6 June 2016
During a routine inspection
Spire Cambridge Lea Hospital is part of Spire Healthcare Limited. Spire Cambridge Lea offers comprehensive services to patients from Cambridge, Suffolk and Peterborough. The hospital is located in the village of Impington, just north of Cambridge and is accessible from the A14 and the M11, as well as being 30 minutes from London Stansted airport.
Healthcare is provided to patients with private medical insurance, those who self-pay and patients referred through NHS contracts. Hospital facilities include an outpatient service, diagnostic imaging service, 15 day-case beds and a 46 bedded inpatient ward. Theatre provision includes five theatres, three of which have laminar flow and an in house sterile services department. From January 2015 to December 2015 there were 7,539 visits to theatre.
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.
We carried out an announced inspection of Spire Cambridge Lea on 6 June 2016, Following this inspection we also undertook an unannounced inspection on the 20 June 2016, to follow up on some additional information.
The inspection team inspected the following core services:
- Surgery
- Outpatients and diagnostics
All services at this hospital were inspected during our visit.
We rated Spire Cambridge Lea as good overall,with caring as outstanding. Core services achieved good overall in surgery and outpatient and diagnostics.
Our key finding were as follows :
Are services safe at this hospital/service
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Staff were aware of the incident reporting system. There were good examples of incident investigations and root cause analysis (RCA). Learning from incidents was shared with staff and there was evidence of recommendations to improve the service.
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The hospital completed a ‘Deep Dive’ into all reported patient deep vein thrombosis. Should there be any cause for concern or learning, an RCA would be performed. The report is submitted to the central clinical governance team. This information is logged and analysed quarterly for trends and learning.
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Staff were aware of duty of candour, and we saw evidence of when duty of candour had been applied in conjunction with incidents.
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The hospital collected data to support the safe running of the service on the clinical scorecard. The scorecard was predominantly positive. However, seven out of the 35 clinical outcomes were not consistently met in 2015, but improvements had been made in 2016 in four of these measures, which improved patient safety. The remaining three measures which were not met in 2016 related to the Net Promoter Score measure for patient satisfaction/feedback. Action plans were in place to monitor improvement.
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The mandatory training target of 95% had been achieved for 2015.
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Safeguarding training had met the hospital’s target of 25% per quarter. Knowledge of safeguarding was good, and staff who required level three safeguarding children, for example consultants and matron, had completed the training. The hospital had recently updated the safeguarding training to include female genital mutilation (FGM) and radicalisation.
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Monitoring of hand hygiene was carried out by measuring hand sanitisation usage, which lacked credibility. The infection control lead nurse had been undertaking local observation hand hygiene audits on a quarterly basis since January 2016 as part of the ‘Saving Lives Care Bundle’ audit. Spire Healthcare were implementing a national observational hand hygiene audit within the clinical scorecard measures from July 2016.
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Nurse staffing levels across the hospital were planned, met consistently and sufficient.
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A single patient record was not held on site, and we found patient records containing loose notes. The hospital had taken steps to address this and had commenced a pilot of a single patient record at the time of our inspection.
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The World Health Organization (WHO) Five Steps to Safer Surgery checklist was in use at the hospital. However, we observed the completion of a WHO checklist prior to the commencement of a surgical procedure and noted poor practice. On our unannounced inspection the hospital had introduced a new WHO checklist which mirrored the one used in the NHS trust. This had been well received by staff. We observed the checklist being completed appropriately and there was evidence of regular auditing to ensure that the new document became embedded.
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Are services effective at this hospital/service
- Hospital policies were evidence based and we saw examples of where policies had been revised in line with best practice guidance.
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There was a good level of local auditing across the hospital, and good examples of participation in national audits in surgery, for example the Health Protection England surgical site infection surveillance.
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The annual compliance score with pre-operative fasting guidelines for 2015 was 41%, but had increased to 55% in the first three months of 2016. However,
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Patient Reported Outcome Measures (PROMS) data was collected for groin hernia surgery, total knee and hip replacements. All results for this hospital were above the England average for NHS patients.
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Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards training compliance was low at 17%. However, this had increased to 70% at end of May 2016, following additional face to face training provided. Staff were knowledgeable about MCA and Deprivation of Liberty Safeguards. There were good processes in place to obtain consent from patients.
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There was evidence of good multidisciplinary team working, between teams and specialists.
Are services caring at this hospital/service
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Friends and Family Test results (July 2015 to December 2015) were consistently above average, scoring between 97 and 100% of people recommending the hospital.
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Patient feedback at the time of inspection was positive, with patients speaking highly of the care and treatment received. Patients and relatives felt involved in decision making.
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A chaperone service was available to support patients undergoing intimate examinations.
Are services responsive at this hospital/service
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Referral to treatment times (RTT) for NHS patients undergoing surgery was within the national expected timescale of 18 weeks for all patients.
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Services were available for patients with additional needs, for example translation services, hearing loops and the ability for relatives to stay with patients who require additional support.
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The hospital provided formal dementia training and this had met the hospital quarterly trajectory for staff attendance.
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Consultant medical cover was available 24 hours per day, seven days per week via clinics, daily inpatient review, the on call system and resident medical officer (RMO). There was a senior nurse on call rota which provided additional support if there were staffing issues on the ward or patients required to be transferred out into an NHS acute hospital.
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There was a robust system for dealing with, and learning from complaints. We saw examples of where the hospital had worked directly with the complainant to improve services. Outcomes and learning from complaints were shared with staff.
Are services well-led at this hospital/service
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The hospital had a clear vision and strategy underpinned by a set of core values for staff to follow. Staff were aware of the vision and strategy.
- Governance processes were well established, including incident management, audit, policy management and learning from complaints. Information flows between committees were well documented. However, review dates on the hospital risk register were not always recorded. This meant we could not be assured risk management and mitigation was being reviewed regularly.
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The hospital had a consultant dashboard, which included the monitoring of practising privileges. Processes were in place with local NHS trusts to ensure communication in relation to consultants’ practice.
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There was an open and transparent attitude to serious incidents which involved duty of candour.
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We reviewed minutes from the medical advisory committee and clinical governance meetings which showed a good level of scrutiny and challenge from a senior level.
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There were examples of innovation and sustainability, such as plans to extend the hospital provision of their Enhanced Recovery Area (ERA) to provide increased capacity to care for level one patients (patients requiring additional monitoring or clinical interventions), with completed staffing competency in place for the end of 2016.
We saw several areas of outstanding practice including:
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There was a system in place which recorded and monitored consultants’ competencies, mandatory training, continued professional development, indemnity and revalidation. This information was part of a rolling programme within the medical advisory committee (MAC) meetings, before being signed off by the hospital director and matron in order to re-establish consulting practising privileges.
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The hospital director, matron and MAC chair had clear oversight on the running of the hospital. The director had worked hard to improve staff engagement since coming into post, and had increased the senior management team to improve visibility and to ensure all areas of the hospital were represented at senior level. Staff had nothing but praise for the management team, with exceptional feedback given for the new matron.
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The hospital responded promptly to all areas of concern raised during our inspection, with changes noted on our unannounced visit. However, changes need to be monitored and embedded.
However, there were also areas of where the provider needs to make improvements.
The provider should:
- Ensure that within the theatre department, improvements made concerning equipment and the World Health Organisation (WHO) Five Steps to Safer Surgery checklist are sustainable.
- Review the Royal College of Surgeons professional standards on consultation for cosmetic surgery and ensure it is working in line with these standards.
- Consider the adequacy of the low compliance target for the percentage of patients being correctly fasted prior to surgery.
- Consider the effectiveness of action planning and follow up to demonstrate improvements.
- Hospital wide and departmental risk registers should be reviewed to ensure that they correlate, and should have a method for capturing review dates, recommendations, actions, responsible individuals, deadlines and dates of completion of actions.