Archived: Spire Hull & East Riding Hospital

Updated 16 May 2016

Spire Hull and East Riding Hospital is operated by Classic Hospitals Limited. The hospital opened in 1986. It is a private hospital situated in Anlaby, located in the west of Hull. Spire Hull and East Riding Hospital primarily serves the communities of the East Riding of Yorkshire and Hull. It also accepts patient referrals outside of this catchment area.

Facilities at the hospital site include an operating suite containing four operating theatres all with laminar flow. The suite also offers an integral, accredited sterile services department and two recovery areas consisting of nine bays in total. There was a three bedded critical care unit in close proximity to the operating suite. Spire Hull and East Riding Hospital is registered with CQC for 56 beds, of which 55 are in use; 49 inpatient beds and six day case beds. There are also x-ray, outpatient and diagnostic facilities.

In 2014 the parent company Classic Hospitals Limited acquired Spire Hesslewood Clinic, which is located approximately one and a half miles south of Spire Hull and East Riding Hospital and is operated as a satellite to Spire Hull and East Riding and is under the same management structure. After a six month commissioning period Spire Hesslewood Clinic began caring for patients from February 2015 on a ‘walk in, walk out’ basis. There are two minor procedures theatres and outpatient consulting rooms at the clinic, which offer services for dermatology, Botox, chronic migraine, dietetics, podiatry, orthotics, rheumatology and outpatient ophthalmology.These services had previously been offered at Spire Hull and East Riding Hospital. Staff are ‘flexed’ across the two sites, which also share the same Medical Advisory Committee, Senior Management Team, a single medical records storage site, policies and procedures. The two sites also have a combined data collection process and clinical dashboard, meaning that data is not available at a site level for Spire Hesslewood Clinic. The two sites are registered separately with CQC.

The hospital’s ward has 34 single rooms, all with en-suite facilities, and a specifically designed suite which consists of three, four and five bedded bays offering single sex accommodation. There is a day case suite which provides six bays. The outpatient department has: 13 consulting rooms; one treatment room; one phlebotomy room; pathology services; imaging (with mobile MRI) and CT service; a cardiac service; and physiotherapy services. Children are treated at Spire Hull and East Riding Hospital from the age of three and upwards for outpatient services, elective day case or overnight surgery. Children under three are treated in Dermatology Outpatients Clinics, however, no interventional treatment is given. There is also a restaurant providing food for patients, staff and visitors.

There were no special reviews or investigations of the hospital ongoing by the CQC at any time during 2014/15. The hospital has been inspected four times, and the most recent inspection took place in November 2013 which showed the hospital was meeting all standards of quality and safety it was inspected against. We inspected this hospital as part of our independent hospital inspection programme. The inspection was conducted using CQC’s new comprehensive inspection methodology. It was a routine planned inspection. For this inspection, the team inspected the following five core services at Hull and East Riding hospital:

• Medicine
• Surgery
• Critical care
• Children and young people
• Outpatient and diagnostic imaging

In August 2015 the longstanding manager of five years was de-registered due to a promotion within the company. At the time of the inspection a new manager was in place and was registered with CQC in September 2015.

Updated 16 May 2016

Spire Hull and East Riding Hospital is operated by Classic Hospitals Limited. Facilities at the hospital site include four operating theatres, a three bedded critical care unit and the hospital is registered with CQC for 56 beds. There are also x-ray, outpatient and diagnostic facilities. We inspected this hospital as part of our independent hospital inspection programme. The inspection was conducted using the Care Quality Commission’s comprehensive inspection methodology. It was a routine planned inspection. We inspected the following five core services at the hospital: medicine, surgery, critical care, children and young people and outpatient and diagnostic imaging. We carried out the announced part of the inspection on the 14, 15, 16 September 2015 along with an unannounced visit to the hospital on 23 September 2015.

Overall we rated children and young people's services, surgery and critical care as requires improvement and outpatient and diagnostic imaging services as good. We inspected but did not rate medical care. This was because: we did not have sufficient evidence, the small size of the service and, most evidence relating to medical inpatient services was included within the surgical report as these were co-located within the surgical ward area.

Are services safe at this hospital/service

The hospital was visibly clean but there were gaps in assessing and auditing of infection prevention and control procedures. Most staff were aware of the duty of candour. Incidents were reported however, the quality of root cause analysis (RCA) investigations was inadequate. Staff received mandatory training in the safeguarding of vulnerable adults and children and the nursing and medical staff we spoke to were aware of their responsibilities and of appropriate safeguarding pathways to use to protect vulnerable adults and children. The resident medical officer (RMO) was based in the hospital 24 hours. We reviewed RMO cover and found it to be sufficient. We reviewed five RMO records and found that three had no DBS check: there was a lack of evidence in the files to provide assurance that the checks required for each RMO, as part of the service level agreement with the employing organisation, had been recorded. Two RMOs had no evidence that safeguarding training had been completed. There was no effective tool used to assess staffing levels within the ward area. There was no specific patient acuity tool. A projected occupancy ratio was used by the hospital as a basis to plan the staffing levels required however this did not take into account dependency or acuity. Additionally there was high throughput of patients on a daily basis who required care from registered nurses. Mandatory training was in place for all employed staff. Spire healthcare used a 12 month training programme with target compliance of 95% at the end of December 2015. Data we reviewed during the inspection showed that some areas of training fell below Spire’s expected compliance levels for the current period of time. For the medical staff, with practice and privilege rights, the mandatory training records were not always completed or checked with substantive employers; there were only three, out of 10, which we checked that had training evidence logged. There was inclusion/exclusion criteria in place for accepting surgical patients. The hospital undertook the ‘five steps to safer surgery’ checks. During the inspection, we observed an episode of non-compliance with these checks. Additionally two ‘never events’ had been reported in 2014/2015, both were as a result of wrong site surgery following inappropriate patient marking. We informed the manager at the time of the inspection of our concerns and formally wrote to the provider requesting further information and actions to ensure patients were safe. The bed spaces and facilities in the critical care unit did not fully comply with current Department of Health building note 04-02.

Are services effective at this hospital/service

Patients mostly were cared for in accordance with evidence-based guidelines. However, not all documentation in critical care was updated to reflect current evidence based best practice.  Critical care staff did not have the appropriate postgraduate training but actions to address this in 2016 were in place.  Consent procedures were in place and training compliance rates for the Mental Capacity Act 2005 were good. Policies were mostly developed nationally. There were clinical indicators, which were monitored and compared across the Spire locations through the publication of a quarterly clinical scorecard. However, there was no evidence to show the children’s and young people’s service monitored specific patient outcomes for children. The hospital held meetings where mortality and morbidity was discussed. The hospital participated in a number of in-house and national audits for surgical patients, such as the National Joint Registry (NJR) and Health Protection Agency (HPA) post-operative surgical wound healing. There were 17 cases of unplanned readmission within 29 days of discharge in the reporting period (Apr 14 to Mar 15) which was ‘similar to expected’ compared to the other independent acute hospitals. Consultants working at the hospital were utilised under practising privileges (authority granted to a physician or dentist by a hospital governing board to provide patient care in the hospital); these, with appraisals were reviewed every year by the senior management team. However, there were gaps in this process identified at the inspection.

Are services caring at this hospital/service

Patients were cared for in a positive and compassionate way. Patients and relatives we spoke with all gave positive examples of caring. We observed positive interaction of staff with patients and staff appeared genuine, supportive and kind. There were high (scores above 85) for the Friends and Family Test (FFT), however the response rate fluctuated from high levels (above 61%) to low levels (less than 30%). Internal organisational patient surveys showed positive responses around care received, discharge information, and privacy and dignity. Patient records we reviewed took into account patient preferences and patients felt they were involved with information and decisions taken about them. There were psychological assessments prior to cosmetic surgery being undertaken and evidence of General Practitioner involvement pre surgery was noted.

Are services responsive at this hospital/service

The service had grown in demand from when the hospital was first developed with further anticipated growth. Plans were in place to build and expand the site. Referral to treatment times (RTT) data for the reporting period April 2014 to March 2015 showed that the provider had exceeded the target of 90% of admitted patients beginning treatment within 18 weeks every month. However, a small number of patients were cancelled on the day of surgery due to over booking of theatre lists, list overruns and staff or equipment not being available. Theatre utilisation was low: utilisation was noted as being 51.66% over a 12 month period for all four theatres. Patients’ individual needs were mostly met. An increased number of complaints had been received in 2014 for the hospital and these had been rated as an amber risk on the corporate scorecard. However, for quarters one and two of 2015 the percentage of complaints responded to within the policy timescales was at 93% and none had been escalated to stage two. Complaints trends were monitored and actioned. There was an active group of volunteers working within the hospital who supported patients through their patient journey.

Are services well-led at this hospital/service

There was a vision and strategy in place for the hospital. However there was a lack of vision and strategy for the smaller core services and staff could not articulate the strategy for these services. Whilst there were governance structures in place for the provider and locally within with the hospital these were not effectively implemented; there was a perceived high element of trust between staff and as a consequence a low formal assurance culture. There was a hospital clinical governance committee in place. This committee fed directly into the medical advisory committee (MAC); the MAC averaged 50% clinical attendance at each meeting. It also had direct links into the senior management team and the hospital l group governance arrangements. We reviewed the hospital business risk register and the hospital risk analysis register. Open risks were noted with the oldest of the risks being documented in 2010. The monitoring system to ensure the doctors’ safety to practice within the hospital, especially the RMOs, was not effective at the time of the inspection, for example, not all the DBS checks were up to date. There was a lack of effective oversight and action to ensure that incident investigations were of a high standard and root causes identified. Staff described leadership and culture of the hospital in a positive manner. Staff were encouraged to suggest ways to make departments run more effectively and efficiently and we saw examples of where staff had made small changes, which made a big difference to patients. The management team actively engaged in proactive recruitment and retention of staff including recent staff incentive packages. The development of a neighbouring site had been identified as necessary to address increasing space constraints within outpatients and also to improve and extend services in response to increased demand.

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

Importantly, the provider must:

1. Ensure compliance with the ‘five steps to safer surgery’ procedures and World health organisation audit, specifically for interventional radiology.
2. Ensure that infection prevention and control policies and procedures are in place and audited specifically in relation to observational audits for hand hygiene, and theatre dress codes.
3. Ensure that there is robust and effective root cause analysis following a serious incident and to share any learning across all services.
4. Take action to ensure that the appropriate checks and records as per HR policies are in place and recorded for the doctors working at the hospital including Disclosure and Barring Service (DBS) checks, mandatory training and appraisals.
5. Ensure that the bed spaces and facilities in the critical care unit fully comply with current Department of Health building note 04-02 for Critical Care Units published in March 2013 and Health Building Note 00-09: Infection control in the built environment (March 2013).
6. Ensure that care pathway documentation in critical care is updated to reflect current evidence research based best practice.
7. Ensure that Midazolam and oxygen are correctly prescribed on a medication chart and signed post administration and that that all CD entries into the CD medicine book are dated within the endoscopy unit.

In addition there were a number of areas where the provider should take action and these are listed at the end of the report.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Updated 16 May 2016

Due to the small size of the service we did not have sufficient, robust information to rate the service.

The hospital had a single ward area. All medical inpatients and surgical patients were cared for in the same ward area and therefore, some aspects of the medical core service report were reflected under the core service surgery report.

We mainly reviewed the endoscopy and chemotherapy services therefore most of our evidence and conclusions relate to these services.

There was limited opportunity to talk with patients and relatives about the care given as there were no medical inpatients on the announced inspection. We did speak with four patients who were having endoscopic procedures and their comments were positive.

The controlled drug register within the endoscopy unit had four entries which were not dated. Prescription charts were not written up for the medications used during medical procedures. Decontamination processes for endoscopies were in-line with best practice guidance.

Updated 16 May 2016

We rated services for children and young people as requires improvement overall because:

The service was not carrying out observational hand hygiene audits. No incidents had been reported which involved children and young people. The environment was visibly clean and personal protective equipment was available.

Nurse staffing for children and young people was predominantly two part time contracted children’s nurses, one of whom was leaving for another position, and bank staff. The service planned elective surgical cases according to availability of appropriately trained staff. Senior staff told us they planned to recruit more children’s nurses.

The environment and equipment were well maintained and mandatory training was up to date. This enabled staff to carry out their roles effectively and safely.Training included awareness of safeguarding procedures and child protection. Procedures were in place for assessing and responding to patient risk, including risk assessment of rooms where child assessments took place. However, patient identification sheets, which were located in the front of each patient’s care records, all had missing entries which meant patients may not always be kept safe.

Children and young people had access to appropriate pain relief as and when required. Staff caring for children and young people had their competencies checked and received professional development, including an annual appraisal. Parents told us the care their children received was supportive and the staff were kind, caring and friendly. Both staff and parents told us they would recommend the service to their families and friends. The service had not received any complaints.

Senior nursing staff were unable to tell us about the vision and strategy for the children’s service. Governance, risk management and quality measurement within the service were not well developed and there was no evidence of continuous quality improvement. The hospital did not carry out any audits relating to services specifically for children and young people. Feedback from staff about the culture within the service, teamwork, staff support and morale was positive.

Updated 16 May 2016

We rated critical care services as requires improvement overall because:

The unit staff were reporting incidents and there was some evidence of some verbal feedback but processes needed to be formalised. There was limited evidence of monitoring of infection control procedures such as hand washing. The unit did not meet the recommended guidelines in terms of the built environment. Bed spaces were smaller than recommended and there was a lack of hand washing facilities and specialist equipment. Patient risks were identified but there was limited evidence that actions were taken to mitigate risks.

There was no lead intensivist although there was a lead anaesthetist. Nursing staff on the unit had not undertaken postgraduate critical care training although following our inspection this was discussed with the hospital management team and we were assured that actions had been put in place to address the nurse competency issues. Local pathways and guidelines had not been reviewed to ensure that these were in line with national guidance and formal procedures to audit compliance with standards were not implemented. Staff were not aware of key quality performance indicators. Staff were aware of their responsibilities regarding the mental capacity act. There had been no complaints about the unit for more than eighteen months. The number of emergency transfers to the local NHS trust for intensive care was low.

Staff were not aware of any vision or strategy for the unit. The lead anaesthetist and nurse manager oversaw the clinical management of the critical care unit. There was little evidence of quality monitoring processes or monitoring of actions taken on identified risks. The unit was described by some staff as a higher observation unit rather than a high dependency unit and there was a lack of clarity about the unit's purpose. Information gathered indicated that predominantly short term level two care was provided in the unit.

Updated 16 May 2016

We rated outpatients and diagnostic imaging services as good overall because:

Incidents were reported, investigated and lessons were learned and shared across the hospital. Risk assessments were up to date and protective measures were put in place where necessary. Staff adhered to policies and procedures and there was sufficient well-trained and competent nursing, allied health professional (AHP) and medical staff within the departments to deliver care safely.

The outpatient and diagnostic imaging departments offered appointments weekdays, evenings and Saturday mornings. Support services such as physiotherapy and radiology were in place 24 hours a day, seven days a week. The department participated in a number of local and national audits; however, information submitted for the inspection did not always include interpretation, benchmarking or actions for either improving or sustaining performance.

Patients told us they were treated with kindness and compassion and that staff were courteous and respectful. Receptionists were reported as excellent and chaperones were offered. Patients felt that confidentiality was excellent. Patients spoke very highly of the service provided by the pain clinic.

Patients could be seen quickly for urgent appointments if required and departments offered flexibility around clinic times. Clinics were rarely cancelled at short notice and waiting times for appointments were well within target timescales.

Staff and managers had a vision for the future of their services and staff felt empowered to express their opinions or concerns. Staff were engaged with the organisation’s mission to deliver the highest quality patient care and patients were given opportunities to provide feedback about their experiences of the services provided.

Updated 16 May 2016

We rated surgical services as requires improvement overall because:

There were omissions in infection control audits; policy implementation and policy into practice audits did not occur. Observational hand hygiene compliance or technique data audits were not performed. Due to the design of the main theatre suite, principles of theatre cleanliness, flow and theatre etiquette were compromised. Overall, limited assurance to support compliance with the hygiene code was provided.

Two wrong site surgeries were reported in 2014/15, both of which were reported as a 'Never event’ which had resulted in some changes in practice. The hospital used the ‘five steps to safer surgery’ checks, however, during the inspection an incident occurred where there was no marking of a patient prior to surgery and we reported this to the senior management team. The quality of root cause analysis (RCA) investigations following incidents was inadequate: we found a poor level of investigation, lack of medical involvement and a lack of conclusions and root causes being identified. This meant little evidence for learning or assurance to prevent re-occurrence.

Paper records we reviewed showed variable levels of completeness. We noted incomplete records for intentional rounding, missed medications, theatre checklists and pre-operative sign in. Assessments were often completed as part of the pre-operative assessment and not re-assessed post admission or surgery.

There was no effective patient acuity tool in use on the ward; instead a projected occupancy ratio was used by the hospital as a basis to plan the staffing levels. It did not take into account acuity and dependency of patients; therefore, the management could not effectively assure themselves that staffing was safe.

Staff received mandatory training however compliance rates in a number of areas, at the time of inspection, were recorded as below the hospital’s expected levels; especially in resuscitation training with below 50% attendance on life support courses. Medical personnel records we reviewed had variable levels of compliance with the HR policies. DBS checks were not performed in line with Spire’s policy and in three sets of records we reviewed no check was recorded. Mandatory training records and certification seen from substantive employers were not always documented as checked, and full sets of references were not always available.