrelationship’s with staff were positive. People said theyfelt supported and said that staff cared about them.

Understanding and involvement of patients and thoseclose to them

• Staff told us that relatives or carers could stay overnightwith patients if they wished. We witnessed this when arelative asked a member of staff if they could stayovernight and was told that it would not be a problem.

• Spire Leicester commissioned the ‘Compassion inPractice’ training course and 69% of staff had attendedthis training by May 2015. There were plans in place forthe remainder of the staff to attend the training.

• Patients told us staff had time to talk, were friendly andmade them feel at ease during embarrassing moments.Patients said they felt involved at every stage in decisionmaking about their treatment.

• Three patients in the chemotherapy suite said that staffhad treated them with dignity and had always respectedtheir privacy. They also said that staff were caring andattentive to their needs.

• The Spire Leicester website contained a range ofinformation for patients including types of treatmentavailable and costs. The business developmentmanager also told us that an information pack was sentto all patients with their appointment letter.

Emotional support

• Two patients felt they could have been offered moreadvice on how to obtain information about welfarebenefits they may have been entitled to.

• Staff told us and we observed how staff had supportedone patient who had a recent bereavement. Thepatients nurse told us they had talked to the patientabout their bereavement, had spent time with andchecked frequently that the patient was not becomingtoo upset or anxious.

• Staff said that clinical psychologist referrals had takenplace for patients when necessary. Additionalinformation in the form of patient leaflets was availablefor patients in the chemotherapy suite, for example,‘Practical and emotional support for anyone affected bycancer’ a leaflet produced by ‘Coping with Cancer.’

• In addition ‘Coping with Cancer’ staff visit the unitregularly to speak with patients and offer additionalemotional and financial support needed

The oncology unit had also recently started contactingpatients by telephone six to eight weeks after completingtreatment to check on how they were feeling. This enabledpatients to express any concerns they were having. Staffcould arrange for patients to be seen back at the hospital ifnecessary.

Are medical care services responsive?

Good –––

The majority of people’s needs were met through the wayservices were organized and delivered. However,unplanned transfers of inpatients to other hospitals hadrisen in the reporting period (April 2014 to March 2015).

Staff acknowledged patient’s individual needs andresponded to them appropriately, however, we could notbe assured that a suitable translator had always beenavailable for patients whose first language was not English.

The hospital had taken steps to improve the care forpeople living with dementia. This had been corroboratedby the hospital ‘patient led assessment of the careenvironment’ which had scored dementia as 80%compared to the national average of 75%. Learning hadresulted from complaints received.

Service planning and delivery to meet the needs oflocal people

• The hospital was established in 1989 under theownership of a different provider as a purpose built

Medicalcare

Medical care

Good –––


private hospital. In 2007 the hospital changedownership. Whilst the focus had remained on the core ofprivate patient business, the hospital had attractedadditional NHS patients through local contracts withNHS trusts and commissioners in Leicester. This hadresulted in local people receiving timely interventionsfor their required procedures.

• The hospital cared for people of all sexes and from allbackgrounds. Care and treatment pre and postoperatively was undertaken in areas where individualpatients could be segregated via curtains or doors toprovide privacy.

Access and flow

• The hospital did not accept emergency or unplannedadmissions. Patients were referred via their GP,insurance company or NHS Choices.

• The hospital had five cases of unplanned transfer toanother hospital from July to September 2014 CQC hasassessed the proportion of unplanned transfers to be‘Similar to expected’ compared to the otherindependent acute hospitals. However the rate has risengreatly in January to March 2015. There had been 15cases of unplanned transfers of an inpatient to anotherhospital in the reporting period (April 2014 to March2015).

• When a patient’s condition deteriorated and theyrequired a higher level of care they had been transferredto a suitable NHS hospital. A protocol was in place forthe transfer of patients to an NHS hospital. The hospitalhad reviewed all incidents of patients who had beentransferred out to NHS hospitals. We saw thedocumented reviews including lessons learnt andactions taken.

• A one stop shop approach was taken with oncologypatients in the outpatient department. A prechemotherapy assessment was completed, blood teststaken, insurance assessment completed, consent formssigned and the patient seen by the consultant.

Meeting people’s individual needs

• An external company provided Interpreting andtranslation services. Interpreters were booked formeetings between the patient and the consultant.Referral letters indicated if an interpreter was requiredfor the patient.

• Staff told us that they used relatives and carers at othertimes or members of staff who were fluent in otherlanguages. We saw a list of the staff that were able tospeak in different languages. The use of family andcarers is not considered good practice.

• The hospital did not provide any training for staff tosupport them in providing interpreting services. Wewere told that when staff had been used as aninterpreter this had been documented on the patient’snotes, we were unable to find evidence of this in theexample given.

• We did not see any patient information leaflets indifferent languages displayed which meant these werenot readily available to patients.

• The hospital had a named nurse for dementia who wasworking on a dementia pathway. A ‘forget- me- notflower sticker attached to their medical records easilyidentified dementia patients. There were five dementiachampions who included staff from the housekeepingteam; we saw the dementia friend badge being worn byone of the housekeeping team.

• Staff had created two memory boxes. Memory boxeshave been shown to distract dementia patients frombecoming anxious, they contained memorabilia andpersonal items.

• In the staff hand over we attended we witnessed staffdiscussing the mini mental capacity test for one patientwho appeared confused. The mini mental test is a seriesof questions and tests which score points and can beused to help diagnose dementia.

• The hospital had taken steps to improve the care forpeople living with dementia. For example, we foundthey had meetings about dementia and their patient ledassessments of the care environment scored dementiaas 80% for the hospital compared to the nationalaverage of 75%.

• The service was responsive to people’s needs. Anexample of this was when the staff had opened thechemotherapy suite especially on a Sunday for a patientso that the oncology nurse could remove her portocath.

• Patients attending the chemotherapy suite werereferred to an organisation called 'Coping with Cancer'.

• The hospital employed a breast care nurse on a bankbasis who saw all newly diagnosed breast cancerpatients in the outpatients department. After this, theircare was handed over to the spire staff for continuingsupport.

Medicalcare

Medical care

Good –––


• A reflexology service was offered to oncology patientsand their relatives.

End of Life Care

• The hospital had several policies and documents inplace relating specifically to end of life care (EOLC) suchas; an end of life care policy, end of life care plan, syringedriver policy, care of deceased patient after death policyand the ‘rest in peace’ hospital pack.

• Staff told us occasionally patients had requested thatthe hospital be their preferred place of care and that thishappened about three to four times per year. Howeverpatients were usually referred to the local hospital.

• Staff working in the chemotherapy suite receivedadditional training in relevant topics. We saw thecertificate of attendance for one member of staff on thetraining course, ‘securing quality and compassion in endof life care’ and another attending a degree levelchemotherapy course.

• One doctor we spoke with was unable to tell us howmany oncology patients who received care at thehospital were deemed to be in the last twelve months oflife, they were also not clear about the gold standardregister. The gold standard register is held by GP’s andshould include all their patients deemed in the last 12months of life. All patients on the register should bediscussed at a multidisciplinary meeting held at the GPpractice.

• The lead pharmacist confirmed that pharmacists hadbeen involved when prescribing anticipatory medicinesfor end of life care situations

Learning from complaints and concerns

• Complaints were logged on an electronic system.• Spire Leicester reported that there had been 77

complaints logged in 2014. All complaints had beenreviewed by the hospital director.

• We saw the complaints flowchart displayed on the wardnotice board. Staff told us patients were encouraged todiscuss complaints so that local resolution could beachieved if possible. We saw the complaints leaflet,’Please Talk to Us’ which was included in the admissioninformation pack.

• During our review of five nurse personal files, we sawgood evidence of reflective practice following onemember of staff’s involvement in a complaint relating topain control.

Are medical care services well-led?

Good –––

The leadership, governance and culture promote thedelivery of high quality person-centred care. Robustgovernance and audit systems were in place.There was aclear statement of vision and values, driven by quality andsafety. It was translated into a credible strategy andwell-defined objectives that were reviewed to ensure thatthey remained achievable and relevant. Staff in all areasknew and understood the vision, values and strategic goals.Staff morale was high and the management team wellthought of by staff and consultants alike.

Shortfalls were found in hospital wide consultants’information; with the exception of consultant staff workingwith children and young people and termination ofpregnancy services. We escalated these findings to theprovider who acknowledged that further work was requiredto ensure all consultants provided evidence of all therequired documentation. Immediate actions wereimplemented by a senior manager to achieve complianceand mitigate risk. By the 20 August 2015, 84% ofconsultants had provided all the required documentation.

Vision, strategy innovation and sustainability for thiscore service

• Spire Leicester Hospital plans to open three outreachclinics in Stamford, Market Harborough and HusbandsBosworth to promote and increase referrals from theseareas. In addition, the service plans to attract additionaloncology patients in conjunction with a new cancercentre at Castle Donnington, which will result in anoverall increase in cancer services.

• Staff we spoke to were aware of the vision and values ofthe hospital and described them to us.

Governance, risk management and qualitymeasurement for this core service

• Shortfalls were found in hospital wide consultants’information; with the exception of consultant staffworking with children and young people andtermination of pregnancy services. Shortfalls in thereceipt of medical staff information were monitored bythe hospital. These shortfalls included up to dateinformation on whole practice appraisals, medical

Medicalcare

Medical care

Good –––


indemnity, disclosure and barring checks, biennialreview and General Medical Council registration expirydates. We escalated these findings to the provider whoacknowledged that further work was required to ensureall consultants provided evidence of all the requireddocumentation. We spoke with a senior manager whoinformed us of immediate actions to achievecompliance and mitigate risk. By the 20 August 2015,84% of consultants had provided all the requireddocumentation. Thirty-four consultants practicingprivileges were suspended until they had submittedtheir documents to the hospital.

• The governance structure showed clear lines ofaccountability from staff delivering the service to thehospital director. Meetings were in place for key areassuch as clinical governance, health and safety, medicaladvisory committee and medicines management.

• Senior nurses told us they felt informed about andinvolved in the governance of the hospital.

• Team meetings and key points from these meetingswere disseminated to staff, which included the lessonslearnt from complaints and incidents. Minutes ofmeetings were emailed to staff unable to attend inperson.

• The hospital attached a monthly staff bulletin to payslips advising of any issues and actions taken. A monthlynewsletter is circulated to staff.

• The ‘Medical Advisory Committee’ linked with thehospital clinical governance meeting.

Leadership/culture of service

• Patients were complimentary about the visibility of thehospital matron. Staff told us they saw matron and thehospital director in the departments and wards onalmost a daily basis.

• Nursing staff told us that if they were mentioned in anaccolade from a patient they would receive a personalletter of thanks from matron.

• A consultant told us that he felt he was working in asupportive environment and that the hospital directordemonstrated a strong ‘top down’ managementapproach.

• Housekeeping staff told us that the leadership team areapproachable and lead by example.

• All staff we talked with told us the hospital was a goodplace to work. They said there were more than adequatetraining and development opportunities, and they feltvalued by managers.

Public and staff engagement

• The matron informed us it had been difficult to involvepatients as much as they would like to. Phone calls weremade to many ex-patients and a new patient focusgroup had been set up with three ex-patients; two morehad been recruited prior to our visit. Two meetings hadbeen held to help resolve any concerns raised bypatients with clear action plans from recommendations/ feedback from patients to drive relevantimprovements. In addition, in 2014, patient forums wereheld involving NHS, Private Insured and Self-Paypatients. A report from this activity was generated andactions have all been closed out.

• Staff had encouraged patients and visitors to visit anewly refurbished room on Ward 2 to receive theirfeedback on décor and layout. Some patients wereasked to stay overnight in the room. Patient commentshad informed the final design of the new rooms. Oneexample of this was feedback, was about the taps inpatient rooms. These taps were now going to bechanged.

• A senior member of staff informed us the relationshipbetween the local Healthwatch group and the hospitalwas very good. Healthwatch had not received anycomplaints relating to the hospital.

Payment for Care and Treatment

• NHS referred patients received exactly the same care asprivate paying and insured patients. This was evident onthe wards.

• The Spire group website had very good informationabout the cost of procedures. The businessdevelopment manager told us that information packswere sent out with appointment letters which gave clearinstruction about cost and payment. We viewed thewebsite and the information pack.

• Patients were advised to check with their insurer if therewere any limitations to services covered in the insurancepolicy.

• Costs and payment were discussed at all stages oftreatment by the consultant at the initial appointmentand later by nursing staff. For example, the patient’spolicy reached the limit of their outpatient diagnostictesting budget.

Medicalcare

Medical care

Good –––


Safe Good –––




Well-led Requires improvement –––

Information about the serviceSurgical services at Spire Hospital Leicester provided dayand overnight facilities for adults and children undergoinga variety of procedures. The majority of patients attendingthe hospital for surgery were privately funded (insured andself-paying). Twenty three percent of patients in the yearApril 2014 to March 2015 were funded by the NHS throughthe ‘NHS e-referral’ service system. Choose and Book is anational electronic referral service which gives low riskpatients a choice of place, date and time for their firstout-patient appointment in a hospital or clinic. Since June2015 this has been replaced by the NHS ‘E-Referral Service.’The hospital offers general surgical and orthopaedicprocedures only through this system.

From April 2014 to March 2015 there were 6,518 visits totheatre. These included general surgery orthopaedics,ophthalmology and cosmetic surgical procedures. Themost commonly performed surgery was for patients withcataracts. Facilities included two wards, four theatres andone area where minor procedures were undertaken.Patients recovering from surgery were cared for in afive-bedded recovery area. In addition two enhancedrecovery beds with appropriate equipment had beenallocated for patients requiring a higher level of care forshort periods of time, for example, following surgery forweight loss.

The hospital provided its own sterile supplies department.This enabled reusable equipment to be cleaned, sterilisedand packed for further use.

During our inspection we spoke with 13 patients and twoaccompanying relatives. We also spoke with staff includingnurses, medical staff, anaesthetists, therapy, supportingstaff and senior managers.

Summary of findingsThe hospital had systems in place to keep patients safe.Processes were in place to report incidents and staffdemonstrated a good awareness of the process foridentifying and reporting any safety incidents showingthe system was embedded. Investigations were robustand staff learned from actions taken. . However, becauseof the small monthly sample size (less than 2%) for theauditing of the five steps to safer surgery checklists wecould not be assured of overall compliance with safepractices in theatre. All patient areas were visibly clean,infection prevention and control processes were inplace and equipment had been checked regularly.Medicines were stored and administered safely.

Staffing was managed effectively to ensure patientsreceived good care with access to medical care

obtained in a timely manner. Staff were well trained andrecords were kept securely.

The Spire Leicester Hospital weekly compliance reportdated the 7 and 11 August 2015 showed shortfalls in thereceipt of medical staff information on medicalindemnity, disclosure and barring checks, GeneralMedical Council registration expiry dates, whole practiceappraisals and biennial review dates. The provideracknowledged that further work was required to ensureall consultants provided evidence of all the requireddocumentation. We spoke with a senior manager whoinformed us of the actions in place to achievecompliance and mitigate risk. By 20 August 2015, 312consultants had provided all the requireddocumentation. The suspension of practising privileges

Surgery

Surgery

Good –––


for thirty-four consultants took place until alldocumentation was submitted to the hospital. Since 20August 2015, the provider confirmed that compliancehas remained at 100% at all times in relation to thecollection of this information and that all medical staffwere fully insured during the CQC inspection, despiteshortfalls having been observed in the collection of thisdata.

Evidence based care and treatment was delivered topatients following national guidance by competent staff.The hospital provided a seven-day week service withpatients having good access to information.

All the patients and relatives we spoke with wereoverwhelmingly positive about the care they hadreceived and the way staff treated them. Patients told usthey were involved in their care and staff explained careand treatment in a way they understood.

Access to care and treatment was monitored andexceeded the national average. Staff acknowledgedpatient’s individual needs and responded to them in anappropriate way although we were not assured asuitable translator was always available for patientswhose first language was not English.

Staff had a good understanding of the complaintsprocess and the hospital learned from complaints,changing care practices if required.

The hospital had a governance system in place whichincluded a comprehensive audit system. Morale wasexcellent with staff talking positively about theorganisation and their local management team. Stafffelt listened to and supported in their role.

Are surgery services safe?

Good –––

The hospital had systems in place to keep patients safe.Processes were in place to report incidents and staffdemonstrated a good awareness of the process foridentifying and reporting any safety incidents showing thesystem was embedded. Investigations were robust andstaff learned from actions taken as a result. However,because of the small monthly sample size (less than 2%) forthe auditing of the five steps to safer surgery checklists wecould not be assured of overall compliance with safepractices in theatre.

The Spire Leicester Hospital weekly compliance reportdated the 7 and 11 August 2015 showed shortfalls in thereceipt of medical staff information on medical indemnity,disclosure and barring checks and General Medical Councilregistration expiry dates. The provider acknowledged thatfurther work was required to ensure all consultantsprovided evidence of all the required documentation. Wespoke with a senior manager who informed us of theactions in place to achieve compliance and mitigate risk.By 20 August 2015, 312 consultants had provided all therequired documentation. The suspension of practisingprivileges for thirty-four consultants took place until alldocumentation was submitted to the hospital. Since 20August 2015, the provider confirmed that compliance hasremained at 100% at all times in relation to the collectionof this information and that all medical staff were fullyinsured during the CQC inspection, despite shortfallshaving been observed in the collection of this data.

Infection prevention and control processes were in place,equipment was checked regularly and medicines werestored and administered safely.

Incidents

• The hospital had reported one ‘never event’ in 2014,which had related to an issue in theatre. Never eventsare classified as 'serious, largely preventable patientsafety incidents that should not occur if the availablepreventative measures have been implemented by

Surgery

Surgery

Good –––


healthcare providers' The event had been investigatedthoroughly and appropriate actions taken to preventany re-occurrence. Staff we spoke with were aware ofthe incident and the actions taken.

• All the staff we spoke with were aware of theirresponsibilities and had individual access to thehospital’s electronic incident reporting system; they allknew how to use it. This allowed staff to report all actualincidents and those where patient safety may have beencompromised. Staff gave examples of reportableincidents where lessons were learned and practiceschanged as a result. Staff we spoke with informed usthere was no blame culture in the service and they feltempowered to report incidents without fear of reprisal.

• Data we had received from the provider showed therehad been 578 clinical incidents across the hospitalservices between April 2014 and March 2015. Overall, therate of clinical incidents per 100 inpatient dischargesacross the hospital had remained largely consistent inthe same period.

• In the same period there had been 19 serious incidentsthat had required investigation. The provider had takenappropriate action to reduce the risk of these occurringagain.

• The hospital had reported seven expected deathsbetween April 2014 and March 2015 across all services.In the same period, there had been two unexpecteddeaths, both reported in March 2015. Although bothpatients had been treated in the hospital, one had diedat home and the other in a local acute trust. Bothdeaths were investigated thoroughly and the providerhad responded appropriately.

Safety thermometer

• The hospital had monitored performance through aseries of assessments to reduce risks to patients. Theseincluded, falls, pressure ulcers (damage to the skincaused by a patient being in the same position for toolong), and venous thromboembolism (VTE). VTE’s orblood clots can form in a vein of a patient and have thepotential to cause severe harm.

• The VTE screening for all patients was consistently 100%in the reporting period between April 2014 and March2015: 95% is the targeted rate for NHS patients. CQC hadassessed the proportion of patients risk assessed forVTE to be ‘much better than expected’ compared toother acute independent hospitals we hold data for.

• The number of patients with hospital acquired provokedVTE or pulmonary embolus (PE) in the period betweenApril 2014 and March 2015 was 13. A PE is a blockage ofan artery in the lungs. The most common cause of theblockage is a blood clot.

• A nutritional assessment had been undertaken for allpatients even if those who had a local anaesthetic.

• Three cases of hospital acquired grade two pressureulcers had been logged as incidents in the twelve monthperiod March 2014 to April 2015. All had beeninvestigated with actions taken and lessons learneddocumented.


• The service had a newly appointed infection controlnurse in post who had attended a recognised infectioncontrol course. Infection control link nurses were inplace in each ward and department.

• Monthly committee meetings with terms of referencehad commenced for the link nurses to discuss theirconcerns and ideas for moving forward. The committeefed into the clinical governance meetings. All infectioncontrol issues fed into the infection control Spirecorporate lead. This gave staff responsible for infectioncontrol the opportunity for peer support and sharedlearning.

• The hospital had forged good links with personnelworking in infection control at a local NHS acute trust;these included a microbiologist. They met on a regularbasis to discuss shared learning.

• Two members of staff had taken part in a study day atPublic Health England with regard to surgical sitewound infections.

• Information the provider sent us showed their infectioncontrol audits between July 2014 - March 2015 rangedfrom 85% and 94% compliance. The infection controlnurse informed us they would like to see 100% abovetheir target rate of 95%.

• The hospital had reported one incidence of MethicillinStaphylococcus Aureus (MRSA) one case of ClostridiumDifficile (C Diff) and no cases of Methicillin-sensitiveStaphylococcus Aureus (MSSA) in the reporting periodbetween April 2014 and March 2015. MRSA, MSSA andC.Diff are all infections that have the capability ofcausing harm to patients. A root cause analysis hadbeen undertaken for each case to highlight any actionsthat needed to be taken. Appropriately trained staffundertook the root cause analysis processes.

Surgery

Surgery

Good –––


• As part of the pre-operative process for patientsadmitted for procedures, high risk patients werescreened for Methicillin-Resistant StaphylococcusAureus (MRSA) and Methicillin-Sensitive StaphylococcusAureus (MSSA). These included patients scheduled fororthopaedic procedures, those who had been inhospital previously and patients who had previouslytested positive for the bacteria. Those patients werescreened at between two and six weeks prior toadmission.

• Two weeks prior to our visit the hospital had put inplace a protocol for all high risk patients, for examplejoint replacement, prescribing a routine five daytreatment for MRSA whether they tested positive for thebacteria or not. The updated protocol covered shortnotice bookings only for patients having surgery withinfive days when there was insufficient time for thereporting of the samples taken.

• Anti-microbial stewardship was in place in the hospitalto ensure the use of antibiotics was controlled and usedappropriately.

• All of the areas in which patients were seen and treatedand where equipment was stored were visibly clean andwell maintained. Equipment was stored off the floor.Equipment not used regularly was covered to preventthe collection of dust.

• The hospital used a system for ensuring equipment wasidentified as having been cleaned, for example ‘I amclean’ stickers. These were clearly visible, dated andsigned appropriately.

• A local policy and procedure was in place for thescrubbing, gowning and gloving of staff prior to surgicalinterventions. We observed staff following theprocedure to ensure infection risk was minimised.

• Processes and procedures were in place for themanagement, storage and disposal of general andclinical waste, disposal of sharps, environmentalcleanliness and the prevention of healthcare acquiredinfection guidance. Clinical waste bags and sharp binswere closed effectively and identified with a uniquenumber. Sharps bins were given to patients ondischarge if they were required, for example, for theadministration of certain medicines

• Cleansing gel was available at the entrances to eacharea and in each room; patients and visitors wereencouraged to use it. There was access to hand washingfacilities and supplies of personal protective equipment,for example gloves and aprons.

• Staff were seen to wash or apply alcohol gel to theirhands on entering and exiting from patients’ rooms anddifferent areas of the hospital.

• All staff were observed complying with the bare belowthe elbows policy and nursing staff were comfortablechallenging medical staff to comply with this policywhere required.

• A hand hygiene benchmark audit had been carried outmonthly. In July 2015 this showed a good compliancerate. In addition, a hand glow audit using a special lightto indicate clean hands had been carried out on staff bythe infection control link nurse in every department.

• On the in-patient ward patients had been asked tocomplete a questionnaire on the use of hand sanitiserby staff. Any staff not undertaking this were identifiedand the issue taken forward.

• Three of the four operating theatres had higher levels ofair filtration (laminar flow) in place; this was particularlyimportant for joint surgery to reduce the risk ofinfection. We saw annual checks had been undertakenon the filtration systems to ensure compliance.

• Deep cleaning of theatres had been undertaken on anannual basis.

• The provider had a wound care management policy andprocedure in place which was in use in the hospital.Staff were aware of this.

• Patients were given written information regardingwound management from the staff before discharge.This was supported by verbal discussion; theinformation included what the patient should do if theywere concerned. Patients were given telephonenumbers of the hospital to contact them if they requiredhelp or support.

• Information received from the provider showed that oneincident of wound infection had occurred between April2014 and March 2015. The incident had been logged onthe hospital’s on-line incident reporting system. Aninvestigation had been undertaken and the patient hadbeen treated appropriately.

• All members of staff had been provided with an easy touse pocket guide that included such items as handhygiene and infection prevention control.

• Senior managers informed us fitted carpets and fabriccurtains were being replaced in patients’ rooms. Thehospital had acknowledged these were difficult fabricsto keep clean. The replacement programme was due tobe completed by the end of 2016.

Surgery

Surgery

Good –––



• Storage facilities within the hospital for supplies andequipment were well organised. For example, theanaesthetic consumable store room was well stockedand clearly labelled.

• The second floor suite of four theatres appeared visiblyclean, well-organised and tidy. The theatre in theoutpatients department was also visibly clean and fullyequipped to undertake minor procedures such asbiopsies and removal of skin lesions.

• Flooring in theatre store rooms were marked to identifywhere equipment was stored and corridors werecompletely clear. Staff informed us this was usualpractice.

• Resuscitation equipment for both adults and childrenwas available in the operating theatres and ward areas.Single-use items were sealed and in date and we sawevidence the equipment had been checked on a dailybasis; this included expiry dates. This meant theequipment was ready for use in an emergency.

• In theatres separate drug boxes for adults and childrenfor use in an emergency were sealed. However, thecolour of the boxes were similar and stored in the sameplace. This meant the wrong box could be picked up inan emergency.

• On the first floor a resuscitation trolley was located inthe oncology department; this was also used for Ward 1.

• On the second floor’ resuscitation equipment included aspecial bag containing all the equipment needed for achild’s emergency resuscitation.

• We found anaesthetic machines were in working orderand safe to use although it had been acknowledged bythe provider they required replacing because of theirage. This would take place in 2016 as part of arefurbishment programme.

• Anaesthetic equipment was checked by an operatingdepartment practitioner (ODP) at the start of each day.We observed regular service checks were also in place.

• The service had equipment for dealing with patientswho may present with uncommon situations that mayoccur during the course of their operation.

• We saw all equipment used for patient-care to be visiblyclean and ready for use. Equipment had been routinelychecked for safety with portable appliance testing labelsstating when the next service was due.

• On wards we saw equipment was readily available, forexample walking crutches.

• The hospital had its own sterile supplies department(SSD) Staff in SSD performed sterilizations and otheractions on medical devices, equipment andconsumables for use by healthcare professional’sworkers in the operating theatre of the hospital.

Medicines

• The hospital used a comprehensive prescription andmedication administration record chart for patientswhich facilitated the safe administration of medicines.

• Medicines interventions by a pharmacist were recordedon the prescription charts to help guide staff in the safeadministration of medicines.

• We looked at the prescription and medicineadministration records for three patients on the twowards. We saw appropriate arrangements in place forrecording the administration of medicines. Theserecords were clear and fully completed .The recordsshowed people had received their medicines whenprescribed. If people were allergic to any medicines thishad been recorded on their prescription chart.

• Medicines, including controlled drugs and thoserequiring cool storage, were stored appropriately.Controlled drugs are medicines which are stored in adesignated cupboard and their use recorded in a specialregister.

• The pharmacy team visited all wards daily. We saw thatpharmacy staff checked that the medicines patientswere taking when they were admitted were correct, thatrecords were up to date and the medicines wereprescribed safely and effectively.

• Patients were responsible for completing their ownpre-admission questionnaire prior to their procedure.This included information about the current medicinesthey were taking.

• If required, additional information for the patient wasrequested from their GP.

• The records were clear and complete. If people wereallergic to any medicines this was recorded.

• The hospital used a number of different medicines forrelieving pain post-operatively dependent upon thesurgery. Eye drops were also used for patients followingophthalmic surgery. All patients were given informationabout the medicine they had been prescribed how touse it and any side effects they may experience.

Records

Surgery

Surgery

Good –––


• We saw records were kept securely when not in use onthe wards. Access to them was via a key code. Anyrecords not used for six weeks were sent off site intosecure storage. We were informed they could beobtained within 24 hours if they were required.

• Staff, including reception staff, were aware of theirresponsibilities with regard to the safekeeping ofrecords and patient confidentiality.

• We looked at five patient records from patients who hadundergone different types of procedures.

• Medical (operation notes and consent form) and nursingrecords (risk assessments and care pathways.) were filedseparately. However, all records for one patient werekept together which meant they were easy for staff tolocate. Medical notes were not always easy to readbecause of the lack of clarity in doctor’s handwriting.

• Nursing and medical records were filed in a specificorder which meant they were easy for staff to locate anduse.

• We saw three records where pieces of information onseparate sheets of paper had not been placed into thefile securely. These related to blood test results, fluidcharts and an anaesthetic record. The providerinformed us loose documents were checked and filed inthe correct order prior to sending notes to medicalrecords for filing.

• All records were complete and up to date. Each patienthad the appropriate care pathway in place dependentupon the procedure they had undertaken and whetherit was a local or general anaesthetic. Evidence wasavailable to show discharge was planned andphysiotherapy arranged where necessary.

• Care pathways were comprehensive in content andincluded pre-operative assessments, anaesthetic,recovery and discharge planning including painmanagement and wound care. The pathways could bepersonalised to reflect patient’s individual needs, forexample, if a patient’s first language was not English; wesaw this in one record we viewed.

• Records showed where staff had completed patient riskassessments. These included risk assessments forpressure ulcers, falls, and malnutrition. All the riskassessments completed followed national guidance, forexample, a score for prevention of pressure ulcers.

• Additional information relating to patient’s individualcare was documented in a communication page.

• One senior manager was due to attend CaldecottGuardian training in October 2015. A Caldecott Guardian

is a senior person responsible for protecting theconfidentiality of a patient and service-user informationand enabling appropriate information sharing withother agencies.

Safeguarding

• The hospital had adopted the corporate safeguardingpolicy and procedure which included guidance onsafeguarding adults and children. We saw the hospitals’policy had been reviewed in June 2015.

• The hospital had a senior named nurse lead forsafeguarding both adults and children.

• Leicestershire safeguarding teams contact names andnumbers were available for staff to access.

• Safeguarding was a standing agenda item on the qualityreport for the hospital; we saw the report for June 2015.

• The safeguarding lead for the hospital receivedthree-monthly safeguarding supervision with the localClinical Commissioning Group lead safeguarding nurse.We saw evidence of those notes for June and July 2015.

• Staff we spoke with had an understanding of how toprotect patients from abuse. They understood theprocess and who to refer any concerns to.

• Safeguarding adults and children training was includedin the mandatory training for all staff, with clinical staffand clearly identified clerical staff in certain areastrained to level 2.

• Four safeguarding incidents had been raised in the lasttwelve months and the hospital had actedappropriately. Discussions held with a senior manageridentified there had been learning from the firstsafeguarding event which had improved practice inrelation to the following safeguarding events.

• The hospital weekly compliance report showed that onthe 11 August 2015 84% of consultant staff had suppliedevidence of their medical indemnity insurance whilst87% of consultant staff had provided evidence of aDisclosure and Barring Service (DBS) check.Since 20 August 2015, the provider confirmedthat compliance has remained at 100% at all times inrelation to the collection of this information and that allmedical staff were fully insured during the CQCinspection, despite shortfalls having been observed inthe collection of this data.

Mandatory training

• Mandatory training for all groups of staff wascomprehensive with many modules accessed through

Surgery

Surgery

Good –––


an on-line learning system. Other training was rolespecific, for example, food hygiene. Mandatory trainingmodules included moving and handling, infectioncontrol, fire and health and safety.

• There was an expectation that all staff completedannual mandatory training. Information provided by thehospital evidenced that percentage completions ofmandatory training varied between staff groups. Forexample 100% of the senior management team hadcompleted the five annual modules for 2015 includingfire safety, health and safety and infection control.Qualified nursing staff and healthcare support workerspercentages for the same modules varied between 71%and 92% although it is acknowledged the year had notfinished. The training year ran from January –December.

• Consultants had to complete mandatory training withthe trust they worked for as part of their appraisalprocess.

• The resident medical officers who worked in thehospital 24 hours a day were required to undertakemandatory training with the agency that supplied themas part of their contract. This included health and safety,fire training, and equality and diversity.

• Other mandatory training included advanced lifesupport and advanced paediatric life support.Completion rates varied between 74% and 76%. Thetraining target for the hospital was identified as 95% andthe hospital had until the end of the year to achievethat.


• All patients saw their named consultant at each stage oftheir patient journey.

• Anaesthetists calculated the patient’s American Societyof Anesthesiologists (ASA) grade as part of theirassessment of a patient about to undergo a generalanaesthetic. The ASA is a system used for assessing thefitness of a patient before surgery and is based on sixdifferent levels with level one being the lowest risk. Thehospital generally undertook procedures for patientsgraded as levels one to three.

• Information from the hospital showed that in the year2015 to date 89 patients had received an anaestheticwith an ASA grade of three and one patient with an ASAgrade of four. ASA grade three patients were discussed

with the appropriate consultant and only treated if therisks were acceptable. The hospital informed us thepatient with an ASA grade of four had only received alocal anaesthetic.

• Because of the narrow entrance to the smaller theatre inoutpatients, any patients deemed at risk were operatedon in the main theatre suite to ensure staff andequipment could be gained quickly.

• Staff in the hospital used a system to record routinephysiological observations such as blood pressure,temperature and heart rate in order to monitor apatient’s clinical condition. This was used as part of anational early warning score (NEWS). If a patient’s scoreincreased, staff were alerted to the fact and a responsewas instigated. The response varied from increasing thefrequency of the patient's observations up to urgentreview by the consultant surgeon and/or consultantanaesthetist. Observation of five records showed thesewere completed.

• The hospital also used a document called a roundingchart to reflect how frequently patients should beobserved. This varied between one and two hoursdependent upon individual patient need. It includedpain control, mouth care, skin care, continence andnutrition.

• The hospital had a service level agreement with thelocal NHS acute trust. This stated patients could betransferred to their care if they deteriorated. Anemergency call to the ambulance service would bemade to transport a patient.

• In the period from April 2014 to March 2015 there hadbeen 20 cases of unplanned transfer. Of those 20 cases,12 patients had been transferred following surgery butno themes had been identified. The data we reviewedshowed a rising rate of unplanned transfers due tocomplications following surgery. Root cause analysiswas completed for each transfer and any lessonslearned was documented. For example, new fluid chartshad been put in place to improve the accuracy of thedocument following a deterioration of a patient thathad not been monitored effectively.

• A resident medical officer (RMO) who had been recruitedthrough a medical agency was on duty 24 hours a day inthe hospital to respond to any concerns staff may have.A paediatric consultant/anaesthetist was alwaysresident in the hospital if children had undergonesurgery.

Surgery

Surgery

Good –––


• Staff we spoke with felt confident about contacting thepatient’s consultant by telephone and told us theywould attend the patient in a short period of time.

• The hospital followed the five steps to safer surgery inthe operating theatre. Staff used a document based onthe World Health Organisation (WHO) five safer steps tosurgery safety procedures for use in an operatingtheatre to ensure any risk to patients was reduced.Medical records we reviewed showed the checklistcompleted in all cases.

• During our observation in theatres, we observed staffadhering to the checklists and signing them off. A rollingprogramme of monthly audits was in place for thechecklist. The results showed 100% compliance in everymonth. However, only ten patient files per month wereaudited, equating to less than 2% of the total surgicalprocedures undertaken, which averaged 543 per monthin the period April 2014 to March 2015. The providerinformed us they were guided by their corporate armwith regard to sample sizes for audit purposes. However,we could not be assured the small sample size wassufficient to determine overall compliance with safepractices in theatre.

• The hospital had a service level agreement in place witha local acute trust to supply adequate blood in thehospital for patients requiring major surgery such as ahip revision or bariatric surgery. If further or unplannedsupplies were needed the hospital could be in receipt ofblood within 20 minutes.

• Scenarios were held on a regular basis to ensure staffresponded appropriately. The week before ourinspection staff had responded to a staged situationinvolving a patient with a large blood loss.

Nursing staffing

• The provider undertook the acuity level of patients onthe wards at 2pm each day retrospectively. The toolused was adapted from a tool that had been usedwidely across the NHS, private sector and in somehospitals overseas for ensuring correct nurse staffinglevels

• The nurse to patient ratio was 1:4 and staff wereallocated patients to be responsible for when they cameon duty.

• Qualified nurses were responsible for any tasks they hadrequested care assistants to undertake.

• During our inspection all the nursing staff we spoke withtold us they had enough staff on duty to deliver goodquality care even though they were sometimes verybusy.

• Patients told us there were sufficient staff to meet theirneeds during their visit to the hospital and the care theyreceived from those staff was extremely good.

• The provider informed us there was a ratio of 1:1.9 nursemanagers to nurse team leaders, one nurse team leaderto other nurses of 1:2 and a ratio of 1: 0.5 of nurses tocare assistants.

• Usage of agency nurses was minimal for the year April2014 to March 2015.

• During periods of sickness and annual leave staffgenerally undertook additional hours to ensure coverwas acceptable. This meant only staff that knew thehospital and had undertaken an appropriate inductionand competency based framework worked in thehospital.

• Daily staffing levels in each area was flexed dependentupon the type of surgical procedures being undertaken.Procedures requiring a general anaesthetic required ahigher nurse to patient ratio than local anaesthetics.

• An escalation policy was in place for concerns relating tonurse staffing levels. Staff were aware of it and knewwhat to do if they had concerns about safe staffinglevels.

Surgical staffing

• There were 347 consultants who had been grantedpracticing privileges at the hospital. The majority ofthese also worked at a local NHS trust. They includedconsultants with specialties such as ophthalmology,urology and orthopaedics. The term “practisingprivileges” refers to medical practitioners being grantedthe right to practise in a hospital. Staff informed us theyhad no concerns obtaining help quickly if it was neededto review a patient’s care.

• The two resident medical officers provided 24-hourmedical cover for patients. They alternated theirworking hours to ensure one doctor was always on duty.

• Operating theatres were generally in use between 8.30am and 9.00 pm Monday to Friday and 8.30am and 5 pmon a Saturday.

• The hospital worked within the recommendations of the‘Association for Perioperative Practice’ with regard to

Surgery

Surgery

Good –––


numbers of staff on duty during a standard operatinglist. This comprised of two nurses, an operatingdepartment practitioner, a healthcare assistant, aconsultant and an anaesthetist.

• If an operation was scheduled when other departmentsor services were not normally available this wasdiscussed and planned for at the time of the booking ofthe procedure.

• If a patient was required to return to theatre out of hoursbecause of complications, a comprehensive on-callsystem was in place to notify staff quickly.


• The hospital did not have designated roles andresponsibilities in the nearby trust’s major incidentpolicy. However, a senior nurse informed us they wouldalways give assistance if requested to do so.

• We were informed of a recent accident occurringoutside the hospital when staff had respondedappropriately.

• The hospital had a comprehensive business continuityplan in place in case of potential emergencies, whichwas reviewed in June 2015. The plan included how torespond to a widespread fire or flood, prolonged loss ofpower, water or communications. Staff were aware ofthe plans in place. Teams of staff had specific roles toco-ordinate the emergency response.

Are surgery services effective?

Good –––

Staffing was managed effectively to ensure patientsreceived good care with access to medical care obtained ina timely manner. Staff were well trained and records keptsecurely. Evidence based care and treatment was deliveredto patients following national guidance by competent staff.The hospital provided a seven day week with patientshaving good access to information.

The Spire Leicester Hospital weekly compliance reportdated the 7 and 11 August 2015 showed shortfalls in thereceipt of medical staff information on whole practiceappraisals and biennial review dates. The provideracknowledged that further work was required to ensure allconsultants provided evidence of all the requireddocumentation. We spoke with a senior manager whoinformed us of the actions in place to achieve compliance

and mitigate risk. By 20 August 2015, 312 consultants hadprovided all the required documentation. The suspensionof practising privileges for thirty-four consultants took placeuntil all documentation was submitted to the hospital.Since 20 August 2015, the provider confirmed thatcompliance has remained at 100% at all times in relation tothe collection of this information and that all medical staffwere fully insured during the CQC inspection, despiteshortfalls having been observed in the collection of thisdata.


• The delivery of day surgery was consistent with the‘British Association of Day Surgery (BADS).’ BADSpromotes excellence in day surgery and providesinformation to patients, relatives, careers, healthcareprofessionals and members of the association.

• Patient needs were assessed throughout their carepathway and care and treatment was generallydelivered in line with ‘National Institute of Health andCare Excellence’ (NICE) quality standards and the RoyalColleges guidelines.

• NICE guidance was sometimes referred to within thecare pathways, for example, reducing the risk of venousthromboembolism (VTE).

• The hospital did not follow the recommended NICEguidance for medicine prophylaxis for VTE. Prophylaxismeans medication or a treatment designed and used tohelp prevent a disease from occurring. Patients who hadreceived a planned hip or knee replacement had notbeen given the NICE recommended treatment for 28 to35 days post operatively; this was highlighted on thehospital’s risk register and regularly reviewed. Thehospital followed instead a process which was in linewith that of the local NHS acute trust to ensure astandardised regime across the local area which wasfamiliar to all consultants and GP’s.

• Of the five 2014 - 2015, commissioning for quality andinnovation (CQUIN) requirements by the clinicalcommissioning group (CCG) all but one had been metby the hospital. These had included the friends andfamily test and ‘theatre time to starve’. This is the lengthof time between stopping a patient eating and drinkingand going to theatre for their operation. The latter wasnot met but significant improvement was reported bythe CCG.

• Three CQUINS had been agreed with commissioners for2015/2016 and included older persons and dementia

Surgery

Surgery

Good –––


champions, ensuring patients were adequatelyhydrated prior to theatre and staff training to ensurepatients received appropriate nutritional advice duringadmission.

• There had been no incidents of surgical sepsis in theprevious twelve months. Staff used a pro-forma fordocumenting patients’ physiological signspost-operatively with a clear pathway in place if thesigns were outside the normal parameters with apossible risk of sepsis.

• Comprehensive care pathways were in place for patientsundergoing any form of anaesthesia for surgeryincluding local and general. This included main qualityindicators of anaesthesia, management of pain andrecommendations for the management of postdischarge complications. This meant there was astandard system in place for each patient admitted.

Pain relief

• Prior to surgery patients were informed about painmanagement following their operation. This enabledthe patient to communicate effectively with staff andobtain the correct pain relieving medication followingtheir surgery.

• We were informed pain relief was given as routine ondischarge.

• The theatre care pathway ensured staff enquired aboutpain from patients and adequate pain relief given in atimely manner. On reviewing two patients post-surgerywe found neither of them were in any pain or distress.

• The hospital’s patient satisfaction survey for 2014indicated that 98% of patients thought staff dideverything they could to control their pain.

• The hospital was supported by a pain team from a localNHS acute trust with a pain specialist nurse available ifrequired.

• For patients requiring palliative (end of life) painmanagement support this was obtained from doctorswho worked at a local hospice.


• All patients were screened for malnutrition and the riskof malnutrition on admission. This included patientsattending for day-case surgery only for both local andgeneral anaesthetics. The tool used was theMalnutrition Universal Screening Tool (MUST).

• Staff followed guidance on fasting prior to surgery whichwas based on best practice. For healthy patients whorequired a general anaesthetic this allowed them to eatup to six hours prior to surgery and to drink water up totwo hours before.

• One of Spire’s objectives was to improve the hydrationof patients before they underwent surgery and to ensurepatients were encouraged to drink water up to twohours before they went to theatre. We were informedthat patients received a phone text message at homereminding them of the need to drink.

• One patient we spoke with had not received the textmessage and had not had anything to drink for threeand a quarter hours prior to surgery. However, weconfirmed that fasting instructions were providedverbally at pre-assessment and in writing in theadmission paperwork, so we were assured patientswere in receipt of the information and were not solelyreliant on the text messaging service.

• The hospital provided three meals a day for in-patients.Choices could be seen on the menus plus a daily‘special’. We were told the chef routinely saw all patientswho had been in hospital for longer than four days todiscuss any individual needs

• Special diets were catered for including vegetarian,Kosher and Halal foods

• If patients were unable to feed themselves staff wouldassist them.

• The ward kitchens had sufficient food stocks to enablestaff to supply sandwiches, soup, toast and cereals ifpatients were hungry at any time.

• A white board in ward kitchens indicated those patientsrequiring special diets.

• Nurses informed us of patients they would refer to adietician; these included those with a weight loss orpatients receiving treatment for cancer.

• Nutrition and hydration prompts were part of therounding charts in use by staff on the ward to ensuretheir patients were safe and comfortable.

Patient outcomes

• Under a service level agreement with a local acute NHStrust, twelve patients had been transferred in the yearApril 2014 to March 2015 because of post-operativecomplications.

• For the time period July to September 2014 theproportion of unplanned transfers was found to be

Surgery

Surgery

Good –––


‘similar to expected’ when compared to otherindependent acute hospitals we hold this data for.However the rate had increased between January andMarch 2015.

• There had been 18 cases of unplanned readmissionwithin 29 days of discharge in the reporting period April2014 and March 2015. CQC had assessed the proportionof unplanned readmissions to be ‘similar to expected’compared to other independent acute hospitals wehold this data for. There had been a falling rate ofreadmissions over the same period.

• The hospital took part in six national audits focussing onpatient outcomes; these included the national jointregistry and surgical site infection rates.

• Patient reported outcome measures (PROMS) for NHSpatients only for the period April 2014 to December 2014assessed patient outcomes for the repair of groinhernias were better compared to the England average.For hip replacements the results were similar toexpected.

• Patients did not leave the hospital after their procedureuntil they had received a discharge letter for their GP.This ensured the GP knew as soon as possible of theprocedure and any further treatment required.

Competent staff

• The provider had put systems in place to ensurequalified doctors and nurses’ registration status hadbeen renewed on an annual basis.

• However, shortfalls were found in hospital wideconsultants’ information; with the exception ofconsultant staff working with children and young peopleand termination of pregnancy services. Informationfrom the hospital weekly compliance report identifiedthe required documentation for hospital wideconsultants. The information showed that on 11 August2015 84% of consultants had received a practiceappraisal and 71% had received a biennial review.Information was not available for consultant GeneralMedical Council (GMC) registration status for the 11August. However, the compliance level for GMCregistration for the 7 August 2015 was identified as 98%on the weekly compliance report.

• Although the percentages of compliance had increasedsince 15 April 2015, the provider acknowledged thatfurther work was required to ensure all consultantsprovided evidence of all the required documentation.

We spoke with a senior manager who informed us ofactions that would be put in place immediately toachieve compliance and mitigate risk. The Consultant’sHandbook stated that consultants were at risk ofsuspension if they did not provide up-to-datedocuments.

• By the 20 August 2015, 84% of consultants had providedall the required documentation. Thirty-four consultantspractising privileges were suspended until thedocuments were submitted to the hospital. Staff hadbeen made aware of whom the consultants were.Since 20 August 2015, the provider confirmedthat compliance has remained at 100% at all times inrelation to the collection of this information and that allmedical staff were fully insured during the CQCinspection, despite shortfalls having been observed inthe collection of this data.

• The percentage of staff that had an appraisal in 2014was 94%. We reviewed three appraisal documents andfound the template used for this purpose had been fullycompleted. Personal objectives had been added tostandard corporate ones and there was evidence ofone-to-one meetings with line managers.

• For consultants with practising privileges, thecompliance lead in the hospital kept a record of theiremploying NHS Trust together with the responsibleofficer’s (RO) name. The term “practising privileges”refers to medical practitioners being granted the right topractise in a hospital.

• Applications for practising privileges from consultantswere granted or rejected by the Medical AdvisoryCommittee (MAC) of the provider. This involved checkingtheir suitability to work at the hospital, checks on theirqualifications as well as references and disclosure andbarring checking with the Disclosure and Barring Service(DBS). There was a system in place to ensure doctorshad undergone revalidation.

• We looked at data relating to the numbers ofconsultants who had undergone an appraisal in theprevious year undertaken by their primary employingtrust; this was 84%.

• We were informed there had been no competencyissues with regard to any of the consultants working inthe hospital. There were processes in place for all staffworking for the provider to ensure issues were dealt

Surgery

Surgery

Good –––


with appropriately. The responsible person for medicalstaff at the employing NHS trust would be contacted ifconcerns regarding a consultant’s working practiceswere raised.

• A group of nurses within the hospital had been set up toreview the processes required for nurse revalidation forthe Spire group of hospitals. Validation is a process thatall nurses and midwives will need to undertake todemonstrate they practise safely and effectivelythroughout their career in order to protect the public; itwill commence in April 2016. The group had developeda draft version of a portfolio for nurses to use to helpthem in the revalidation process.

• A formal comprehensive induction system was in placefor new staff which included local induction for thedepartment/ward they were working in as well as twodays clinical training. Induction included responding toa cardiac arrest, infection control and reporting adverseevents. The clinical training programme was on-goingand held monthly; existing staff were required to attendevery year as part of their mandatory training. Thetraining programme was updated on a regular basis andat the time of inspection included nurse revalidationand prevention of thromboembolism. Staff remainedsupernumerary (additional to the rostered staff) forthree weeks. New staff were expected to complete theirinduction programme and be signed off as competentwithin this timescale.

• Competency programmes were available for all groupsof staff on the provider’s intranet system including coreand specific competencies. For example, for qualifiedstaff one of the extra competencies was bloodtransfusions. Staff were not permitted to undertaketasks until they had been deemed competent to do so.

• The provider was reviewing requirements for carecertification for health care assistants. At the time of ourinspection there was no National VocationalQualification training offered to care assistants whowere new into the role. Formal documentedassessments on their competencies were undertakenfollowing induction and a mentor was assigned to allnew care assistants.

• Staff were able to access additional training to ensurethey kept up-to-date and acquired additional skills toensure good quality care for patients. We reviewed a listof additional training that had been completed in 2015or been booked to attend either on site or externally.These included transfusion, recovery skills and crisis

management and palliative care. Staff theatres andwards had been identified. A staff member we spokewith told us there was always a lot to learn because ofthe different patient’s needs they cared for but thatsenior staff were always approachable if they requiredhelp.

• The critical care lead nurse for the hospital was able toaccess the local acute trust to keep updated withclinical practice and have competencies assessed.

Multidisciplinary working (in relation to this coreservice only)

• A multidisciplinary review was held for any patientrequiring it and referrals were made to an acute trustwhen necessary.

• Specialty oncology nurses were involved in themeetings if this was appropriate.

• A team brief was held in theatre prior to each listcommencing. These were brief face-to-face meetingswith staff involved in the operating list. Any concernsabout safety and the forthcoming operating list werediscussed. The meetings were not documentedalthough we were informed there were plans for this inthe future. Following our inspection we were informedby the provider this had commenced.

• A physiotherapy service was available in the hospital.This was provided by a team of qualified professionalswho saw all patients requiring physiotherapy input, forexample following joint surgery. Physiotherapists wespoke with felt they were providing a good service forpatients.

Seven-day services

• The hospital had four operating theatres and a minorprocedures theatre which were utilised between fiveand six days a week. An on-call rota was in place for staffable to attend quickly if a theatre was needed on aSunday or out-of-hours.

• On-call arrangements were in place to ensure patientshad speedy access to services.

• Physiotherapy services were provided seven days aweek and an on-call system was in operation if theywere required out-of-hours.

• Consultants were responsible for the care of theirpatients from pre-admission consultation until theconclusion of their episode of care.

Surgery

Surgery

Good –––


• Medication could be prescribed and dispensed topatients prior to their discharge. This was available at alltimes the hospital was open. A pharmacy on-call systemwas operated to provide a seven day service whenrequired.

• Patients had access to the hospital and its staff 24 hoursa day as an inpatient and following their discharge whenit was required.

• Other services, for example x-ray facilities were on-callout-of-hours and equipment engineers were called forwhen it was necessary.

• We spoke with a consultant about supporting servicessuch as histology and pathology. They told us bloodtests were returned very quickly, mostly the same daybut that histology (tissue specimens) results could takeup to two or three weeks unless they were marked‘urgent’. In that case they were returned within three orfour days.


• For some patients referral notes from a GP wereavailable with comprehensive patient information priorto their initial consultation. For example, NHS e-referral’patients. This ensured the hospital had the informationrequired to make informed judgements about patientcare.

• Patients were required to complete a comprehensivepre-admission questionnaire prior to surgery whichincluded their past medical history and their currentmedicines. Dependent upon a patient’s history, patientsmay be requested to undertake a physical face to facemeeting with assessment staff where a number ofinvestigations could take place, for example, anelectrocardiogram or ECG. This would provide healthprofessionals information of the patient’s current stateof health.

• For some private patients who had previouslyundergone surgery the assessment team requested thepatient’s permission to contact their GP for furtherinformation. This meant care could be tailored to anindividual patient’s needs to ensure it was safe becausethey had access to the information required.


• The provider had a consent policy and staff we spokewith were aware of it. Within the policy was a section onensuring the patient could make informed consent totreatment and what to do if they were unable to do so.

• A senior member of staff informed us the hospitaloccasionally treated patients who they were concernedlacked the capacity to make informed choices or giveconsent. Staff knew what to do in those circumstancesand how to document it.

• Staff we spoke with had received training about consentand the Mental Capacity Act 2005 (MCA). Staff stated ifthey had concerns about a patient’s capacity they wouldrefer the issue to a senior member of staff. Seniormembers of staff were aware of their responsibilitiesunder the Mental Capacity Act 2005.

• We reviewed three consent forms. All had beencompleted appropriately although one relative hadacted as an interpreter prior to the signing of theconsent.

• Patients we spoke with informed us they were given asmuch information as they required from their consultantprior to their operation to give informed consent to theprocedure and any risks had been explained to them.

• In the past twelve months, the hospital had referred onepatient for a Deprivation of Liberty Safeguard (DoLS)which had been granted. DoLS is part of the MentalCapacity Act 2005. This aims to make sure that people insuch places as care homes and hospitals are lookedafter in a way that does not inappropriately restrict theirfreedom. The safeguards ensured the hospital onlydeprived the patient of their liberty in a safe and correctway. The application was undertaken because it was inthe best interests of the patient and there was no otherway to look after them.

Are surgery services caring?

Good –––

All the patients and relatives we spoke with wereoverwhelmingly positive about the care they had receivedand the way staff treated them. We observed staff speakingin a friendly and polite manner to patients and treatingthem with dignity and respect as well as providingemotional support when required. Patients told us theywere involved in their care and staff explained care and

Surgery

Surgery

Good –––


treatment in a way they understood. The provider hadachieved high scores in patient feedback from the NHSFriends and Family test and the hospital’s satisfactionsurvey.

Compassionate care

• All the patients and relatives we spoke with were verycomplimentary about the staff and gave us positivefeedback about the care they received. One patient toldus ‘all the staff are fantastic, nothing is too muchtrouble’; another said the care they had received was‘outstanding.’

• Staff spoke to patients in a polite and friendly manner.• Several of the staff we spoke to said they had the time to

talk to their patients and were able to give the care theywanted to. One nurse spoke of how rewarding her rolewas and that it made her proud to be a nurse.

• The hospital supported the 6Cs initiative. The 6Cs is anational initiative to promote care, compassion,competence, communication, courage andcommitment. We saw posters displayed promoting the6Cs, and some of the nursing staff were able to talk to usabout it.

• Patients told us staff treated them with respect and theirdignity was maintained. We observed nurses knockingon room doors before entering and waiting for aresponse before entering. The hospital conducted apatient satisfaction survey every month and betweenJanuary 2015 and June 2015 at least 98% of patientssaid they had always been treated with respect anddignity.

• Patients also told us the staff had time to care withoutrushing and patients felt their wellbeing really matteredto staff.

• The NHS ‘Friends and Family Test’ is a satisfactionsurvey that measures patients’ satisfaction with the carethey have received and asks if they would recommendthe service to their friends and family. For the periodOctober 2014 to March 2015 around 80% of patientswho completed this would recommend this hospital.Response rates for this period were between 20% and40%. The monthly hospital survey asked the samequestion and for the period between January 2015 andJune 2015 this survey showed that at least 98% ofpatients would recommend the hospital to their friendsand family. It can therefore be seen that there is adifference of 18% who would recommend the hospitalin the two questionnaires.


• Patient records we looked at included a preadmissionassessment that took into account individual needs andpreferences for example dietary requirements.

• Patients and relatives told us they had felt involved intheir care. They told us they had received fullexplanations of all procedures and the care they wouldneed following their operation. The hospital’s patientsatisfaction survey, for the period between for January2015 and June 2015 showed that between 88% and 94%of patients said they were involved as much as theywanted to be in decisions about their care. We observedstaff explaining to patients exactly what would happenafter their operation and we saw examples of writteninformation that was given to patient’s to take home.

Emotional support

• We observed staff giving reassurance to patients. Forexample we witnessed staff encouraging a patient asthey mobilised for the first time following knee surgery.During our visit one of the patients required extraemotional support, we saw a nurse spend time with thispatient and made arrangements for their priest to visit.

Are surgery services responsive?

Good –––

Access to care and treatment was monitored and exceededthe national average. Staff acknowledged patient’sindividual needs and responded to them in an appropriateway although we were not assured a suitable translatorwas always obtained for patients whose first language wasnot English. Staff had a good understanding of thecomplaints process and the hospital learned fromcomplaints, changing care practices if required.


• The hospital had been established in 1989 under theownership of a different provider as a purpose builtprivate hospital. In 2007 the hospital changedownership. Whilst the focus had remained on the core ofprivate patient business, the hospital had attracted

Surgery

Surgery

Good –––


additional NHS patients through local contracts withNHS trusts and commissioners in Leicester. This hadresulted in local people receiving timely interventionsfor their required procedures.

• Equality and diversity training for staff meant the diverseneeds of all patients were met.

Access and flow

• The national standard for referral to treatment (RTT)time states that 95% of patients should start consultantled treatment within 18 weeks of referral. Data showedthat between April 2014 and March 2015 100% ofpatients were seen within this 18 week target.

• Appointments for surgical procedures were routinelymade on the same day as the patient saw theconsultant at their initial outpatient appointment.

• Occupancy rates in the in-patient area were below ‘full’at all times between April 2014 and March 2015. Thismeant any day-case patients who were not fit enough togo home on the day of their surgery were able to stayovernight.

• Only qualified nursing staff who had been trained orwere competent in the process undertook pre-operativeassessments of patients.

• All pathways stated the average length of stay a patientshould experience for the procedure they hadundergone. Staff told us this was generally achievedwith the good care and treatment they were able to givepatients. However, if complications occurred the timecould be extended.


• Relatives were able to stay with their loved onesovernight if this was required; a collapsible bed wasprovided for them.

• The hospital used representatives from an interpretingcompany based locally for accessing interpreters forpatients whose first language was not English.

• A patient information leaflet “Pain relief after youroperation,” was handed to patients prior to theirsurgery. It explained the different types of pain relief andhow they could be administered.

• Staff informed us they had many colleagues who couldspeak different languages and who were often used toact as interpreters when required.

• We saw a care plan for a patient whose first languagewas not English; this had been completed appropriately

and indicated a family member would translate forthem. Documentation stated that they had been rung toensure the patient received the correct meal. The use offamily and carers is not considered good practice whenclinical issues are discussed.

• In the same care plan documentation was in place thatconfirmed the patient had signed a consent form toreceive blood. It was not signed by the translator who,we were informed had been present when consent hadbeen given. This would indicate the patient may nothave understood what they were signing for as thetranslator was also required to sign the consent form aspart of the process.

• Any information leaflets given to patients were inEnglish only. A member of staff told us they could obtainleaflets in other languages if required.

• Specialist nurses for specific patient groups wereavailable, for example, stoma care and breast care,although a diabetic specialist nurse was not available.The endocrinologist would be made aware of anydiabetic patient admitted.

• We saw that patients with specific needs for example,poor mobility, had been individually assessed, theirneeds addressed and documented.

• All people over the age of 75 had been assessed fordementia as part of the hospital’s targets forcommissioning for quality and innovation (CQUIN)requirements. Any patient with a raised score wasreferred back to their GP for follow-up.

• Patients living with a dementia were able to have theirmain carer present for most of their treatment.

• A senior member of staff had set up a new dementiagroup in the hospital six months prior to our visit.Personnel included patient services staff, housekeepers,the resident medical officer and nursing staff. The grouplead had undertaken training for chefs andhousekeeping staff to raise their awareness of thecondition and improve the care for patients living withdementia by teaching staff how to respond to them.

• Although there was no room available specificallyequipped for patients with a dementia, plans were inplace to develop one during the refurbishmentprogramme.

• Signage in all areas was small and only in English whichcould have proved a challenge for those with poor sightor whose first language was not English. The providerinformed us after the inspection that patients werecollected and accompanied by a member of staff from

Surgery

Surgery

Good –––


the waiting area to the department they were visiting.Visitors were directed by reception staff to the area theywished to visit verbally and were accompanied whereadditional assistance was required.

• A pastoral service was available for patients to providesupport for families and their relatives if required. Thisalso included an out of hours service when necessary.

• The provider informed us key members of staff hadreceived training in breaking bad news to families; wedid not speak with any of those staff during our visit.

• The hospital had a chaperone policy in place. Staff wespoke with told us that almost every time a chaperonewas required they were asked to assist. However,occasionally they did not realise doctors were presenton the wards and doctors did not always approach staffto provide a chaperone.

• Staff could access social services support to aid patientswith discharge arrangements if required Staff informedus they received a good service when this was used.

• Patient information leaflets, followed national guidanceand were available for those surgical proceduresundertaken at the hospital.


• The provider had received 77 complaints from patientsor relatives in 2014. They had policies and procedures inplace relating to complaint handling. This includedensuring all complaints were logged and reported.

• Complaints leaflets were available (‘Please talk to us’)for patients to use when required. It explained the threestage process used for complaint handling.

• Staff informed us they would speak to anyone raising acomplaint at the time they raised it. The aim was to tryand resolve the issue at the earliest opportunity.

• A senior manager from the hospital wrote to allcomplainants, reviewed the complaint and sent awritten response after an investigation had beencompleted.

• There was an expectation that complaints would beresolved within 20 days. If they could not, a letter wassent to the complainant explaining why.

• The Clinical Governance Committee reviewed allcomplaints and discussed possible trends. If thecomplaint involved a consultant this was raised with thechair of the Medical Advisory Committee (MAC) to takeforward.

• Complaints were discussed with all members of staffwith any learning points identified and addressed. Themeant the hospital learned from complaints andimproved services where appropriate.

• The hospital’s Medical Advisory Committee regularlyreviewed all complaints involving a clinical element.

• Complaints were discussed in the provider’s qualityreport. The report dated June 2015 reviewed 13complaints. Any actions taken to respond to the issuesand changes of practice were documented.

Are surgery services well-led?


Shortfalls were found in hospital wide consultants’information; with the exception of consultant staff workingwith children and young people and termination ofpregnancy services. We escalated these findings to theprovider who acknowledged that further work was requiredto ensure all consultants provided evidence of all therequired documentation. Immediate actions wereimplemented by a senior manager to achieve complianceand mitigate risk. Despite this, by the 20 August 2015, 84%of consultants had provided all the requireddocumentation.

However the hospital had a governance system in placewhich included an audit system. Morale was excellent withstaff talking positively about the organisation and theirlocal management team. Staff felt listened to andsupported.

Vision and strategy for this service

• The staff we spoke with were aware of the provider’spurpose; providing excellent individualised care to allpatient and generating income.

• Staff were aware of the plans for refurbishment in 2015/16 and looking forward to it. No date had been set forthe commencement of this work. Since our inspectionwe have been informed the work commenced on 1October 2015.

• Senior staff had knowledge of a new contract awardedto the hospital, which would mean additional servicesbeing required for children and young people. Plans forthis were just beginning.

Surgery

Surgery

Good –––


Governance, risk management and qualitymeasurement

• Shortfalls in the receipt of medical staff informationwere monitored by the hospital. These shortfallsincluded up to date information on whole practiceappraisals, medical indemnity, disclosure and barringchecks, biennial review and General Medical Councilregistration expiry dates. We escalated these findings tothe provider who acknowledged that further work wasrequired to ensure all consultants provided evidence ofall the required documentation. A senior managerinformed us that actions would be put in placeimmediately to achieve compliance and mitigate risk.Despite this, by the 20 August 2015, 84% of consultantshad provided all the required documentation.Thirty-four consultants practising privileges weresuspended until they had submitted their documents tothe hospital.

• A rolling programme of monthly audits was in place forexample, five steps to safer surgery checklists andinfection control. The results showed consistent highlevels of completion.

• The hospital had a governance process in place as laidout in the clinical governance and quality assurancepolicy dated October 2014, which incorporated thegovernance structure and reporting channels.

• Eleven different staff groups met to discuss issuesrelated to incidents, risk, complaints management andclinical audits. These groups included the hospital’smedical advisory committee and clinical governancecommittee. The latter fed into the provider’s executivemeetings and upwards to the Board. All staff groupswere represented.

• Team meetings were held in each department and wardincluding theatres. These were used for the passing oftwo-way information. Staff forums gave staff theopportunity to raise issues.

• The risk register was up to date. It documented a namedindividual responsible for the actions taken to reducethe risk with a review date. The risk register wasmonitored through the clinical governance committeemeeting.

• The clinical governance meeting was held monthly andincluded items such as medicines management, healthand safety and infection control.

• There was a positive working relationship with thecommissioners of the service, a local clinical

commissioning group (CCG). Senior managers met withthe commissioners quarterly to review the hospital’sperformance via their results of specific measuredoutcomes for quality and innovation (CQUIN). ThreeCQUIN’s were in place for the year 2015/16. The hospitalprovided the CCG with a monthly report on the progressof the CQUIN’s.

• The last visit by the local CCG was in May 2015. Actionshad been highlighted including the documentation ofthe volume of fluid taken by a patient pre-operativelyand ensuring temporary closure mechanisms were usedon sharps bins; these had been actioned.

• The matron was aware of the new regulation relating toDuty of Candour and was aware of their responsibilities.She was able to assure us the hospital viewed their dutyseriously and was able to give an example of where thehospital had apologised to a patient following anaccident although the patient had not suffered anyserious injury.

Leadership of service

• Team leaders were available in all areas of the hospitaland were visible to staff. Staff told us they knew who toapproach if they had any concerns and would nothesitate to do so.

• The hospital had a matron and medical director whoprovided professional leadership for all clinical staff.Both of those members of staff were visible and staffinformed us of their ability to approach them withoutquestion for guidance and support when necessary.

• All the staff we spoke with described both members ofthe senior team as having adopted an ‘open door’policy.

Culture within the service

• Staff we spoke with told us of their commitment toproviding safe, compassionate and caring services totheir patients. They spoke positively about the morale inthe hospital and the care they delivered; we saw thiswhen undertaking observations Staff said that althoughat times they could be very busy they felt they had thetime to care for their patients on an individual basis; thiscreated a calm atmosphere in the hospital whichbenefited both patients and staff. Staff felt valued andinvolved in operational changes and told us they wereproud to work at the hospital.

Surgery

Surgery

Good –––


• There was an open culture in the hospital withnon-medical staff feeling able to speak to medical staffon an equal footing.

• We viewed the staff safety culture survey results for2014. Two of the top scoring items included peersupport for staff (86%) and ensuring patient safetyissues were resolved to prevent any reoccurrence (85%).The five bottom scoring items had actions to addresseach of them. These included not having enough staff tohandle the workload (46%) and staff feeling able toquestion the decisions of actions of those with moreauthority (63%)

• We viewed the results of the staff survey for 2014.Topscores included the fact that staff believed that whatthey did at work made a positive difference to thehospital (98%) and 94% of staff got personal satisfactionfor the work they did. Only 39% thought otherdepartments understood the impact their action had onanother staff team and 65% thought senior managersprovided the rationale for decisions that impacted on amember of staff.

• As a result of the 2014 staff survey the hospital hadincreased its staff by 11.8 whole time equivalents inresponse to comments made. The 2015 staff survey willbe undertaken later in the year.

• The provider had an equal opportunity policy in place.


• The matron informed us it had been difficult to involvepatients as much as they would like to. Phone calls hadbeen made to many ex-patients and a new patient focusgroup had been set up with three ex-patients; two morehad been recruited prior to our visit. Two meetings hadbeen held to help resolve any concerns raised bypatients.

• Staff had encouraged patients and visitors to visit anewly refurbished room on Ward 2 to receive theirfeedback on décor and layout. Some patients had beenasked to stay overnight in the room. Their commentshad been noted and would be taken into considerationprior to the final design of the new rooms being decidedupon. Matron informed us the taps would be alteredbecause of feedback received.

• A senior member of staff informed us the relationshipbetween the local Healthwatch group and the hospitalwas very good. Healthwatch had not received anycomplaints relating to the hospital.

Innovation, improvement and sustainability

• Two senior nurse managers were developing a scorecard for the hospital which all departments will use toaudit outcomes on a monthly basis for such issues ashigh impact interventions, cannula care, wound careand hand hygiene. Any low score areas will be targetedfor improvement. The small team were hopeful that thiswill be rolled out corporately.

Surgery

Surgery

Good –––


Safe Good –––

Effective Requires improvement –––




Information about the serviceSpire Leicester Hospital established its service for childrenand young people in 2013. The hospital offers limitedoutpatients consultation services for children under three.Services available to children and young people from theage of three to 18 include outpatient consultation,diagnostic testing, day case, overnight surgery andphysiotherapy. The hospital did not offer critical or urgentcare for children and young people.

From January 2014 to December 2014, the hospital held148 outpatients appointments for under threes, 1796appointments for three to 15 year olds and 806appointments for 16 and 17 year olds. Children’sappointments were equivalent to approximately 3% of thehospital’s activity.

Most children came into the hospital as outpatients. In2014, 12 patients who were under 16 stayed overnight asinpatients and 55 had day-case procedures. This was a 52%increase on 2013 activity levels. Many of the day caseadmissions were for ear, nose and throat (ENT) operations.There were 1313 paediatric outpatient first attendancesand 1340 outpatient follow ups.

There were no wards or waiting areas specifically forchildren. Instead, staff adapted existing adult bedroomswith child or young person friendly duvet covers and books.

We spoke with nine parents, the lead paediatric nurse,three staff nurses, the critical care lead, an anaesthetist,one of the lead paediatric consultants, the matron anddeputy matron.

Summary of findingsThe children’s service had a good track record on safety.The hospital safeguarded children and young peoplethrough offering care tailored to their needs. If a childwas admitted overnight, a paediatric consultant and achildren’s nurse stayed on site to look after them. Staffworking with children were qualified to ‘NationalSociety of Prevention of Cruelty to Children’safeguarding level three, in line with good practice. Thechildren’s nurses had specialist training in paediatric lifesupport and the lead nurse promoted skills in nursingchildren.

The hospital routinely conducted a range of riskassessments and there were procedures to treatchildren whose health was deteriorating after anoperation. However, some of these risk assessmentswere not signed or fully completed.

The hospital lacked specific waiting areas andconsulting rooms for children, but staff minimised therisk of mixing with adults.

The children’s services were relatively new and did nothave a quality dashboard to monitor their performanceover time. They had not developed systems to carry outbenchmarking or clinical audits, which limitedorganisational learning. However, since the inspectionwe have been informed that a children’s qualitydashboard has been implemented.

Parents said their children received compassionate care.They said the hospital gave them good information andinvolved them in decisions about their child’s treatmentand care. Child friendly information was available for

Servicesforchildrenandyoungpeople

Services for children and youngpeople

Good –––


children about their procedures, nurses and consultantsencouraged them to ask questions about their care.Nursing staff offered children and parents emotionalsupport when needed. The hospital planned care forchildren taking into account emotional, spiritual, social,mental and physical needs.

Children’s and young people’s services were responsiveand provided access at times to suit children, youngpeople and their parents.

Nurses encouraged children to keep in touch withfriends and family and the hospital provided beds inchildren’s rooms and a meal if a parent wanted to sayovernight. The service was sensitive to children who hadbeen inpatients and introduced them to theenvironment through a visit and a pre-assessmentappointment, so that everything would be familiar.Nurses and consultants ensured that children who hadbehavioural challenges also felt at home and werecared for well.

The service had a vision for expansion in the future.There was a positive culture and staff showed clearmotivation to do their best for children and youngpeople. There was a good risk management structureand children’s nurses worked well with consultants todevelop policies and plan services.

Are services for children and youngpeople safe?

Good –––

We judged safety as good. Children were protected fromavoidable harm and the service had a good safety record.The safety incident record for children and young peoplewas good. The service was very new and had only treated asmall number of children and no clinical incidents hadoccurred at the time of the inspection visit. However,discussions with staff confirmed that they were aware ofhow to report incidents and would not hesitate to do so.

The hospital safeguarded children and young peoplethrough offering care tailored to their needs. If a child wasadmitted overnight, a paediatric consultant and achildren’s nurse stayed on site to look after them. Staff weretrained to level three in safeguarding, the appropriate levelfor treating children. Although there were no children onlywaiting rooms or consulting rooms, staff accompaniedchildren through the process, limiting the risk.

The children’s nurses had specialist training and the leadnurse promoted skills in nursing children, trainingnon-specialist nurses in paediatric lifesaving skills. Theservice had a good safety record and there had been noserious incidents involving children or young people. Therewere procedures to treat children whose health wasdeteriorating after an operation. A range of riskassessments were in place. However, these riskassessments were not always fully completed or signed. Wealso observed information gaps in fluid charts and theabsence of consultant signatures on either the preliminarydischarge letter or young person’s risk assessment. Thehospital had not audited medical records for children.

There were no specific protocols for children or youngpeople who had mental health problems or learningdisabilities.

Incidents

• The safety incident record for children and youngpeople was good. The service was very new and hadonly treated a small number of children and no clinical



Good –––


incidents had occurred at the time of the inspectionvisit. However, discussions with staff confirmed that theywere aware of how to report incidents and would nothesitate to do so.

• Managers could not identify any clinical incident, whichhad involved a child or young person. The hospital’sadverse event reporting system contained onenon-clinical concern relating to children. We saw thatstaff had taken the appropriate action in relation to thisincident, which resulted in learning and a change inpractice for the x-ray service. The change of practice wasto ask patients and parents to leave their mobile phonesor cameras outside the x-ray suite. The serviceimplemented this to ensure that children and youngpeople’s dignity was respected while they wereundergoing procedures.

• The service did not hold children’s and young people’smortality and morbidity meetings. This was because thehospital specialised in straightforward procedures andoperations for children, such as ear, nose and throatprocedures.

• The lead children’s nurse received national patientsafety alerts for children. So far, they had not receivedissues of relevance to the hospital. For example, therewas an alert regarding coin batteries in children’s toys,but the hospital had no toys of this type.

• The hospital held a briefing session on the ‘Duty ofCandour’ and nurses at all levels were clear about this.They told us they would have to explain, and apologiseto the patient and their parents if nurses or cliniciansmade a mistake. They would also have to rectify themistake if they had not done so previously. However,this situation had not arisen.


• The outpatient’s area and equipment used for childrenappeared visibly clean; as did the recovery area, wardareas and the children’s soft play area in outpatients.

• The hospital’s facilities contractor cleaned the toys inoutpatients every day, and recorded this. The leadchildren’s nurse cleaned before and after each use, thetoys she used with child inpatients. The hospital did nothave a cleaning policy specifically for toys, but all toyswere cleaned daily in outpatients and between eachinpatient use.

• We observed nurses in outpatients and wards usinghand gel frequently and washing their hands before andafter seeing patients.

• Staff who worked with children had received onlineinfection control training but this was not tailored to thecare of children. The lead children’s nurse was the linknurse for infection control. She used hand washingcolouring packs with the children to encourage them towash their hands.

• The service worked well with parents on infectioncontrol. We saw patient literature tailored to children onaftercare, which explained how to help preventinfections after an operation. We heard from parentsthat nurses gave them verbal advice on keeping woundsclean.

• When we inspected, the hospital had not auditedchildren’s infection control.


• The outpatient’s service used an environmentalchecklist. This helped monitor whether toys availablefor children were compliant with national standards. Italso helped ensure that items such as sharps (syringes),medicines and cleaning products were properly storedout of the reach of children.

• Resuscitation trolleys contained specialist equipmentfor children. We checked all of the resuscitation trolleys,which were located in outpatients, Ward Two andrecovery. These included Broselow bags (bags withresuscitation equipment colour coded for children ofdifferent sizes.) All items were within their expiry date.

Medicines

• The hospital kept a range of medicines for use withchildren. We reviewed notes for three inpatient andthree day case children. Information on children’sallergies and analgesics (medicines to relieve pain) waswell completed in patient records. We saw that allchildren had a good range of post-operative analgesicsprescribed so that the nurse could respond quickly if achild was in pain. Allergies were clearly documented inpatient notes. Children’s weights were clearlydocumented, which ensured that a child would beprescribed the correct dosage of medication.

• The hospital had procedures to ensure the safety ofcontrolled drugs administration. The use of controlleddrugs required two qualified members of staff to checkthe medication and record this in the controlled drugbook. For children’s drugs, one member of staff had tobe a registered children’s nurse. The hospitalpharmacist told us that copies of the children’s ‘British



Good –––


National Formulae’ (BNF) for drugs were available inpharmacy, on the wards and in outpatients. We saw acopy in the outpatients consulting room, which meantstaff had access to the BNF for matters related toadministration of drugs for children.

Records

• We reviewed 16 sets of children’s notes and found thatrisk assessments such as for moving and handling weresometimes not fully completed or signed. Four recordsdid not have completed fluid charts. Five sets of notesdid not have consultant signatures on the youngperson’s risk assessment. The hospital had not auditedmedical records for children.

• There was a system in place to ensure that medicalrecords generated by staff holding practising privilegeswere available to staff or other providers who may berequired to provide care or treatment to the patient.

• Care plans and nursing assessments were in line withthe Nursing and Midwives Council guidance on recordkeeping. For example, they included notes ofconversations and information given to the child’sfamily.

Safeguarding

• The hospital checked in July 2015 whether itsconsultants had the correct level of safeguardingtraining to deal with children. Consultants could only begranted practising privileges (contracts enablingconsultants working in the NHS to work in privatehospitals) if they had correct and up to date training.The hospital confirmed that all 45 consultants who sawchildren at the hospital were qualified to level three in‘National Society for the Prevention of Cruelty toChildren’ safeguarding, in line with good practice.

• Children’s nurses including the lead children’s nursewho was the children’s safeguarding lead and thematron, had level three safeguarding trainingaccreditation

• The hospital set safeguarding standards for otherclinicians who worked with children. It stipulated thatanaesthetists who worked with children at the hospitalshould have level two safeguarding training, andconfirmed that this was the case. The hospital’sphysiotherapists who worked with children had levelthree safeguarding training, in line with good practice.

• Staff and managers discussed safeguarding issues atmonthly clinical governance and ward staff meetings, six

weekly theatre staff meetings and monthly Spire matroncluster meetings. None of the safeguarding events at thehospital involved patients under the age of eighteenyears.

• The hospital took measures to safeguard children andyoung people at risk of female genital mutilation (FGM).Spire Healthcare’ s corporate policy , the ‘Procedure forthe care of Children and Young People in SpireHealthcare’ outlined how staff should treat FGM as childabuse and make a safeguarding referral to the localauthority.

• The hospital also had a local policy ‘SafeguardingChildren and Young People’ written in June 2015. Thisclarified local standards and responsibilities, training,information sharing and multidisciplinary teamarrangements.

• The hospital had a clear response if a child wasabducted. The procedure for the care of childrenoutlined what staff should do if a child was missing. Ifstaff did not find the child within 15 to 30 minutes, thepolice and the safeguarding team would be alerted.There were also arrangements for children admittedunder a Child Protection Plan, which included protocolsfor safeguarded children. However, there were noelectronic alert systems to flag up children on the childprotection register. Children on the child protectionregister are those at risk of abuse or neglect. This meantthat this risk may not be immediately apparent to staff.

• Nurses were able to monitor child patients closely. Thehospital admitted a limited number of children andyoung people at one time, usually a maximum of four.The lead children’s nurse was able to supervise and carefor them personally.

Mandatory training

• The children’s nursing team received mandatorytraining to keep children safe. The hospital trainingtarget was to train 95% of staff on each mandatorysubject. The training year ran from January toDecember. The hospital’s records showed that thechildren’s nursing team achieved 66.7%During ourinspection, nurses told us that they were up to date,apart from one nurse who had not done two on-linemodules.

• The children’s lead nurse held the European paediatricintensive life support qualification. She was proactive in



Good –––


training other nurses on basic and intensive life supportfor children during the monthly training days. Sheattended Spire Group networking days to furtherenhance her knowledge.

• Clinical staff treating and caring for children had lifesupport training. Consultants and anaesthetists hadEuropean paediatric life support qualifications.Physiotherapists worked with children had Europeanbasic life support training.


• Spire Leicester used the provider’s corporate policysetting out criteria for admitting children, either for daycase procedures or overnight. This stated that thereshould be five days’ notice to parents of pre-assessmentand that pre-assessment should take place at least twoweeks before surgery. Clinicians carried out a clinicalrisk assessment at the same time as thepre-assessment. As far as possible, children had theiroperations as part of a children only list. The children’srecovery area was partitioned off, rather thancompletely separate.

• The hospital managed the risk of a child’s healthdeteriorating after an operation. They used thepaediatric early warning system (PEWS), which wasincluded in the patient’s notes. A flowchart andobservation guidelines were in use with the PEWsscoring to explain how staff needed to take action atvarious levels of risk. This ensured that a child was caredfor according to their condition, and was monitoredmore frequently or transferred to another hospital ifnecessary.

• If a child remained at a high PEWs score, had respiratoryor cardiac problems or excessive blood loss, the childwould be transferred to the local acute NHS trust forurgent care. The provider detailed in a local procedureon child transfer the circumstances when this wouldapply, the handover and relevant responsibilities.

• The hospital had risk assessment tools to addressfrequent child health risks. These were for deteriorationof a child patient under 16; chicken pox; child havingblood tests; and a child who may hurt themselves.However, there were no specific arrangements outlinedin the procedure for children or young people regardingchildren who had mental health problems or learningdisabilities.

• The imaging department had a protocol for childrenand their level of exposure to magnetic resonance

imaging and x- rays and relevant safe dosage levels. Theservice also maintained safety before x-ray exposure byroutinely checking if young female patients might bepregnant.

Nursing staffing

• Staffing arrangements were safe for children and metRoyal College of Nursing (RCN) guidelines. The childrenand young people’s service was staffed by a children’slead nurse, and a children’s recovery nurse in theatre.Another trained permanent children’s nurse was onmaternity leave when we visited. In addition, twochildren’s nurses worked flexible hours, on the ward andin the outpatients department.

• The service did not employ agency nurses. If the servicecould not ensure that staffing was at a safe level, it didnot admit children. When we inspected, the leadchildren’s nurse was on holiday and no children wereadmitted for inpatient treatment that week. If achildren’s nurse became ill during her duty, the hospitalwould transfer children out to the local acute NHS trustwhere safe staffing levels using children’s nurses couldbe assured.

• One parent stated that although the lead children’snurse appeared to be constantly present for thechildren, she did not have much time for a break. Thehospital was in the process of recruiting anotherchildren’s lead nurse. It recognised that staffing did notallow for an increase in child patient numbers or giveflexibility for cover.

Medical staffing

• Medical staffing for children was safe. All children werecared for by a named consultant at all times. A namedconsultant paediatrician was available for liaison andimmediate cover when a child was admitted.

• Staff told us that if a child or young person was admittedfor an operation, the paediatrician would stay at thehospital as long as the child did. This meant that if thechild stayed overnight, the paediatrician did too,providing out of hours cover. As a result, there wasalways a paediatrician available for liaison and advice,and who could treat the child within 30 minutes.


The hospital had a backup electricity generator so thatchildren’s services continued running during a power



Good –––


failure. The generator could cover essential services withone or two other functions such as x-ray machines andautoclaves. The generators were tested every month andserviced every six months.

Are services for children and youngpeople effective?


We judged effectiveness as requiring improvement.

The hospital did not have an identified children’s auditplan, which meant that it had not learnt from formalclinical audits, benchmarking or tracking clinical outcomes.The service did not have performance indicators tomeasure trends in the quality of services for children andyoung people over time.However, since the inspection wehave been informed that a children’s quality dashboardhad been implemented.

Multi-disciplinary team working resulted in positiveoutcomes for children. There was good partnershipworking with other organisations. Parents we spoke withwere very pleased with the outcomes for their children.Food for children was appetising and tailored to theirneeds. The service had access to x-rays and pharmacy forchildren 24 hours, seven days a week. There were cleararrangements for parents and children to consent tooperations and treatment.

The service benefitted from the NHS experience of itsconsultants and from networking with other Spirehospitals.


• Co-operative working and benchmarking within theSpire group helped to develop procedures and policiesfor children in Leicester. The lead children’s nursenetworked regularly with other Spire Hospitals withlarger and more established children’s services. Thisnetworking produced corporate policies such as the‘Procedure for the care of children’. However, becausemanagers agreed these policies shortly before ourinspection, the service had not had time to auditcompliance.

Pain relief

• The children’s lead nurse was responsible for children’spost-operative pain relief. She was qualified in palliativecare and the training had included several modules onpain control and pain relief. Pain relief training wasplanned for the other permanent full time children’snurse.

• The hospital had a pain management policy forchildren. Parents told us that nurses managed theirchildren’s pain well.


• The hospital provided food for children according totheir age, height and weight. There was an adaptedmenu for very small children. At pre-operativeassessment stage, the hospital asked the child andparents about dietary needs and preferences. Theytailored catering according to the child’s needs. Foodallergies were marked on a white board in the kitchen.

• After an operation, the child could choose to have apicnic box of easily digestible food. Typically this wouldcontain sandwiches on white or brown bread, a fruitbag, a packet of crispy snacks and a fruit juice. Thekitchens made sandwiches more exciting for children bycutting them into dolphin shapes. Parents we spokewith were satisfied that the food for children and youngpeople was attractive and nutritious.

• The hospital had clear pre-operation fasting guidelineswhich were listed in the ‘Procedure for Children andYoung People.’ Parents told us that consultants gavethem clear instructions on their child’s fasting at thepre-admission meeting.

• The hospital dietician worked with paediatric patients atthe local NHS trust and was available to provide adviceon paediatric dietary issues.

Patient outcomes

• The hospital set up the service for children and youngpeople in 2013. It started with small numbers of childrenand staff. So far it had not had enough nursing staff tocarry out formal audits on agreed guidance such as thatfrom the National Institute of Clinical Excellence (NICE)or the Royal College of Surgeons, for example onasthma or diabetes care for children. As a result theservice had not been able to learn from these andimprove practices.

• The service did not monitor patient outcomes and hadnot established quality monitoring measures. It lackedperformance indicators to measure trends in the quality



Good –––


of services for children and young people overtime.However, since the inspection we have beeninformed that a children’s quality dashboard had beenimplemented.

• Patients we spoke to were pleased with the outcomesfor their children. For example, they told us about atonsillectomy which resulted in easier breathing, and anoperation to correct folded ears, which boosted thechild’s confidence.

Competent staff

• We were informed there had been no competencyissues with regard to any of the consultants working inthe hospital. There were processes in place for all staffworking for the provider to ensure issues were dealtwith appropriately. The responsible person for medicalstaff at the employing NHS trust would be contacted ifconcerns regarding a consultant’s working practiceswere raised.

• The provider had put systems in place to ensurequalified doctors and nurses’ registration status hadbeen renewed on an annual basis.

• Nurses told us they had appraisals. These meetings tookplace at the beginning, middle and end of every year.The two permanent nurses at work had their appraisals,and the nurse on maternity leave would have an updateand appraisal meeting on her return. When we visited,they had received their January and June 2015objective setting and follow up. They thought themeetings were useful. They discussed hospital values,personal and organisational objectives and trainingneeds.

• The children’s nursing team were experienced registeredchildren’s nurses. The children’s lead nurse hadexperience with children with communication andlearning difficulties, and skills in paediatric bereavementand palliative care. The children’s outpatient’s nursehad extensive experience of caring for children inoutpatients settings.


• The service had a policy for the transfer of a sick child tothe local NHS trust, written in July 2015. This includedbriefing parents during pre-assessment about thepossibility of transfer. The policy outlined the urgentand non-urgent circumstances under which a childmight be transferred and handover arrangements.

• Multidisciplinary teams could be organised for childrenwith complex needs. The hospital had an agreementwith an external provider to organise quick assessmentsinvolving, for example, paediatricians, occupational andspeech therapists.

Seven-day services

• The lead paediatric consultant and lead nurse ensuredthat if a child was admitted overnight they were wellcared for. The clinicians stayed on site overnight, offeredreassurance to the children and could respond quickly ifneeded.

• Diagnostics services such as X rays and pharmacyservices for children were available seven days a week.The hospital had agreements with external providers toensure these were available.


• Children’s nurses encouraged the use of ‘Personal ChildHealth Records’ (Red books) so that parents had acontinuous record of their child’s growth anddevelopment, and could share the information withother health professionals. The lead nurse planned tostart their use with parents when the new babyimmunisation clinic opened in September 2015.

• We found that discharge forms were informative andtimely. Clinicians sent care summaries to a child’s GP,usually within two weeks, to ensure that childrencontinued to be cared for in the community.

Consent

• Staff understood arrangements for consent and therelevant legislation. The hospital had different rules forchildren and young people at different ages. Thehospital’s ‘Procedure for the Care of Children’ made thepatient’s best interests central to the process. If a youngperson was under 16 and wished to consent to theirown treatment, the treating doctor assessed whetherthe young person would have the maturity andintelligence (known as Gillick Competency) tounderstand the nature of treatments. They would givethe young person time to consider all the options.

• Consent forms were easy for patients for follow. Theparental agreement to investigation or treatment was inplain English and explained parental responsibility andwho could give consent. The child or young person



Good –––


could also add their signature to this form. There wasalso a ‘confirmation of consent’ box for the clinician tosign. We reviewed these forms, which were correctlycompleted.

• Nurses told us that if parents were not capable ofproviding consent, they would act in the child’s bestinterests. They explained that they would refer to theSpire Group’s Consent Policy and consult the group’slegal team.

• Parents told us the hospital gave them time to make aninformed choice about treatment. They could seekfurther advice if necessary and felt the process includedtheir child’s point of view. Clinicians offered parentshelpful information about their options. Parents told usthat the anaesthetist explained the process to thembefore the operation.

Are services for children and youngpeople caring?

Good –––

Parents said their children had received compassionatecare and they were fully informed and involved in decisionsabout their child’s treatment and care. Child-friendlyinformation was available for children about theirprocedures, and nurses and consultants encouraged themto ask questions about their care.

Nursing staff offered children and parents emotionalsupport when needed. The hospital planned care forchildren taking into account emotional, spiritual, social,mental and physical needs.

Compassionate care

• We spoke with 11 parents and/or guardians whoinformed us that the lead children’s nurse looked after amaximum of four or five children as inpatients; oftenthough there were only two or three children at any onetime. The nurse was able to supervise the children, playand sing with them and involve clinicians as needed.Parents told us the children’s lead nurse respondedquickly if their child was in pain or discomfort.

• We reviewed ten recent patient surveys, which childrenand young people had completed. Most patients werevery pleased with communication before, during and

after the treatment. Everyone who responded statedthat the nursing care was very good or excellent.However, one young person felt the nurse call buttonand pre-admission visit were poorly explained.

• We observed the children’s nurse and consultantinteracted very well with children who had come to thehospital for an operation. Nurses were compassionateand caring with children young people and theirrelatives.

• Staff respected the privacy and dignity of children andyoung people. No child was examined without achaperone present, in addition to the parent orguardian.


• Patient and parent feedback showed they were satisfiedwith communication and care. We heard from parentshow paediatric nurses were sympathetic andencouraging towards children and provided play,reassurance and advice.

• Information and support was provided in achild-friendly format to help children make decisionsabout their own care, including an attractive set ofleaflets for children about surgical procedures.

• Children, young people and their parents were involvedin care plans. We heard from parents that theydiscussed the options with clinicians for treatment andcare for their children going forward. This enabled themto weigh up the risks and advantages of a giventreatment.

• Older children were able to talk to a clinician withouttheir parent(s) present. The hospital had a clear policyon consent at different age ranges, and that 16 to 17year olds were entitled to withhold consent. Thetreating doctor would have to decide whether the youngperson had the competence to make their own decision.

Emotional support

• Staff provided emotional support. Children came to thehospital on pre-operative familiarisation visits wherethey met nurses, clinicians and the anaesthetist. Thiswas important in reducing their anxiety when they wereaway from home. One of the paediatric nurses was onhand to play with children who were scared or upset.



Good –––


We heard from parents how the paediatric lead nursesupported and reassured them at sensitive times, forexample if their child was slow to recover fromanaesthetic.

• Parents told us that consultants tailored services to thechild or young person and took a range of emotional,spiritual, mental and physical factors into account. Oneset of medical records we reviewed included a schoolreport and details of hobbies such as yoga. This ensuredthat consultants were able to better focuspost-operative care.

• Consultants and managers explained the options andpossible timescales to parents without exerting anypressure, ensuring that parents could decide abouttreatment in a measured and unhurried way.

• Staff had not had experience in breaking bad news toparents as the service carried out routine low riskoperations. The lead nurse had bereavement andpalliative training and the hospital had a psychologyteam, which could offer additional support.

Are services for children and youngpeople responsive?

Good –––

Children’s and young people’s services were responsiveand provided access at times to suit children, young peopleand their parents. Nurses encouraged children to keep intouch with friends and family and the hospital providedbeds in children’s rooms and a meal if a parent wanted tosay overnight.

The service was sensitive to children who had beeninpatients and introduced them to the environmentthrough a visit and a pre-assessment appointment, so thateverything would be familiar. Nurses and consultantsensured that children who had behavioural challenges alsofelt at home and were cared for well.


• The hospital was developing its services aroundchildren’s needs. We heard about the plans for a newbaby clinic and immunisation service, starting withmeningitis B vaccination in September 2015. Staff hadreceived training to give these vaccinations.

• The hospital had also won an additional contract and itestimated that this would lead to 50 extra childadmissions each year. It planned to expand children’sday care services, particularly ear nose and throat (ENT)treatment, optometry and squint surgery. We observedthat staff offered refreshments to patients and theirfamilies. In the main outpatient waiting area, there wasa children’s soft play area, which was brightly colouredand visibly clean. It also had books and access to atelevision. Staff provided toys on request.

• Existing facilities were not suitable for children’s care atthe hospital, given the need to expand due to the newcontract. Managers recognised this and planned toconvert an area at the back of Ward One to a children’sward with four beds, and to create a children’s waitingroom in outpatients.

• We saw from medical records that the service workedeffectively with other health providers, for example,occupational therapists, schools and speech therapists.This enabled them to provide a holistic treatment,which worked for all aspects of a child’s life.

• At Spire Leicester, most of the procedures were routineday casework such as ENT operations, with very fewchildren staying overnight.

• Parents told us that consultants and managersdiscussed cost issues with them in a sensitive manner,and informed them of their options.

Access and flow

• The hospital offered good access for children’s routineoperations. Outpatient’s clinics were available in theevening as well as during the day. Children could haveoperations during the school holidays. Consultantscould also perform day case procedures at short notice,providing there was sufficient time for the pre-operativeassessment.

• The hospital had a policy for admitting children, and theprocess was different from the adult pathway. Childrenhad an appointment with the consultant, then a furtherappointment for pre-assessment and familiarisation.

• The paediatric service did not routinely measure howlong children waited for their operations. Parents told usthat waiting times for operations were tailored to theirneeds. For example, they would schedule an operationduring the school holidays if this was more convenient.If a child needed an urgent operation, the service had



Good –––


the flexibility to do this. Although the service aimed forchildren-only theatre lists, the hospital sometimesprioritised children to have their operations first, aheadof an adult theatre list.

• There were no next-day clinics, but parents told usconsultants fitted in urgent child outpatientappointments in a few days.


• The hospital co-ordinated appointments for childrenwith complex needs. There was a multidisciplinary teamapproach for children who needed to see a number ofprofessionals, for example, a paediatrician, an ENTspecialist and a speech therapist.

• Staff responded to a patient’s individual needs. Weheard from parents that the hospital had plannedtreatment around their child’s emotional, mentalphysical and spiritual needs. Senior nurses gave us anexample of staff planning care for a child withbehavioural challenges. They contacted the parents of achild with Asperger’s syndrome in advance of theirappointment to enquire about the best way to helpthem prepare for admission and reduce their anxiety.

• The hospital offered outpatients appointments andoperation times to suit the individual family. Mostparents chose operation times during the schoolholidays, as this did not disrupt schooling or drawattention to the child’s operation.

• The hospital used an interpreting service and askedemployees with language skills to interpret. However,we heard that on one occasion, it was difficult to obtainconsent for a child’s treatment from parents, becausethey could not understand English well enough. Thehospital could not find an interpreter, so the matter wasunresolved. They rescheduled the appointment foranother day, delaying treatment.

• Nurses encouraged children and young people to keepin touch with friends and family. Parents told us thatthey helped children plug in their electronic devices andaccess Wi-Fi. Staff also encouraged parents to stayovernight on a temporary bed in the same room as theirchild to reduce anxiety, and would provide a meal ifneeded


• The service used the Spire corporate complaints policy.The complaints process was clear and parents said that

they would have no difficulty giving feedback. However,the service had not received any official complaintsfrom parents in relation to their child’s care since theservice began in 2013.

• Small children received a bright pictorial patient surveywhich was easy to follow and tailored to them. Olderchildren received the adult survey. Children and youngpeople responded that they were happy with theservice.

• The service did not analyse by age group complaints,comments or concerns raised in the patient survey.Therefore, the service was unable to identify any needsor trends pertinent to an age group, so that servicecould be tailored around this.

Are services for children and youngpeople well-led?

Good –––

The service had a vision for children’s facilities andexpansion of services in the future, shared with staff. Therewas a positive culture and staff showed clear motivation todo their best for children and young people. There was agood risk management structure and children’s nursesworked well with consultants to develop policies and planservices. The governance structure helped deliver goodquality care.

Senior managers recognised that the lead children’s nurseprovided good care to children and had represented theservice well within the Spire Group.

However, staff and managers recognised that there was aneed to strengthen quality and performance management,for example quality monitoring measures, and to introducelearning from audits and benchmarking. They also neededto assess staffing for their expansion plans.

Vision and strategy for this core service

• Hospital managers, paediatric nurses and consultantshad a vision for children and young people’s services.They had recently introduced a strategy ‘Paediatricservices for children and young people at Leicester SpireHospital’ which was drafted with children’s nurses andother stakeholders in August 2015. They aimed toexpand the range of children’s services offered.



Good –––



• The matron, who was also the senior safeguardingcontact, took the lead at executive level. The two leadpaediatric consultants represented the interests ofchildren and young people at the Medical AdvisoryCommittee. They also attended the paediatric steeringgroup which met every two months with a serviceimprovement/development agenda.

• Staff who worked with children and young people wereaware of the governance structure. All children’s nursesattended the ‘Paediatric Steering Group’, which was themain meeting for service development and review ofadverse events. We saw minutes of this meeting andsaw that it had led to positive outcomes such asimmunisation training. It was also attended bypaediatric consultants, the matron and the trainingcoordinator. This meeting linked with the medicaladvisory committee.

• The hospital had not assessed staffing needs to meetthis increase in demand. They were recruiting anadditional children’s nurse.

• The additional children’s nurse would be responsible fordeveloping audits and quality and performancemonitoring. The strategy for children and young peopleshowed the team planned to carry out audits onpolicies, for example, transfers for children and‘Paediatric Early Warning Scores.’ They also planned toset up monitoring and comparison of performance onquality indicators such as unexpected re-admission rate,complication rate and mortality. This would form part ofthe new lead nurse’s role.

Leadership

• There was a ‘can-do’ culture within the service and stafffelt respected and valued. Staff felt that all seniormanagers were good role models and approachable.They were aware of the hospital’s values and there wasclear two-way communication between managementand staff for example via the staff forum.

• Senior managers recognised that the lead children’snurse provided good care to children and hadrepresented the service well within the Spire group.However, they identified a need to strengthenleadership capacity as a result of a new contract toexpand children’s services.


• Staff aimed to give children pleasant memories of thehospital and worked creatively to achieve this. Thehospital invited children who had recently had anoperation to a ‘Tigers Tea Party’ earlier in 2015, and fourmembers of Leicester Tigers rugby team attended.

• The culture was centred on the needs of the child usingthe service. We heard from parents how hospital staffand doctors tailored treatment and hospital stays to theneeds of the child.


• The hospital gathered views through patient satisfactionforms and informal parent and patient feedback. It tookaction on these suggestions, for example throughproviding multicultural food such as curry. However, ithad no formal group for parents to help shape servicesor future facilities for children.

• Children’s nurses were activity engaged in the planningof services. For example, they were provided withimmunisation training to prepare for the well-baby clinicand advised on how long a clinic appointment shouldbe. They also suggested a lifestyle clinic to supportyoung people with eating disorders and were arrangingto work with a paediatric dietician on developing this.


• Spire Group recognised Leicester Spire’s paediatric earlywarning system (PEWS) chart, developed by the leadchildren’s nurse, as good practice. They planned toimplement it in all Spire hospitals. The lead children’snurse also represented Leicester Spire on a networkinggroup with other children’s leads in the Spire Group,influencing corporate policy and sharing knowledge.

• We saw evidence that staff were focused on continuallydeveloping and improving the quality of care. Forexample, paediatric steering group minutes showedthat nurses and other staff designed and printed newpatient leaflets with an elephant logo. The paediatricsteering group also took action to prevent outpatients’appointments running behind schedule for children.

• Just before our inspection, the hospital won a newcontract and had calculated that from January 2016there would be approximately 50 additional childadmissions per year. The service also planned to startcorrective squint surgery, optometry and routineimmunisation and travel vaccination for children andyoung people. This would start with meningitis Bvaccinations in September 2015. The paediatric nurses



Good –––


and a paediatric consultant received immunisationtraining in April 2015. This showed that staffcompetencies improved in anticipation of the newservices.

• The service also planned to set up a lifestyle clinic forchildren with eating disorders and the hospital wasassessing the market for these services. The seniormanagement team and the paediatric steering groupmonitored and reviewed progress against these plans.

The hospital ensured that there would be better facilitiesfor children and young people in future. It had committedcapital funds for building outpatient’s consulting roomsand an inpatient’s ward specifically for children. It plannedto start survey work in September 2015, consult withparents and child patients in November 2015 and completebuilding work in May 2016.



Good –––


Safe Requires improvement –––

Effective


Responsive Requires improvement –––


Information about the serviceThe outpatient and diagnostic imaging department atSpire Leicester Hospital provide outpatient clinics anddiagnostic imaging services to self-fund and NHS patients.

The outpatient and imaging services had 72,022attendances between April 2014 and March 2015, 13% ofthese were attendances by NHS patients. Services wereprovided predominantly to adults, the department saw asmall number of children equating to 4% of theattendances.

The outpatient department held clinics for a range ofdifferent specialities including orthopaedics,ophthalmology, cosmetic surgery, gastroenterology, ENT,gynaecology, general surgery, cardiology, dermatology,rheumatology and oral surgery. The diagnostic andimaging services offer Computerised Tomography (CT),Magnetic Resonance Imaging (MRI), X-Ray and Ultrasound.Physiotherapy was also contained in the outpatientsdepartment and provided a range of treatments includingacupuncture, sports rehabilitation and pain management.

As part of this inspection we visited all outpatient locationsand diagnostic areas. We spoke with 15 patients and fourrelatives, 18 staff and departmental managers. Weobserved care and treatment and looked at patientrecords. Information provided by the hospital before theinspection was also reviewed.

Summary of findingsEmergency equipment was not immediately availablewithin the department. However, since the inspectionthe provider has confirmed that the resuscitation trolleyhas been re-sited. Staff in outpatients department hadlimited knowledge in regards to decontaminationfollowing patients with suspected communicablediseases.

The Spire Leicester Hospital weekly compliance reportdated the 7 and 11 August 2015 showed shortfalls in thereceipt of medical staff information on medicalindemnity, disclosure and barring checks, GeneralMedical Council registration expiry dates, whole practiceappraisals and biennial review dates. The provideracknowledged that further work was required to ensureall consultants provided evidence of all the requireddocumentation. We spoke with a senior manager whoinformed us of the actions in place to achievecompliance and mitigate risk. By 20 August 2015, 312consultants had provided all the requireddocumentation. The suspension of practising privilegesfor thirty-four consultants took place until alldocumentation was submitted to the hospital. Since 20August 2015, the provider confirmed that compliancehas remained at 100% at all times in relation to thecollection of this information and that all medical staffwere fully insured during the CQC inspection, despiteshortfalls having been observed in the collection of thisdata.

Safety concerns were identified and addressed in atimely manner. All staff were aware of responsibilities inrelation to reporting incidents and the duty of candour.There were effective systems in place to protect people


Outpatients and diagnosticimaging



from avoidable harm and lessons were learnt from anyincidents within the department. We found thatequipment was appropriately serviced and calibrated.Staff received training in mandatory and role specificareas. Patient risk was assessed and responded toappropriately.

We saw that staff were caring towards patients andrespected their privacy and dignity. Patients understoodoptions available to them and were able to chooseappointments to suit their needs. Information wasavailable for patients throughout the department andstaff had the appropriate skills and knowledge to seekconsent from patients throughout their care.

Waiting times and attendances were not alwaysmonitored and collated effectively; this was notrecognised as an issue within the hospital. Patientoutcomes were not looked alongside cancelled clinicsto ensure there was not a negative effect. People couldaccess the right care at the right time and patient needswere taken into account. Signage was not always clearto patients visiting the outpatient and imagingdepartment. Consideration was not always given tothose with cultural needs and staff said they wouldbenefit from further training in this area.

Complaints were investigated and where necessaryclinical and administrative practice had changed toprevent recurrence. Radiation regulations were followedand staff received the necessary training andcompetency assessment to ensure patient safety.

Staff felt valued and were positive about their roles.There was a shared vision throughout the hospital andsafe patient care was paramount. Innovation andimprovement was encouraged in outpatient andimaging areas, with evidence to support this. Feedbackwas a valued tool and the department strived toimprove following any negative comments frompatients or relatives.

Are outpatients and diagnostic imagingservices safe?


The outpatient and diagnostic imaging services requiredimprovement.

The hospital’s risk register identified that not all areas ofoutpatients and imaging, including sinks and carpetedareas, were compliant with Department of Healthguidelines.

The hospitals risk register identified the access and exit tothe minor operations room as a risk. The doorway wassmall and in a narrow corridor, this meant that if a patientbecame unwell in the room it might be problematic whenmoving them out, potentially delaying treatment.

Staff in outpatients department had limited knowledge inregards to decontamination following patients withsuspected communicable diseases.

The Spire Leicester Hospital weekly compliance reportdated the 7 and 11 August 2015 showed shortfalls in thereceipt of medical staff information on medical indemnity,disclosure and barring checks and General Medical Councilregistration expiry dates. The provider acknowledged thatfurther work was required to ensure all consultantsprovided evidence of all the required documentation. Wespoke with a senior manager who informed us of theactions in place to achieve compliance and mitigate risk.By 20 August 2015, 312 consultants had provided all therequired documentation. The suspension of practisingprivileges for thirty-four consultants took place until alldocumentation was submitted to the hospital. Since 20August 2015, the provider confirmed that compliance hasremained at 100% at all times in relation to the collectionof this information and that all medical staff were fullyinsured during the CQC inspection, despite shortfallshaving been observed in the collection of this data.

Medicines were stored securely and monitoredappropriately. Prescription pads were signed out toconsulting rooms when they were in use. However, norecords were kept to show how many were used or theprescription number. We were advised during ourinspection that this would be rectified with a new system to





ensure all prescriptions could be tracked and volumesmonitored. We saw this system in place during a follow upinspection to the hospital and were satisfied that thisenabled prescriptions to be tracked and monitored.

Equipment was appropriately serviced and calibrated.Resuscitation equipment was in place to deal withemergencies; however, this was not immediately availableas it was kept in a key code locked room.However, since theinspection the provider has confirmed that theresuscitation trolley has been re-sited.

Staff adhered to infection prevention and control policiesand procedures. There were facilities available in all areasfor staff to maintain appropriate hand hygiene practices.Environmental audits were completed regularly inoutpatients and imaging.

Staff were aware of responsibilities in relation to reportingincidents and the duty of candour. There were effectivesystems in place to protect patients from harm and lessonswere learnt from any incidents in the department.

Effective systems were in place for managing medicalrecords and less than 1% of patients were seen withouttheir records since January 2015.

Staff were aware of procedures when a patient deterioratedand could give a recent example of when this hadhappened in the imaging department. Feedback was givento staff to advise they had followed procedures correctly.

Incidents

• The hospital used an electronic incident reportingsystem and all staff we spoke with described ordemonstrated how to report incidents using the system.All staff gave examples of incidents such as medicationerrors and injuries in the department.Acknowledgements were sent to the staff member afterreporting an incident to confirm the incident was beinginvestigated.

• Staff in outpatients confirmed all incidents had a rootcause analysis completed. We were told of a variety ofclinical and non-clinical incidents that had occurred inthe department in the last six months.

• We saw examples of learning and action plans beingimplemented following incidents. Staff told us thatincidents were taken seriously by management teamsand feedback was provided in a timely way.

• Weekly rapid response meetings took place whereincidents in the department were reviewed. Theinvestigation process was discussed along with anyaction plans. Shared learning and feedback followingincidents was shared with the relevant department.

• Following an investigation of a serious incidentinvolving a medication error in outpatients we sawchanges had been made, which included medicationchecks in a quiet area and with another member of staff.This meant the hospital had taken steps to improvepatient safety and avoid harm.

• The service had not reported any Ionising Radiation(Medical Exposure) Regulations (IR(ME)R) or magnetrelated events in the last 12 months.

• Staff were aware of the duty of candour. The duty ofcandour regulation requires providers of health servicesto be open and transparent when things go wrong. Thisincludes some specific requirements, such as providingtruthful information and an apology. The outpatientdepartment senior sister was able to provide anexample of this in relation to a medicationadministration error. Following the error the patient wasinformed immediately and it was escalated to thedeputy matron. The senior sister told us support wasprovided to the patient and staff member throughoutthe process.

• We saw leaflets available in all staff areas advising onthe duty of candour. This meant we were assured thatstaff were aware of the new regulation regarding beingopen and honest.


• The hospital risk register identified some areas in theoutpatient department were non-compliant withDepartment of Health guidance (Health Building note00-09). A refurbishment plan was in place to rectify theareas including carpeted rooms and sinks.

• The majority of consulting rooms had carpeted floors,which were deep cleaned twice yearly. Staff told us thatcarpeted rooms were deep cleaned twice yearly, whenthey appeared dirty or when a spillage occurred.

• There were disposable curtains in all the treatment andconsulting rooms with a date on when they were put upand when they were due to be changed.

• Equipment and patient furniture in consulting roomsand storerooms had green stickers to confirm it wasclean and ready for use.





• We found outpatient and imaging waiting areas,consultation rooms and treatment rooms to be visiblyclean and tidy.

• Staff were observed and noted to be ‘bare below theelbow’ in line with the hospitals infection control policy.

• Staff working in the outpatients and diagnostic imagingdepartment understood their responsibilities in relationto cleaning and infection prevention and control.

• There were enough hand washing facilities includinghand washbasins and hand gel sanitizers within allareas of outpatients and imaging. We observed staffpractising appropriate hand hygiene routines betweenpatients.

• We inspected six consulting rooms and noted all hadgloves available. Although aprons were not readilyavailable we were told they could be acquired whereneeded.

• We saw all rooms had appropriate facilities for disposalof clinical waste and sharps.

• Spillage kits were available as required. Staff were notable to tell us what they would do in regards todecontamination following patients with suspectedcommunicable diseases.

• Environmental audits in relation to cleanliness andinfection control were conducted regularly. Action plansdemonstrated the changes that had been madefollowing the audits, staff in the departments wereaware if anything from their area was on this actionplan. Within the physiotherapy area staff told us it hadbeen identified that some items of equipment werebeing stored on the floor, to rectify this racking had beenordered.

• Imaging rooms were cleaned daily with only radiologystaff cleaning the equipment. This was to ensure staffthat were aware of radiology risks and were kept safe.


• We inspected resuscitation equipment for outpatientsand radiology. The equipment was located in-betweenthe two departments in a key code locked room with aself-closing door. This was not in line with theResuscitation Council’s guidance. We spoke to theresuscitation officer for the hospital who advised us thishad not been risk assessed and had not previously beenthought of as an issue. Since the inspection the providerhas confirmed that the resuscitation trolley has beenre-sited.

• We were not assured that staff could accessresuscitation and emergency equipment promptly dueto its location and therefore could delay care to apatient in a medical emergency.

• Equipment in the resuscitation trolley was appropriateand checked daily to ensure that it was ready for use.We saw evidence of weekly checks that were thoroughand meant drugs and equipment were monitored forexpiration dates. Policies related to resuscitation andequipment checks were visible and all staff we spoke towere aware of these policies.

• The access and exit to the minor operations room wasdocumented in the hospitals risk register. The door waywas small and in a narrow corridor, this meant that if apatient became unwell in the room it may beproblematic when moving them out. Regular scenarioswere carried out by staff to ensure this risk wasminimised.

• The outpatients and diagnostic imaging departmentwas uncluttered, and well maintained. All patientwaiting areas were visibly clean with sufficient seatingfor patients and their relatives.

• All equipment had been appropriately maintained andserviced; we were shown evidence of service recordsthat were clear and up to date.

• Within all rooms and in waiting areas there was a colourcoded alarm system that allowed staff or patients toalert others to a medical emergency. Within theconsulting rooms there was also a button to requestassistance or a chaperone.

• Daily self-checks and calibrations were performed whenMRI and CT scans were active, this further ensured theequipment was safe to use.

• All rooms had warning signs in relation to radiation atthe entry point.

• Imaging staff told us that appropriate protectiveequipment, such as lead coats, was available and that itwas checked yearly to ensure it could provide sufficientprotection.

Medicines

• We looked at storage of medicines throughout theoutpatients and imaging department and found themall to be in date and stored appropriately.

• We saw a safe system in place for transferring drugs totreatment and consulting rooms where required byconsultants. High cost medicines had a register thatstaff signed once administered or removed.





• Prescription pads were signed out to consulting roomswhen they were in use; however no records were kept toshow how many had been used or the prescriptionnumber. This meant that there was no audit trail anddiscrepancies in volume of prescriptions would bedifficult to identify.

• We were advised during our inspection that this wouldbe rectified with a new system to ensure allprescriptions could be tracked and volumes monitored.We saw this system in place during a follow upinspection to the hospital and were satisfied that thisenabled prescriptions to be tracked and monitored.

Records

• We found gaps in some of the patient records wereviewed. We were told that some consultants usedtheir own notes rather than Spire medical records inwhich to record the patient’s outpatient consultationand not all those notes were retained within the Spiremedical record. Patient records that weren’t retainedwithin the Spire medical records were available onrequest from the Consultant or their secretary in linewith hospital policy.

• Staff we spoke with could not recall an occasion wheremedical records had not been available for a clinic, orwhen a patient could not be seen because their recordswere not available. Data we received prior to inspectioninformed us that the number of records which wereunavailable was less than 1% (20 patients since January2015.)

• Imaging requests were handwritten and then scannedonto the computer system by imaging administrativestaff. We were shown five patient records and theimaging requests that had been scanned; all werelegible and had been double checked with the patientas they booked in.

• Records were held at the hospital for six months andthen transferred to another Spire site for storage. Wewere advised that notes can be requested to be sentback should a patient return for further treatment, stafftold us this was a 24 hour service.

• Medical records were audited monthly to ensure allrelevant information regarding the patients care wasdocumented. We saw evidence of one month’s auditwhich showed staff not signing in all required areas ofdocumentation. Any recommendations following theaudit would be circulated to the relevant areas.

Safeguarding

• We saw systems in place to ensure the right personreceived the right radiological scan at the right time.Reception staff told us they confirmed patient detailsincluding the area they were expecting the imaging on.If the area of the body differed they would look back tothe referral and establish if it was a clerical error or areferral error. We saw radiology staff check details of theareas of the body they expected to be imaged to ensurethat they had the correct information beforecommencing the imaging process. This confirmed thatsafe systems were in place to protect patients fromunnecessary radiation through referral and clericalerrors.

• All staff we spoke with informed us they had receivedsafeguarding training for both adults and children in thelast year. We checked eight staff files across outpatientsand imaging and saw evidence of this.

• A senior physiotherapist provided us an example ofwhen staff had followed the hospital’s safeguardingpolicy and made an appropriate referral to the hospitalsafeguarding lead. Feedback was given to the reportingstaff member and to the rest of the departmentfollowing the referral.

• All staff were aware of what action to take if they felt apatient required safeguarding. This meant we wereassured that training was adequate and staff would beable to protect vulnerable patients.

• The Spire Leicester Hospital weekly compliance reportdated the 7 and 11 August 2015 showed shortfalls in thereceipt of medical staff information on medicalindemnity, disclosure and barring checks, GeneralMedical Council registration expiry dates. The provideracknowledged that further work was required to ensureall consultants provided evidence of all the requireddocumentation. We spoke with a senior manager whoinformed us of the actions in place to achievecompliance and mitigate risk. By 20 August 2015, 312consultants had provided all the requireddocumentation. The suspension of practising privilegesfor thirty-four consultants took place until alldocumentation was submitted to the hospital. Since 20August 2015, the provider confirmed that compliancehas remained at 100% at all times in relation to the





collection of this information and that all medical staffwere fully insured during the CQC inspection, despiteshortfalls having been observed in the collection of thisdata.

Mandatory training

• Managers in all areas of outpatients and imaging told ustheir staff had all completed mandatory training. Staffalso supported this and told us they had completed allrequired learning. Staff told us that training includedsubjects such as manual handling, infection control,safeguarding, basic and intermediate life support andfire safety.

• We checked nine staff records in outpatients andimaging and saw that all had up to date training recordsthat documented mandatory training had been carriedout in the last year.

• We were informed that monitoring of mandatorytraining levels was carried out by a different departmentand that managers of outpatients and imaging were notinvolved in this.


• Staff informed us that if a patient deteriorated in thedepartment the resident medical officer (RMO) wouldassess the patient. Radiology staff were able to provideus of an example of where a patient became unwellprior to imaging, the emergency button within the roomwas pressed and the RMO attended. Followingassessment the patient was transferred to the accidentand emergency department of a local NHS hospital byambulance. Feedback was given to staff involved,confirming that correct procedures had been followedand this was shared with the rest of the department.

• Administrative staff told us that if a patient collapsed inthe waiting area they would press the emergency buttonto alert other staff. This meant that in the event of amedical emergency appropriate action would be takento assess and respond to the patients’ needs withoutputting them at risk of deterioration.

• Radiography staff informed us they were aware ofcontrast-inducted reactions and that they could easilylocate the anaphylaxis kit to use should these reactionsoccur. Staff told us that if anaphylaxis was suspectedthey would contact the RMO who would treat thepatient appropriately.

• Signs in relation to radiation exposure and pregnancywere seen throughout the imaging department.

• Radiographers conducted a check on the pregnancystatus of all women of childbearing potential prior toimaging in line with national guidance. Pregnancystatus checks were audited by the radiation protectionadvisor (RPA) to ensure that these were conducted andpatients were kept safe.

Nursing staffing

• The hospital used an adapted version of the Shelfordacuity and dependency tool to establish their staffinglevels.

• Records provided to us prior to inspection showed useof agency staff varied throughout outpatient andimaging areas. The imaging department had no use ofagency staff. Outpatients had minimal use of agencystaff, while physiotherapy were currently using agencystaff to cover due to a vacancy and staff sickness.Physiotherapy staff told us that the hospital tried to usethe same agency staff where possible to enablecontinuity.

• We were advised that if agency staff were used in anyareas that they were given sufficient information andthe hospitals procedures discussed with them alongwith an induction checklist. This meant that patientscould be assured that staff were familiar with the serviceprovided and the needs of the patients.

Medical staffing

• Resident medical officer (RMO) cover was providedthroughout the 24-hour period, RMOs had beenemployed through an agency that ensured necessaryemployment and registration checks had taken place forall RMOs that work in the hospital.

• Staff told us that consultants were generally on time fortheir clinics. However, some consultants came fromlocal NHS hospitals and if their lists overran or had acomplication this meant there would be an impact ontheir clinics. This information was not collated ormonitored and therefore we were unable to see howoften this occurred or the impact it had.

• Radiologists did not provide cover over evenings andweekends. There was no procedure in place should onebe required urgently other than calling each oneindividually to see if they could attend the hospital. Staffwithin the department felt this was an issue but statedthere had never been an incident where a radiologistcould not be contacted. There was no plan to alter thispractice.






• We were informed prior to inspection that the hospitalwould provide support should there be a major incidentwithin the area. We spoke to the leads of bothoutpatients and imaging who were not able to tell usthe role of the department should there be a majorincident. However both members of staff informed usthere was a policy and they would be able to access thisto establish their roles.

• Post inspection we were provided with information toshow that major incident plans were currently beingdiscussed with the head of emergency preparedness,resilience and response for the Central Midlands. Thematron informed us that once plans had beendeveloped further then staff would receive informationand training.

Are outpatients and diagnostic imagingservices effective?

Pain relief was assessed and patients were supported withpain management, through medication and/orcomplimentary therapies. We saw evidence of patientoutcomes being measured in some areas of thedepartment.

Staff received appropriate training for their roles and wereencouraged to develop further through external training.Appraisals were carried out yearly with a six month review.Staff felt these were meaningful and were clear of anyactions required by them afterwards.

The Spire Leicester Hospital weekly compliance reportdated the 7 and 11 August 2015 showed shortfalls in thereceipt of medical staff information on whole practiceappraisals and biennial review dates. The provideracknowledged that further work was required to ensure allconsultants provided evidence of all the requireddocumentation. We spoke with a senior manager whoinformed us of the actions in place to achieve complianceand mitigate risk. By 20 August 2015, 312 consultants hadprovided all the required documentation. The suspensionof practising privileges for thirty-four consultants took placeuntil all documentation was submitted to the hospital.Since 20 August 2015, the provider confirmed thatcompliance has remained at 100% at all times in relation to

the collection of this information and that all medical staffwere fully insured during the CQC inspection, despiteshortfalls having been observed in the collection of thisdata.

Services were not available seven days a week, but themajority of areas provided an on call service should staff berequired.

Staff had an understanding of consent, Mental Capacity Actand Deprivation of Liberty Safeguards and were able toprovide examples of where they had experienced these inpractice.


• Staff told us they worked to local policies that werereviewed regularly as part of the governancearrangements for the service.

• National Institute for Health and Care Excellence (NICE)guidance was being used in medical and surgical clinicsas part of patient care and treatment.

• The imaging department used diagnostic referencelevels (DRLs) as an aid to optimisation in medicalexposure. DRLs were cross referenced to national auditlevels and if they were found to be high a report to theradiation protection advisor (RPA) would be made.

• A folder was kept in the staff office with relevant localpolicies and procedures; these were all up to date andhad been reviewed within the necessary timescale.Policies and procedures followed national guidelines foroutpatients and diagnostic imaging.

• Staff we spoke with were aware of how to access thepolicies and procedures folder. Staff could also locatefurther guidance on the hospitals computer systemwhich was demonstrated to us.

• The hospitals clinical audit schedule outlined when,how often and who would conduct audits in the variousareas. These audits included quarterly medication andresuscitation equipment audits along with annual lasersafety audits to ensure national guidelines had beenfollowed.

Pain relief

• Patients were assessed for pain relief duringassessments and supported in managing pain throughprescriptions with the appropriate medication.

• Complimentary pain relief therapies were available suchas acupuncture and massage. These therapies wereprovided by physiotherapists. Pilates was previously





offered to patients but was stopped due to staffsickness. The physiotherapy team felt this treatmentwas very beneficial and were therefore undertakingtraining to be able to provide it again.

• We spoke with one patient who had used thephysiotherapy service for pain relief, they felt positiveabout the services offered and said their pain hadimproved following treatment.

Patient outcomes

• Staff in the physiotherapy department informed us theymeasured outcomes and told us that this was through apatient self-assessment questionnaire. Staff showed usevidence of these questionnaires and were able todescribe how these were audited and treatmentsadjusted based on the findings.

• There was no evidence of outpatients and imagingtaking part in national audits.

• The ‘United Kingdom Accreditation Service’ hadawarded the hospital pathology services clinicalpathology accreditation. The most recent documentedassessment of clinical pathology services was dated the5 February 2013.

Competent staff

• Shortfalls were found in hospital wide consultants’information with the exception of consultant staffworking with children and young people andtermination of pregnancy services. Information receivedfrom the provider relating to required documentationfor hospital wide consultants, showed that on 11 August2015, 84% of consultants had received a practiceappraisal and 71% of consultants had received abiennial review. Although the percentages ofcompliance had increased since 15 April 2015, theprovider acknowledged that further work was requiredto ensure all consultants provided evidence of all therequired documentation. We spoke with a seniormanager who informed us of actions that would be putin place immediately to achieve compliance andmitigate risk. The Consultant’s Handbook stated thatconsultants were at risk of suspension if they did notprovide up-to-date documents.

• The Spire Leicester Hospital weekly compliance reportdated the 7 and 11 August 2015 showed shortfalls in thereceipt of medical staff information on whole practiceappraisals and biennial review dates. The provideracknowledged that further work was required to ensure

all consultants provided evidence of all the requireddocumentation. We spoke with a senior manager whoinformed us of the actions in place to achievecompliance and mitigate risk. By 20 August 2015, 312consultants had provided all the requireddocumentation. The suspension of practising privilegesfor thirty-four consultants took place until alldocumentation was submitted to the hospital. Since 20August 2015, the provider confirmed that compliancehas remained at 100% at all times in relation to thecollection of this information and that all medical staffwere fully insured during the CQC inspection, despiteshortfalls having been observed in the collection of thisdata.

• Managers and staff told us performance and practicewas continually assessed during mid-year reviews andat the end of year appraisal. Staff we spoke withconfirmed they received regular appraisals and we sawevidence that the appraisal completion rate foroutpatients and diagnostic imaging staff was 100%.

• Staff told us they were encouraged to undertakecontinuous professional development and were givenopportunities to develop their skills and knowledgethrough training relevant to their role. Examples oftraining courses attended included Master’s degreeswhich had been partially funded by the hospital.

• Medical consultants with NHS contracts had theirappraisals and revalidation done at their employingtrust and a copy had been provided to the hospital.Following our inspection we were provided withevidence to show 100% of consultants had completedrevalidation and had current Disclosure and BarringService (DBS) checks.


• There was a drinks machine available in the departmentfor patients to access, and food could be acquired onrequest.


• Staff told us that communication and workingrelationships were good throughout the departmentand with the rest of the hospital. We observed staffworked together as a team and provided support toensure that care and treatment was managedeffectively.





• There were no multidisciplinary clinics availablehowever staff told us that access to different disciplineswas very easy.

Seven-day services

• Radiologists did not have rotas for weekend working oran on call rota. We were told that if a radiologist wasneeded at the weekend then staff would have to phonearound to try and reach one of them.

• Radiographers were available during evening andweekends on an on-call basis. Staff told us they were allflexible and would help cover the department whereneeded.


• All staff had access to policies, procedures, ande-learning on the hospital’s intranet. All clinic rooms hadcomputer terminals enabling staff to access patientinformation such as x-rays, blood results, medicalrecords and physiotherapy records via the electronicsystem.

• Radiologists were now able to use voice recognition forreporting, this meant reports were available sooner andmore time effective for radiologists.

• There was a secure image exchange portal transfer ofinformation between local NHS trusts and the hospital.This meant that images were shared between providersto prevent unjustified re-imaging of patients.


• Staff told us they were aware of the hospital's consentpolicy. Consent was sought from patients prior to thedelivery of care and treatment. In the diagnosticimaging department, radiographers obtained writtenconsent from all patients before commencing anyprocedure.

• All staff we spoke with were aware of the MentalCapacity Act (MCA) and were aware of implications itmay have in practice. Staff were able to tell us what theywould do if they felt a patient lacked capacity and wewere given two examples of where this had previouslyoccurred in the department.

• We saw evidence of staff completing MCA andDeprivation of Liberty Safeguards training in outpatientsand imaging.

Are outpatients and diagnostic imagingservices caring?

Good –––

Staff were respectful and polite towards patients and carewas good throughout the department. Patients understoodoptions available to them and were able to chooseappointments to suit their needs.

Patients and their relatives we spoke with were pleasedwith the care they had received. Survey results showed themajority of patients would recommend the outpatientsdepartment to their family and friends for similartreatment.

Information was available for patients throughout thedepartment and staff had the appropriate skills andknowledge to seek consent from patients throughout theircare. Psychological support was available for patients andthose that had received it felt it was very useful and tailoredto their needs.

Compassionate care

• Reception staff were very respectful and polite topatients, assisting them with enquiries.

• We spoke with 15 patients who were very happy withthe care that they had received. One patient told us theyhad received treatment at the hospital over severalyears, stating they would, “Always come here,” and “Thephysio staff are really good.” Another patient who told usit was their first visit to the radiology department said, “Itmet expectations and staff are welcoming and friendly.”

• Feedback from NHS patients over July 2015 stated that77% would recommend the outpatient department tofriends or family. One patient stated, “All aspects of whatI experienced were first rate.”

• We observed staff assisting patients in the department,approaching them rather than waiting for requests forassistance. For example, staff offered patients withreduced mobility assistance to move to the receptiondesk and seating area.

• Patients' privacy was respected and they wereaddressed and treated respectfully by all staff. Staff were





observed to knock on consulting and treatment roomdoors before entering. Curtains were drawn and doorsclosed when patients were having their consultation ortreatment.

• We spoke to six family members of patients who hadreceived treatment. They all stated they were pleasedwith the care provided to their relative.


• Patients we spoke with told us they fully understoodtheir care and were informed of risks and benefitsduring consultations. Patients were given writteninformation throughout care and treatment whichensured they knew who to contact for advice or support.

• Patients were given advice regarding how long resultsfrom blood tests would take. This information was easilyaccessible to staff to make sure patients received thecorrect information prior to leaving the hospital.

Emotional support

• We spoke to a family who had all received treatment inoutpatients. They felt involved in all aspects of care andwere offered psychological services that they felt weretailored well to their needs following treatment.

• We were informed during the inspection that variousavenues of support, including in the community, werebeing discussed by the leadership team to ensurepatients were well supported during and aftertreatment.

• We saw clear signs in all consulting rooms and waitingareas advising patients they could request a chaperone.We were told that if a patient requested a chaperone themember of staff pressed the chaperone button in theroom to request another member of staff.

Are outpatients and diagnostic imagingservices responsive?


The responsiveness of the outpatients and diagnosticservice required improvement.

Delays, cancellations and attendances rates were notalways responded to within the department. Data wascollected but not audited or actioned further to prevent orreduce these events in future.

Staff informed us that if a patient could not speak Englishthen they would either allow the family to translate or see ifanother staff member spoke the necessary language. Staffdid not receive training to perform this role.

Patients had easy access to services and appointmentswere given in a timely manner, with referral to treatmenttimes for NHS patients being met. Radiology services didnot always run on time. Patients were informed if a clinic orappointment was delayed or cancelled and most patientsfelt this was done in a timely way.

Complaints were discussed openly in the department andlearning shared following them.


• The outpatient and imaging departments were signposted from the entrance of the hospital and all areaswere within a short walking distance. Signage aroundthe outpatient and diagnostic imaging department wasin English only. We saw staff stopping to ask patientsand visitors if they required assistance or directions ifthey saw them appearing to be lost.

• We were told by staff and patients that was someconfusion over one of the imaging receptions as theydealt with MRI bookings only, but the sign stated CT andMRI. This was confusing for patients and meant they hadto go to a separate area to book CT scans.

• We saw various information leaflets throughoutoutpatients and imaging including CT scanning, MRIscanning and information from the British HeartFoundation. Leaflets in the department were all inEnglish. Different languages were available on requestbut this was not clear to patients.

• Some patients told us car parking was problematic,meaning that they sometimes had to park on thepavements on the entrance and exit of the hospital site.

• Waiting areas and consulting rooms were appropriateand patients told us they felt the department was ’openand airy ‘and they liked the brightness of thedepartment. Toilet facilities, drinks machines andmagazines were available in all waiting rooms whichpatients told us was beneficial.





• Evening and Saturday clinics were available to patients,dependant on consultant specialty.

Access and flow

• We spoke with administrative staff in all areas ofoutpatients and imaging.

• In radiology appointment availability depended on thetype of imaging required. Patients who required plainfilm imaging generally had them done on a ’walk in‘basis which followed their consultant appointment. Forother imaging such as MRI and CT we were told patientscould normally be given an appointment within a week.

• Patients told us they were normally seen on time in theimaging department but there were sometimes delayswhich they had subsequently been informed of.Administrative staff confirmed that delays inappointments happened on average once per week andthis was usually due to patients arriving late or movingduring imaging meaning the procedure had to berepeated. These waiting times were not collected,audited or monitored regularly for review.

• During our inspection the MRI scanner was not workingwhich meant patients had appointments cancelled atshort notice. It was the administrative staff’sresponsibility to call patients and inform them of theneed to cancel their appointment; they were offeredanother appointment within 48 hours. We asked howoften this occurred and were told it had begunhappening more often with the MRI scanner and staffestimated it had happened once a month.

• Prior to inspection, we were informed that in theoutpatients department the monthly average ofpatients that do not attend (DNA) appointmentsbetween January 2015 and July 2015 was 358 patients(6%). We asked what the process was to follow thesepatients up and there was no set procedure in place.Some staff told us that if they were NHS patients thenthey would complete a form so that it was documented;other staff told us they would call patients dependingon the nature of the consultation. Although DNA rateswere collated each month we saw no evidence that theywere assessed or audited to attempt to improve them.

• We were provided with outpatient clinic cancellationsbetween January 2015 and June 2015, on average 222clinics were cancelled per month (156 had no patients

booked), resulting in 166 patients having theirappointment times changed. We discussed this, alongwith DNA rates, with departmental managers who couldnot advise us why they were not acted upon.

• We were advised that consultants were required to givesix weeks’ notice before cancelling a clinic, unless therewas an exceptional circumstance, for example familybereavement. We saw a spreadsheet which detailedwhich consultants cancelled clinics, but there were noother systems in place to ensure the movement ofpatient appointments was kept to a minimum.

• Referral to treatment time of 18 weeks for NHS patientsattending outpatients and imaging department wereconsistently met.


• The outpatient reception area allowed patients to speakto a receptionist without being overheard and signsrequested that further patients wait to be called forwardto allow this.

• The CT/MRI reception areas did not allow for privacyduring busy times. The area was small in size and thereception window located in the centre.

• The hospital had access to an interpretation andtranslation service in the event that a patient requiredassistance.

• Staff informed us that if a patient could not speakEnglish then they would either allow the family totranslate or see if another staff member spoke thenecessary language. Staff did not receive training toperform this role. The use of family and carers is notconsidered good practice.

• Staff told us their yearly training included equality anddiversity and 91% of staff in outpatients and imaginghad recently completed the training. Two members ofstaff told us that they would like to know more and felt itcould be more in depth.

• Appointments in the radiology department werebooked by the estimated time the imaging would take;this meant that appointment lengths were tailored topatient needs. However there was no time allowance forerrors or mistakes and therefore occasionally led todelays if one imaging procedure over ran.

• The outpatient department was located on the groundfloor and had accessible toilet facilities for disabledpatients. We observed that there was a wheelchairlocated by the entrance should it be required.





• Relatives we spoke to told us they felt fully involved intheir family’s care where necessary. A child with learningdisabilities received treatment at the hospital and thefamily were very positive about how staff interacted withtheir child and the care they received.

• Staff told us that if a patient had any additional needsthis could be communicated through the hospital easilyto ensure those involved in the patients care wereinformed.

• The imaging department had several individualchanging cubicles for patients to use; they were notseparated into male and female. There were smallsub-waiting areas for patients once they had changed,however patients could be seen from the main waitingareas. Staff advised us that the majority of the timepatients remained in the changing room until they wentinto the imaging suite. During the inspection, we sawfour patients sitting in the sub-waiting area in gowns.

• Information related to fees for self-funded patients wasreadily available and given prior to any treatment orcare.


• The majority of patients we spoke with were unsure ofthe complaints process. However, they did tell us thatthey believed this information had been given to themby the hospital but they had not read thedocumentation. We saw patient leaflets in all areas ofthe department detailing the complaints process so thatpatients had access to information to support them inraising complaints or concerns.

• No accessible feedback forms were seen in thedepartment for patients to access, however there wereleaflets explaining the complaints process.

• Staff told us that if a patient complained directly tothem they would enter it on the electronic incidentreporting system so it could be dealt with. We were alsotold that any complaints were discussed at the rapidresponse meetings to ensure they were dealt withquickly and learnt from as a department.

• We saw that there had been one complaint related tohistology results not being available for a patient’sconsultation two weeks after a biopsy had been taken.Changes had been made to practice including the use ofa whiteboard in the department. To ensure that thischange in practice had been effective, plans were inplace to audit the use of the whiteboard and sampleturnaround times.

• Complaints and comments were reviewed anddiscussed by teams at monthly staff meetings. We sawminutes of meetings which demonstrated thatcomplaint themes and learning were shared with staff.Complaints made included delays in diagnostic resultsand unexpected payment fees.

Are outpatients and diagnostic imagingservices well-led?

Good –––

Leadership in outpatients and diagnostic imaging wasgood.

Effective governance and risk management systems werein place and quality was measured regularly in a variety ofareas. Risks were shared in the department and staff knewof action plans in place to rectify them.

Feedback was sought within the departments but actionplans were not always put in place to rectify negativeexperiences.

Shortfalls in the receipt of medical staff information weremonitored by the hospital. We escalated these findings tothe provider who acknowledged that further work wasrequired to ensure all consultants provided evidence of allthe required documentation. Immediate actions wereimplemented by a senior manager to achieve complianceand mitigate risk. By the 20 August 2015, 84% ofconsultants had provided all the required documentation.

Staff were aware of departmental and hospital wideleadership teams and felt they were visible andapproachable. Improvements and innovations wereencouraged within the department.

Vision and strategy for this service

• All staff were aware of the corporate provider's visionand values that included a passion for caring, successand driving excellence. Staff stated patient safety was akey priority for the hospital.

• Staff told us of plans to improve facilities in outpatientsand imaging with plans being discussed with themlocally. However within the overall hospitals strategythere were no specific areas documented relation tooutpatients and imaging.





Governance, risk management and qualitymeasurement

• Shortfalls in the receipt of medical staff informationwere monitored by the hospital. These shortfallsincluded up to date information on whole practiceappraisals, medical indemnity, disclosure and barringchecks, biennial review and General Medical Councilregistration expiry dates. We escalated these findings tothe provider who acknowledged that further work wasrequired to ensure all consultants provided evidence ofall the required documentation. We spoke with a seniormanager who informed us of actions that would be putin place immediately to achieve compliance andmitigate risk. By the 20 August 2015, 84% of consultantshad provided all the required documentation.Thirty-four consultants practicing privileges weresuspended until they had submitted their documents tothe hospital.

• The hospitals live risk register identified some areas inoutpatients were non-compliant with Department ofHealth guidance (Health Building note 00-09), thisincluded sinks and carpeted rooms. A refurbishmentplan was in place to rectify this but changes had not yetbeen made.

• Effective governance was in place to support thedelivery of quality care and regular reviews andimprovements were made. When we asked staff if theywould change anything in their area the responses wereceived aligned with what was on the hospitals riskregister. This included refurbishment of rooms to makethe areas more patient friendly. This demonstrated risksand necessary improvements were shared amongst allstaff levels and areas.

• There were regular team meetings to discuss issues,concerns and complaints. Staff were given feedback atthese meetings about incidents and lessons learnt.

• The hospitals clinical audit schedule outlined when,how often and who would conduct audits in the variousareas such as quarterly medication and resuscitationequipment audits along with annual laser safety audits.We saw evidence of resuscitation audits which showedhigh levels of compliance consistently.

• Representatives from outpatients and imaging attendedmonthly clinical governance meetings so that any

problems within the department could be raised fordiscussion amongst other hospital staff. We sawevidence of meeting minutes which included areas suchas radiation protection and training updates.

• We reviewed a number of policies and procedures in thedepartment and found that they were up to date andrelevant to practice. They all had review datesdocumented and who was responsible for this. We sawstaff were able to locate local and corporate policieselectronically.

Leadership of the service

• There were clear lines of accountability andresponsibility in the outpatients and diagnostic imagingdepartment. Staff in all areas stated that they were wellsupported by their managers, that their managers werevisible and provided clear leadership.

• All staff we spoke with described the leadership team inthe hospital as having an ’open door’ policy and thatthey were accessible.

• Managers in outpatients and imaging were also involvedin direct clinical patient care. This meant their skills andknowledge were maintained to be able to provide thenecessary support to other staff working in thedepartment.

• Leaders in outpatients and imaging demonstrated to usthat they encouraged staff to take on additionalresponsibilities based in their interests. This could bethrough leading a change in the department ordeveloping areas of patient care.


• Staff told us that the leadership team wereapproachable, supportive and made them feel valued.

• All staff we spoke with felt that there were good workingrelationships between clinical and non-clinical staff,they felt that staff could contribute from any area andthere was no divide.

• There was clear collaborative working in thedepartment and openness and honesty wasencouraged. Staff felt did not feel a blame cultureexisted and told us of incidents that had occurred andthe support they had been given.





• We saw examples where staff had put forwardimprovement ideas and they had been supported bythe management teams in the department. There was astrong emphasis on including staff on improvementsand changes within the department.

• Action was taken where necessary to ensure staffperformance was satisfactory and consistent; we sawthis recorded in staff appraisals. Action was taken toencourage staff to improve and assistance was provideduntil performance was met.


• The hospital collected patient views using a patientsatisfaction questionnaire. Questionnaires werecompleted twice a year for the majority of patients. NHSoutpatient feedback was collated monthly. Over thepast six months four comments related to a lack ofseating, delayed appointments and poor signage in thedepartment. All other comments were positive. We sawno action plans to improve any of the negative issuesraised by patients.

• Staff informed us that they felt able to share their ideasand opinions to develop and improve the outpatientservices. Regular team meetings were held as a forum tofacilitate this.

• The hospital had a patient steering group that enabledpatients who had used the service to provide feedbackto the leadership team. We saw there had been noparticular feedback recently in regards to outpatient orimaging services.

• It was clear that patient feedback was valued by thehospital and this was discussed at a variety of meetingsto establish whether changes could be made to avoidsimilar feedback in future and improve patientexperiences. Positive feedback was passed ontoappropriate departments and staff members.


• In the physiotherapy area staff had plans to create wallart to make the environment brighter following patientfeedback. A box was located in the department forpatients and staff to provide input to influence the wallart. This showed innovation in the department and stafftold us they felt it was important to act on feedback tomake the department as pleasant as possible forpatients.

• Staff told us of the refurbishment plan for the outpatientand imaging areas.





Safe Good –––





Information about the serviceSpire Healthcare provided a termination of pregnancyservice at Spire Hospital Leicester.

The hospital offered early medical abortion procedures forpatients with a gestational age up to nine weeks andsurgical abortion procedures for patients with a gestationalage up to 12 weeks. The medical termination of pregnancyservice was a new service which commenced in August2014. Termination of pregnancy was only provided towomen over 18 years of age.

The medical termination service was provided on aMonday and Friday evening and was led by an NHSconsultant obstetrician/gynaecologist who was based atthe local NHS hospital. Surgical termination of pregnancywas offered as a day case procedure under generalanaesthetic. From August 2014 to 2015 a total of 84termination of pregnancy procedures were carried out atthis hospital, out of which 75 procedures were earlymedical abortions and nine were surgical abortions.

The termination of pregnancy service was delivered inaccordance with the Royal College of Obstetrics andGynaecology (RCOG) Guidance in Relation to Requirementsof the Abortion Act and the Department of Health (DH)guidelines Procedures for the Approval of IndependentSector Places for the Termination of Pregnancy whichincludes the Required Standard Operating Procedures(RSOP).

Summary of findingsThe termination of pregnancy service at Spire LeicesterHospital offered safe care to the patients.

There were sufficient numbers of suitably trained staffavailable to care for patients. The environment andequipment was visibly clean and infection controlprocedures were followed. Staff were aware ofsafeguarding procedures and had received training insafeguarding adults, the Mental Capacity Act (2005) andDeprivation of Liberties (DOLs.)

Medicines management was safe and there was a clearaudit trail for the request and receipt of the medication.

There were appropriate procedures to provide effectivecare. Care was provided in line with national bestpractice guidance. Arrangements were in place toensure that staff had the necessary skills andcompetence to look after patients. Patients had accessto Spire Leicester Hospital out of hour’s aftercare 24hours a day, seven days a week. Patients were cared forby a multidisciplinary team working in a coordinatedway.

Patients received compassionate care that respectedtheir privacy and dignity. All the patients consideringtermination of pregnancy had access to pre-terminationcounselling. Patient’s wishes were respected and theirbeliefs and faith were taken into consideration regardingthe sensitive disposal arrangements for pregnancyremains.

Terminationofpregnancy

Termination of pregnancy

Good –––


The hospital was responsive to patient needs.Professional interpretation service was available toenable staff to communicate with patients for whomEnglish was not their first language.

The service was compliant with the guidance from theRoyal College of Obstetrics and Gynaecology (RCOG)Guidance in Relation to Requirements of the AbortionAct and the Department of Health guidelinesProcedures for the Approval of Independent SectorPlaces for the Termination of Pregnancy RequiredStandard Operating Procedures (RSOP). The hospitalmonitored its performance against the RSOPs.

There were effective governance arrangements in placeand staff felt supported by the senior managementteam. The culture in the hospital was caring andsupportive. Staff said that the leadership and visibility ofthe hospital director, matron and senior managers wasgood. Staff spoke positively about the high quality careand services they provided for patients and were proudto work for Spire Leicester Hospital.

Are termination of pregnancy servicessafe?

Good –––

Termination of pregnancy service provision for bothmedical and surgical procedures were safe and in line withthe guidance from the Department of Health (DH) RequiredStandard Operating Procedures.

Staff were encouraged to report incidents through therecently introduced electronic reporting system and hadreceived feedback on the incidents they had reported.Spire has introduced a Sign up to Safety Action Plan dated11 September 2014 to learn and take action to improvepatient safety. Learning and actions as a result of incidentswithin the hospital were shared with the staff in teammeetings.

The environment was visibly clean. We observed that allthe clinical staff regularly washed their hands in betweenpatients, used personal protective equipment (PPE) suchas gloves and aprons and observed the ‘bare below theelbow’ guidance.

Equipment had been maintained and checked regularly toensure it continued to be safe to use. Portable ApplianceTesting (PAT) testing stickers were visible on the equipmentand equipment maintenance records confirmed anongoing maintenance programme. Resuscitationequipment was available in case of an emergency and hadbeen checked daily. We saw documentation whichconfirmed these checks had been completed daily.

There was an established system for the management ofmedicines to ensure they were safe to use and there was aclear audit trail for the request and receipt of medication.Only a consultant for patients undergoing early medicalabortion prescribed abortifacient medication (themedication used to induce abortion).

Patient records for termination of pregnancy had a uniqueidentifier identified by a red star. When patient recordswere completed, we saw they had been stored separatelyand securely.



Good –––


There were sufficient numbers of suitably trained staffavailable to care for patients. Staff had undertakencompetency based training for the medical termination ofpregnancy and were up to date with mandatory training asof August 2015.

Clinical and non-clinical staff were aware of safeguardingprocedures and had received training in safeguardingadults at either level 1 through e-learning or level 2.

All the patients undergoing surgical abortion hadundergone a venous thromboembolism (VTE) riskassessment in accordance with the recommendations fromthe National Institute for Health and Care Excellence (NICE).During surgical procedures, staff used the World HealthOrganisation’s (WHO) pre-operative checklist incorporatingthe National Patient Safety Agency surgical safety checklist,which is designed to prevent avoidable mistakes. Thesewere completed appropriately in the patient records wereviewed.

Incidents

• Staff were encouraged to report incidents through theincident reporting system and received feedback on theincidents they had reported. Spire had introduced a‘Sign up to Safety Action Plan’ dated 11 September 2014to learn and take action to improve patient safety. Anexample of this was a commitment to reduce avoidableharm in the hospital by 50% and to ensure key patientsafety priorities were reported and monitored. Localactions included publishing audits and adverse eventsin the monthly Clinical Governance and Quality reportsand feeding back to the Medical Advisory Committee.

• All staff we spoke with were familiar with how to reportincidents and gave us examples of incidents they hadreported.

• Clinical incidents were reviewed and it was clearlydemonstrated that investigations and root causeanalysis had taken place. Action plans had beendeveloped to reduce the risk of a similar incidentreoccurring. There had been no serious incidentsreported in relation to termination of pregnancy serviceprovision.

• A clinical practice and governance manager - reviewsand monitors the incident reporting forms. The lead forclinical audits is the deputy matron.

• Clinical governance meetings were held monthly andrapid response meetings were held weekly to discusscomplaints and any adverse incidents. The learning and

actions required were cascaded to clinical staff at teammeetings. The clinical governance report was submittedto the hospital Medical Advisory Committee forcomment.

• The Spire Board of Directors received a report from allthe Spire hospitals through the Incident ReviewCommittee and weekly reports from the centralGovernance team.


• All the clinical and non-clinical areas we visited werevisibly clean.

• In all areas, we observed staff to be complying with bestpractice with regard to infection prevention and controlpolicies. Medical and nursing staff in the clinical areaswere observed to be adhering with the bare below theelbow policy to enable good hand washing and reducethe risk of infection. There was access to hand washingfacilities and a supply of personal protective equipment,which included gloves and aprons. Staff washed orapplied hand gel to their hands between patients.Handwashing audits had been completed by theinfection control lead nurse and showed 100% staffcompliance.

• The hospital had reported no incidence of Methicillinresistant Staphylococcus Aureus (MRSA) and clostridiumdifficile in the reporting period to June 2015. The resultsof MRSA audits were displayed on the website and in theclinical areas.

• Audits and checks were in place to monitor standards ofcleanliness. Staff told us that infection control auditswere completed by the infection control lead. Theresults of the infection control audits were reportedthrough clinical governance.

• The hospital had recently appointed a new infectioncontrol nurse who had developed an infection controlannual plan to monitor and control infection and tomaintain a clean and appropriate environment.

• The hospital had a service level agreement with a localNHS Trust. This was for infection control support andadvice in relation to antimicrobial prescribing from anNHS Consultant Microbiologist who had practisingprivileges with the hospital. The Infection Controlmeetings are held on a quarterly basis and attended bythe consultant microbiologist. Minutes of meetings wereavailable.




Good –––


• Patients were seen on the ward area in one of theprivate rooms.

• We observed all patient-care equipment to be visiblyclean and ready for use. Patient equipment had beenroutinely checked for safety and was clearly labelledstating the date when the next service was due. Theequipment was also labelled to indicate that portableappliance testing had been carried out to ensure it wasfit to use. The annual contract service report andcertificate for the medical device ultrasound scanner(Phillips Scanner) dated 2 September 2014 was seen.Resuscitation equipment was available in all clinicalareas. Single-use items were sealed and in date, andemergency equipment had been serviced.

Medicines

• We observed that there was an established system forthe management of medicines to ensure they were safeto use. This included clear monitoring of the stocklevels, stock rotation and the expiry dates of medication.The minimum and maximum temperature of fridgeswhere medication was stored was monitored to ensurethat medication was stored at the correct temperature.

• There was a clear audit trail for the request and receiptof medication for the anti-abortifacient medication andthe Anti D injections.

• The audit review of the management of controlled drugsfor the hospital dated April and May 2014 had identifiedsome issues and an action plan had been completed.We observed that medicines were securely stored, keptin locked cupboards and fridges.

• There was system in place for the safe disposalmedication. This was to place the medication into adedicated disposal bin that could be tracked to theplace of origin.

• Patients were asked if they had any known allergies andit was seen to be clearly recorded in the fivepre-assessment forms we reviewed.

• Following a face to face consultation with a member ofthe nursing team a consultant prescribed the requiredmedication for patients undergoing early medicalabortion.

• Anti-microbial drugs were prescribed to all patientshaving medical termination of pregnancy. To reduce therisk of infection and the local trust antimicrobialprescribing protocols for the administration ofantibiotics were used. There were clear guidelines onwhen these were to be used.

• Anti-sickness drugs were prescribed for the women aspart of the patient pathway for early medical abortionsto reduce the side effect of vomiting.

Records

• Patient records were paper based .Patient informationand records were kept separately and were heldsecurely in a lockable cabinet in matron’s office.

• Patient records were well maintained and documentedwith clear dates, times and designation of the persondocumenting. We reviewed five sets of patient records.These records were written legibly and assessmentswere comprehensive and complete, with associatedaction plans and dates. Comprehensive pre-operativeassessments as part of the pathway were undertakenand recorded where patients under went surgicalabortion.

• The record keeping audit undertaken for early medicaltermination pathways in quarter two dated 10 August2015 was 100% compliant. An audit for the completionof the legal documentation dated 12 September 2014 to31 December 2014 which included (the HSA1 forms)checking the grounds for carrying out an abortion andthat two medical practitioner signatures were on theforms was 100% compliant.

Safeguarding

• Trained staff and non-clinical staff we spoke with knewwho the safeguarding adult lead was and where to seekadvice.

• Spire safeguarding policies and procedures were inplace which linked into the local authority.

• The information provided by the organisationdemonstrated that all the clinical staff were trained insafeguarding adults - to level two. We were informedthat level three training had been undertaken by thesafeguarding lead for adults and the paediatric nurselead.

• All staff we spoke with had received safeguardingtraining through e-learning at Level 1 or at Level 2 aboutsafeguarding children and adults. They were clear abouttheir responsibilities and how to report concerns.

• The service was not provided for any woman under theage of 18 years and patients signed a form declaringtheir date of birth. If there were any cause for concernwe were informed that this would be escalated to thematron.



Good –––


• Safeguarding risk assessments were carried outappropriately when there was a suspected case ofabuse and safeguarding referrals were made to localsafeguarding team when appropriate. There had beenno reported safeguarding events for the termination ofpregnancy service.

Mandatory training

• Mandatory training covered a range of topics includingfire safety, health and safety, basic life support,safeguarding, manual handling, infection control andinformation governance training, Mental Capacity Actand DOLs. Staff told us they were up to date with theirmandatory training. The senior sister on Ward 2informed us that she had recently attended MentalCapacity Act training at level 2.

• Data provided by the organisation showed that staff inthe department were up to date with mandatorytraining as of August 2015.There were systems in placeto remind staff if they were due for the mandatorytraining.


• Patients who had undergone a termination ofpregnancy underwent a venous thromboembolism(VTE) risk assessment. These were documented in thepatient’s records and included actions to mitigate therisks identified. The risk assessments informed staff ifprophylactic treatments were required. An audits of thesurgical termination of pregnancy care pathway showedthat VTE assessments were routinely completed.

• Prior to termination procedures all patients should havea blood test to identify their blood group. It is importantthat any patient who has a rhesus negative blood groupreceives treatment with an injection of anti-D. Thistreatment protects against complications should thepatient have future pregnancies. The records that wereviewed demonstrated that all the patients underwenta series of blood tests prior to the terminationprocedure, which included blood group, haemoglobinand Rhesus factor. Those patients who had a rhesusnegative blood group received an anti-D injection within72 hours of the procedure.

• During surgical procedures, staff used the World HealthOrganisation’s (WHO) pre-operative checklistincorporating the National Patient Safety Agencysurgical safety checklist’, which is designed to preventavoidable mistakes. These were completed

appropriately in the patient records we reviewed. Thehospital had also undertaken a surgical safety checklistaudit. The audit performed in August 2014 showed thatthe compliance was 100% for surgical termination ofpregnancies.

• Nursing staff had good access to medical support in theevent of a patient’s condition deteriorating. There was aresident medical officer (RMO) on site 24 hours a daywho was trained to registrar level.

Nursing staffing

• The medical termination of pregnancy service was ledby the matron and supported by the senior sister inoutpatients who has a background in gynaecology. Thesenior sister was supported by two other registeredgeneral nurses who had completed - competency basedtraining. The surgical termination of pregnancy service isbased on the wards as a short stay day case and wassupported by the senior sister who also has abackground in gynaecology.

• A minimal staffing policy was followed in determiningthe staffing level which was reflected by the staffingrotas which we saw for the previous four months. Forpre and post-surgical care, there were sufficient staff onduty to care for patients. When there had been staffingshortfalls due to holiday or sickness these had beencovered by internal arrangements.

• Nurses demonstrated their clinical competencies fortermination of pregnancy and this was recorded in theirpersonal files.

Medical staffing

• The medical termination service was led by an NHSconsultant obstetrician / gynaecologist based at a localNHS Trust The consultant was a Member of the RoyalCollege of Obstetricians and Gynaecologists (MRCOG)and was on the specialist register. He was the lead forthe service at the local NHS trust. There were other twoconsultant gynaecologists involved in the Early MedicalAbortions who would cover for the holiday or sicknessperiod.

• Consultations and treatments for Early MedicalAbortions were held every Monday and Friday evening.Surgical abortions had been carried out by obstetricand gynaecology consultants as day case procedures.



Good –––


• Counselling was undertaken by the lead consultant andthere was also a service level agreement in place forpatients to be referred for independent counselling ifrequested.

• The staff told us that the consultants were alwaysavailable and accessible when they needed support.

• The patients were seen at a second appointment by aprivate GP at the hospital for the second signature to besigned on the grounds for carrying out an abortion(HSA1 forms) for an opinion in good faith.

• The consultants at the hospital worked under practicingprivileges. There was a robust process in place to ensurethat suitable checks were carried out to enable staff topractice and have practising privileges with the hospital.The range of checks were undertaken by the hospitalmanagers personal assistant which includedqualification, insurance, registration, references,appraisals from the NHS trust, Disclosure and BarringService checks (DBS) and revalidation reports. Followingthese checks, the hospital manager and the medicaladvisory committee (MAC) granted the practicingprivileges.

• We reviewed the personnel files for the lead consultantgynaecologist for the service and the consultantmicrobiologist. The files contained the relevantdocumentation to enable them to have ongoingpractising privileges with the hospital.

• The resident medical officers were trained in advancedlife support (ALS).


• Emergency plans and evacuation procedures were inplace.

Are termination of pregnancy serviceseffective?

Good –––

Care was provided in line with national best practiceguidelines. Patients were offered appropriate pain relief,anti-emetics, prophylactic antibiotic treatments andpost-surgical contraceptives. The hospital performedaudits recommended by Royal College of Obstetricians andGynaecology (RCOG). These audits included, infectioncontrol, consenting for treatment, discussions related to

different options of abortion, contraception discussion,confirmation of gestation and medical assessments audits.The outcomes of these audits reflected patient safety andpatient choice. Compliance was 100%.

Staff told us they had annual appraisals and had alsoreceived clinical supervision. Staff had access to specifictraining to ensure they were able to meet the needs of thepatients. Medical staff, nursing staff and other non-clinicalstaff worked well together as a team.

Advice was accessible 24 hours per day, seven days a week.Patients were consented appropriately and correctly. Staffwere clear about their roles and responsibilities regardingthe Mental Capacity Act 2005 (MCA) and Deprivation ofLiberty (DOLs) Safeguards. The MCA forms part of the carepathways and when patients did not have the capacity togive consent to their treatment, the Mental Capacity Act2005 was implemented. Senior nurses had receivedtraining at level two for MCA and also for DOLs. This trainingwas in the process of being rolled out to other staff.


• The Royal College of Obstetricians and Gynaecology(RCOG) guidelines for the treatment of patients such astermination of pregnancy for foetal anomaly andectopic pregnancy were adhered to and were part ofpatients care pathways.

• Policies were accessible for staff and were developed inline with the updated Department of Health RequiredStandard Operating Procedures (RSOPs) and guidance.

• A referral pathway was followed by clinical staff in asuspected case of ectopic pregnancy.

• All patients underwent an ultra sound scan by theconsultant at consultation to determine gestation of thepregnancy. This was in line with the RCOG clinicalguideline for all abortions.

• RCOG guidance ‘the care of women requesting inducedabortion’ suggest that services should make availableinformation about the prevention of sexuallytransmitted infections (STI).It also suggests that allmethods of contraception should be discussed withwomen at the initial assessment and a plan should beagreed for contraception after the abortion. All thepatients attending for consultation for termination ofpregnancy were offered screening for chlamydia prior toany treatment. Patients with positive test results wouldbe referred to the sexual health services at the NHStrust.



Good –––


• Contraceptive options were discussed with patients atthe initial consultation and a plan was agreed forcontraception after abortion. The patients had beenadvised about the different contraceptive options andreferred to the local NHS clinic. These included LongActing Reversible methods (LARC) which are consideredto be most effective.

• Records audits showed that the centre was 100%compliant in following the discussion aroundcontraceptive advice.

Pain relief

• Pre and post procedural pain relief was prescribed onmedication records. Best practice was followed asnon-steroidal anti-inflammatory drugs (NSAIDs) wereusually prescribed. These are recognised as beingeffective for the pain experienced during terminations ofpregnancy. Feedback from patients at follow-up wasrecorded in the patient records.

• Staff we spoke with were clear about which medicationwould be offered to patients for both surgical and earlymedical procedures and staff followed therecommended guidance as part of the pathway.

• The pain score was recorded on the pain tool in thepatient records

Patient outcomes

• The organisation performed various auditsrecommended by RCOG such as audits related toinfection control, consenting for treatment-retainedproducts of conception and failed procedures. Anexample of a change to clinical practice was thatpatients at the second visit are routinely given a seconddose of the abortion medication to take at home twohours later.

• Patients who had undergone a medical abortion wereasked to return for a follow up scan two weeks postprocedure to ensure that the procedure has beensuccessful.

• Women who had undergone a surgical procedure werealso offered a follow up appointment but we were toldby nursing staff that women did not tend to take up thisoption routinely.

• We saw on the register that there had been one retainedproducts of conception which required a surgicalevaluation and two patients who required further oraltermination medication in the last 12 months.

Competent staff

• We reviewed the personnel files for the lead consultantgynaecologist for the service and the consultantmicrobiologist. The files contained the relevantdocumentation to enable them to have ongoingpractising privileges with the hospital. The filesconfirmed that both consultants had receivedappraisals from the local NHS trust where they wereemployed and had undergone revalidation with theGMC. To maintain and update competencies we sawthat staff had attended relevant training for theirspeciality.

• Staff told us they had annual appraisals and hadreceived clinical supervision.

• Information provided by the hospital showed that 100%of staff working in this service had completed anappraisal in the time period to July 2015.

• There was an induction programme for all new staff,which covered a variety of topics, and training and staffwho had attended this programme felt it met theirneeds.

• Staff were supported through an induction process andcompetence based training relevant to this role.

• The ‘Required Standard Operating Procedures’ (RSOP)set by the Department of Health required that staffinvolved in pre assessment counselling be trained todiploma level in counselling.

• All the patients were offered counselling prior to thetreatment by the consultant lead at first visit.Counselling was also available pre and post terminationprocedure if required through a service level agreementwith an independent counsellor with an accrediteddiploma in counselling. Referrals would be made if apatient required further support and counselling.


• Medical staff, nursing staff and other non-clinical staffworked well together as a team. There were clear linesof accountability that contributed to the effectiveplanning and delivery of patient care.

• The service had close working relationships with thesexual health team based at the NHS trust as part of thepatient pathway.



Good –––


• The staff told us that they had close links with otheragencies and services such as the local safeguardingteam and the early pregnancy unit at the local NHStrust. This had helped to improve the patient carepathway.

• Spire Leicester Hospital had a service level agreementwith the local NHS Trust which allowed them to transfera patient to the hospital in case of medical or surgicalemergency.

Seven day services

• Termination of pregnancy procedures were carried outas either surgical short stay day procedures oroutpatient early medical procedures.

• Patients were phoned the day following the procedureby the trained nurses.

• There was an expectation that patients had access to a24-hour emergency number should they be worried andrequire advice.

• There was a resident medical officer available 24 hoursat the hospital.

• The consultants and the senior nurse for the servicewere available for advice.


• As part of the patient’s pathway during the consultationwith the consultant consent for the procedure had beenobtained and documented. It was explained that if apatient expressed any doubts, efforts were made, by thestaff to carefully discuss any sensitive information.Patients were offered a second consultation if they werenot entirely sure about their decision to terminate thepregnancy.

• Patients were asked if they wanted their GP to beinformed by letter about the care and treatment theyreceived. Patient’s decisions were recorded and theirwishes were respected. Confidentiality was paramountand no correspondence or billing was sent to thepatient.

• The five care records we reviewed contained signedconsent from patients. Possible side effects andcomplications were recorded and had been explainedto patients.

• Ward staff were clear about their roles andresponsibilities regarding the Mental Capacity Act 2005(MCA) and Deprivation of Liberty Safeguards (DOLs). The

ward sister described a recent DOLs referral shereported which involved a patient who becameconfused and agitated who required one to one supportto prevent harm from falling until the prescribedantibiotics took effect. She explained that all thepathways have an element relating to MCA.

• Patients signed a consent form for the sensitive disposalof pregnancy remains and this was recorded in thepatient records. We were shown a completed form.

Are termination of pregnancy servicescaring?

Good –––

Patients were treated by staff with compassion, dignity andrespect. The staff focused on the needs of patients andwere caring, compassionate and responded quickly to theirneeds. Patients’ preferences for sharing information withtheir partner or family members were established,respected and reviewed throughout their care.

The staff explained the different methods and optionsavailable for abortion. If patients needed time to make adecision, this was supported by the staff. All the patientsconsidering termination of pregnancy had access topre-termination counselling. Appropriate support wasgiven where a patient underwent termination of pregnancydue to foetal anomaly.

Patient’s wishes were respected and their beliefs and faithwere taken into consideration regarding the disposalarrangements for foetal tissue.

The results of the hospital BUPA Customer SatisfactionResults 2014 Friends and Family element demonstratedthat 98 % of patients were ‘extremely likely’ to recommendthe service to family and friends.

Compassionate care

• Throughout our inspection, we observed patients weretreated with compassion, dignity and respect.

• We observed positive interactions between patients andstaff. Patients were introduced to all healthcareprofessionals involved in their care, and were madeaware of the roles and responsibilities of the membersof the healthcare team.



Good –––


• Patients’ preferences for sharing information with theirpartner or family members were established, respectedand reviewed throughout their care.

• Staff had a non-directive and non-judgementalapproach to patients who had or were to receivetreatment for a termination of pregnancy. Staff wereresponsive to the individual needs of patientsundergoing medical or surgical termination.


• The initial consultation by the consultant and nursingstaff explained all the available methods for terminationof pregnancy that were appropriate and safe to patients.The staff considered gestational age and other clinicalneeds whilst suggesting these options.

• Patients were given leaflets, which had informationregarding different methods and options available forabortion.

• A nurse chaperone was present during consultationsand examinations.

• Patients had been involved in their care.• The five records we reviewed considered and recorded

the post discharge support available for patients athome. Women were given written information aboutaccessing a 24 hour emergency number for supportfollowing abortion procedure.

• Patients were contacted the day following theprocedure to reassure them and to check if they had anyconcerns and this was documented in their records.

Emotional support

• Patients considering termination of pregnancy shouldhave access to pre-termination counselling. All thepatients who attended for consultation were offeredcounselling either with the consultant or referred to anindependent counsellor if required.

• At initial consultation a discussion is held with patientsregarding the disposal arrangements for pregnancyremains. Patient’s wishes were respected and theirbeliefs and faith were taken into consideration. Theservice supported if the patients had specific wishesabout burial or sensitive disposal of pregnancy remains.Staff provided women with specific information abouthow this could be managed and arranged.

Are termination of pregnancy servicesresponsive?

Good –––

Patients could access the services telephone numberthrough the website and book for a consultation with thespecialist customer services team. Confidentiality isparamount and no correspondence or billing is sent to thepatient.

‘Department of Health Required Standard OperatingProcedures’ indicate that there should be a 10 working dayreferral to procedure process time. The timescales fromreferral to treatment were within those timeframes.

A professional interpreter service was available to enablestaff to communicate with patients for whom English wasnot their first language. There was a clearly definedspecialist referral process for women who required aspecialist service.

Formal complaints were managed by matron. There hadbeen no complaints for termination of pregnancy.


• The service is advertised on the Spire Leicester websiteand patients can either self-refer or go to their GP forreferral. A specialist team within customer services canarrange an appointment for initial consultation with theconsultant. Patients were offered a choice ofappointment to the Monday or the Friday evening clinicto access treatment as early as possible.

• There was a service level agreement with the local NHStrust and sensitive clinical waste was collected andtaken to the trust and then to the local crematorium. Afull audit trail was maintained at the trust.

• Patients had been signposted to either a local supportcentre or an independent counsellor who supportwomen with post-termination counselling sessions ifrequired.

Access and flow

• Patients were referred from a variety of sources such asGPs or self-referrals through the website number to aspecialist team in customer services. The hospital



Good –––


undertook all aspects of pre assessment care pathwayincluding counselling, date checking scans to confirmpregnancy and to determine gestational age and otherpre-termination assessments.

• Department of Health guidelines state the total timefrom access to procedure should not exceed tenworking days in order that patients get timely access toterminations. We were informed that patients were seenat initial consultation and treated within that timeframe. This was corroborated when checking therecords.

• If there were a foetal abnormality, the patient would bewas seen and treated in the NHS trust by the consultantas genetic follow up screening would be required. Forthose women having difficulty coping due to specialcircumstances such as foetal abnormality, referrals weremade to specialist organisations.


• The hospital was accessible to wheelchairs users anddisabled toilets were available.

• A professional interpreter service was available toenable staff to communicate with patients for whomEnglish was not their first language.

• Consent forms were based on the Department of Healthconsent forms and were used as part of the patientpathway for short stay surgical termination of pregnancyand early medical abortions. Staff told us that theycould use the interpreter service to ensure the patientunderstood and could weigh up the decision tocontinue the treatment.

• Support was available for patients with a learningdisability or other complex needs to ensure they wereable to make an informed choice.

• There was a clearly defined specialist referral process forwomen who required a specialist service for foetalabnormality or if the gestation of the pregnancy wasover 12 weeks.

• Patient information leaflets included both surgical andearly medical termination of pregnancy procedures.This explained about different options available fortermination of pregnancy including what to expectwhen undergoing a surgical termination. This alsoincluded any potential risks.

• Leaflets were given to patients to inform them what toexpect after the procedure. This included a 24-houremergency telephone number of where patients couldseek advice if they were worried.

• The Early Medical Termination of Pregnancy registershowed that there was an occasion when the patientchanged their mind about terminating their pregnancy.The sister informed us that under these circumstancesthe consultant would refer them to the antenatal clinicfor a booking scan or back to their own GP to access amidwife.

• The hospital adhered to the management of clinicalwaste policy specifically for the sensitive disposal ofpregnancy remains. Patients were given informationleaflets, which detailed the options available for thesensitive disposal of the pregnancy loss. Where a patientwished to dispose of the pregnancy remains privately,staff provided them with a specific information sheet,which laid out how the arrangements should bemanaged, and a pregnancy loss authorisation forrelease of pregnancy remains was signed. Wherewomen did not have specific wishes with regard todisposal, the pregnancy remains were stored inaccordance with the hospital policy for the storage andsensitive disposal of pregnancy remains.


• Patients were encouraged to raise a concern or make acomplaint and staff were positive about learning fromcomplaints.

• Literature and posters were displayed advising patientshow they could raise a concern or complaint formally orinformally. A separate leaflet was also available.

• We were told by staff that the management ofcomplaints was discussed as part of the corporateinduction days.

• We were informed that there had been no complaintsrelating to the service for either medical or surgicalTOPs. However, the policy should there be a complaintwas that it would be managed by the matron. Weeklyrapid response meetings were held where anycomplaints would be discussed. A full investigation of acomplaint would be undertaken and feedback wasgiven to the staff. Complaints form part of the clinicalgovernance report.



Good –––


Are termination of pregnancy serviceswell-led?

Good –––

Staff could tell us about the hospital’s value to treat allpatients with dignity and respect and provide aconfidential, non-judgmental service.

There was a robust governance structure to manage riskand quality. Staff told us they felt supported by the seniormanagers and that the leadership and visibility of seniormanagers was good.

The culture within the service was caring and supportive.Staff were actively engaged. Innovative ideas andapproaches to care were encouraged and supported. Staffspoke positively about the high quality care and servicesthey provided for patients and were proud to work for theSpire Leicester Hospital.

Patients were engaged through feedback at follow upconsultation and by means of a patient satisfaction form.Staff however, told us that due to the sensitivity of theprocedure and the procedures being potentially emotionalexperience for the patients it was challenging to engagewith the patients.

The certificate of approval for carrying out termination ofpregnancy (issued by the Department of Health) wasdisplayed.

Vision, strategy, innovation and sustainability andstrategy for this this core service

• Staff were positive and focused on how to improve theservices for patients and about providing a high qualityservice.

• There was a vision and strategy in place dated 6 August2015 to develop the early medical termination ofpregnancy service and to ensure that the serviceadvertised on the website was accessible, offeredinformed choice and a seamless service. To treat all thepatients with dignity and respect and provide aconfidential, non-judgmental services.

• The certificate of approval for carrying out terminationof pregnancy (issued by the Department of Health) wasdisplayed and dated 17 July 2014 valid until 31 July2018.


• There was a robust governance structure to manage riskand quality. Staff felt supported by the hospital director,the matron and senior managers. Staff said that theleadership and visibility of senior managers was good.

• The early medical abortion service and the surgicaltermination of pregnancy service staff told us that dueto the sensitivity of the procedure and the proceduresbeing a potentially emotional experience for thepatients it was challenging to engage with the patients.They were in the process of developing a specificquestionnaire, which could be completed following thetreatment to capture the patient views.

• There is a general risk register with various areas of riskidentified. The register included review dates, currentratings and target ratings based on the traffic lightsystem and a record of the action being taken to reducethe level of risk was maintained.

• A risk assessment has been undertaken for both surgicaland medical termination of pregnancy. The terminationof pregnancy core service was not identified as a risk tothe hospital.

• A team brief was circulated to all staff and includedgeneric, financial marketing and clinical elements.

• The consultant leading the early medical abortionservice took a lead role in ensuring that the hospital wasworking in line with current national guidance.

• The assessment process for termination of pregnancylegally requires that two doctors agree with the reasonfor the termination and sign a form to indicate theiragreement (the HSA1 Form). We looked at five patientrecords and found that all forms included twosignatures and the reason for the termination based onthe DH opinion in good faith.

• Spire Leicester had completed an HSA1 audit to ensureand evidence compliance. The audit ‘Completion ofLegal Documentation’ was carried out between Augustand December 2014 and demonstrated 100%compliance.

• The Department of Health (DH) required every providerundertaking termination of pregnancy to submitdemographical data following every termination ofpregnancy procedure performed. These contribute to anational report on the termination of pregnancy (HSA4forms). Patients were made aware that information isreported to and used statistically by the DH. The HSA4



Good –––


forms were signed within 14 days on the completion ofthe abortion by the consultant who terminated thepregnancy. The forms were then submitted to DH by theoutpatient senior sister following the medicaltermination procedure and the ward coordinator sisterfollowing the surgical procedure. It was discussed that itmay be more appropriate for the outpatient senior sisterto collate the HSA4 forms as part of the pathway andsubmit to DH.

• The Early Medical Abortion service maintained a registerof patients undergoing a termination of pregnancy,which was completed in respect of each person at thetime the termination was undertaken and was retainedfor a period of not less than three years beginning onthe date of the last entry.

• The surgical termination of pregnancy procedures wereidentified in the theatre register with a unique identifierof a red star.

Leadership/culture of service

• The senior sisters involved in the service felt very wellsupported by the matron and felt there was clearleadership.

• The culture within the hospital was caring andsupportive. Staff were actively engaged. Innovativeideas and approaches to care were encouraged andsupported particularly since the appointment of thenew matron. Staff spoke positively about the highquality care and services they provided for patients andwere proud to work for Spire Leicester.

• Staff displayed an enthusiastic, compassionate andcaring manner to the care they delivered. Theyrecognised that it was a difficult decision for patients toseek and undergo a termination of pregnancy.

• Staff spoke positively about the high quality care andservices they provided for patients. They described SpireLeicester Hospital as a good place to work and they feltempowered to be innovative particularly since the newMatron had been in post.

• Staff told us they were comfortable reporting incidentsand raising concerns. They told us they wereencouraged to learn from incidents. Staff felt they couldopenly approach senior managers if they felt the needto seek advice and support.


• Patients had been given feedback forms which asked fortheir opinion of the service. Staff however, told us thatdue to the sensitivity of the procedure and theprocedures being potentially emotional experience forthe patients it was challenging to engage with thepatients.

• The results of the BUPA Customer Satisfaction Results2014 Friends and Family element demonstrated that 98% of patients were ‘extremely likely’ to recommend theservice to family and friends.

• Staff surveys were completed to gain staff opinion ofworking at the hospital. The staff survey results for 2014were generally positive.

• The service facilitated wherever possible and legal, anyrequest made by a patient concerning management ofthe pregnancy remains, and provided relevant trainingto staff to enable them to meet those needs. Stafffollowed the policy ‘Consent for Disposal PregnancyLoss (2014)’ in accordance with ‘Human TissueAuthority, Code of Practice 5, and Disposal of HumanTissue (2009)’. All patients signed a consent form for thedisposal of pregnancy remains. Following a surgicalprocedure the pregnancy loss is stored sensitively andseparately in an opaque container and kept for sixweeks.

• Where a patient wished to dispose of the pregnancyremains privately, staff provided them with a specificinformation sheet which laid out how this processshould be managed and how the patient would maketheir own arrangements. We were informed that thishad recently happened as a patient had requested thepregnancy remains on religious grounds. This had beendealt with sensitively and with dignity.


• Medical termination of pregnancy was an example of aninnovative service as it enabled women to have choiceother than a surgical procedure within an independenthospital setting. It was driven in response to patientdemand and offered women choice.



Good –––


Areas for improvement

Action the provider MUST take to improve

• Ensure that you maintain securely an accurate,complete and contemporaneous record in respect ofeach service user, including a record of the care andtreatment provided to the service user and ofdecisions taken in relation to the care and treatmentprovided. There was no audit system for ensuring thatmedical notes were fully completed within thechildren’s and young people’s service.

• Ensure arrangements are put in place to monitoroutpatient appointment cancellations and delays.

Action the provider SHOULD take to improve

• Ensure paediatric and adult drug boxes forresuscitation are not of a similar colour to aid quickidentification in an emergency.

• Ensure appropriate interpreting services following bestpractice are always available for those whose firstlanguage is not English.

• Ensure auditing samples for compliance with the fivesafer steps to surgery are more representative of thenumber of patients undergoing surgical procedures.

• Ensure that there is an effective system in place forcontacting a radiologist urgently.

• Ensure that the minor operations room has a plan inplace for ensuring patient safety and that treatmentcan be provided rapidly without delay.

• Ensure that the privacy and dignity of patients usingthe imaging department is maintained.

• Ensure that all staff working with oncology patients inthe chemotherapy unit are aware of the goldstandards framework.

• Ensure practice is reviewed around the use of themalnutrition universal screening tool.

• Ensure a protocol for children with learning difficultiesis developed.

• Ensure that staffing and workforce development plansare developed in parallel with the paediatric strategy

• Ensure the areas where children are cared for areappropriate for the needs of the child.

Outstandingpracticeandareasforimprovement

Outstanding practice and areasfor improvement


Action we have told the provider to takeThe table below shows the legal requirements that were not being met. The provider must send CQC a report that sayswhat action they are going to take to meet these requirements.

Regulated activity

Diagnostic and screening procedures

Surgical procedures

Treatment of disease, disorder or injury

Regulation 17 HSCA (RA) Regulations 2014 Goodgovernance

Regulation 17(1)(2)(c) of the Health and Social CareAct 2008 (Regulated Activities) Regulations 2014:Good Governance

How the regulation was not being met:

Systems or processes must be established and operatedeffectively to ensure compliance with the requirementsin this part.

Without limiting paragraph (1), such systems orprocesses must enable the registered person, inparticular, to –

‘’Maintain securely an accurate, complete andcontemporaneous record in respect of each service user,including a record of the care and treatment provided tothe service user and of decisions taken in relation to thecare and treatment provided.’’

We found gaps in some of the patient records wereviewed. We were told that some consultants used theirown notes rather than Spire medical records in which torecord the patient’s outpatient consultation and not allthose notes were retained within the Spire medicalrecord.

Regulation

This section is primarily information for the provider

Requirement noticesRequirementnotices


There was no audit system for ensuring that medicalnotes were fully completed within the children’s andyoung people’s service.

Regulated activity

Diagnostic and screening procedures

Surgical procedures

Treatment of disease, disorder or injury

Regulation 17 HSCA (RA) Regulations 2014 Goodgovernance

Regulation 17(1)(2)(a)(b) of the Health and SocialCare Act 2008 (Regulated Activities) Regulations 2014:Good governance

How the regulation was not being met:

The provider did not ensure that cancellations anddelays with patient appointments are monitored. Datawas collected but not audited or actioned further toprevent or reduce these events in future.

Regulation

This section is primarily information for the provider

Requirement noticesRequirementnotices


spire leicester hospital newapproachcomprehensive report ... ·...

Documents