spire nottingham hospital newapproachcomprehensive report … · 2020. 4. 21. ·...

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 Outstanding –

Are services safe? Good –––

Are services effective? Good –––

Are services caring? Good –––

Are services responsive? Outstanding –

Are services well-led? Outstanding –

Mental Health Act responsibilities and Mental Capacity Act and Deprivation of LibertySafeguardsWe include our assessment of the provider’s compliance with the Mental Capacity Act and, where relevant, MentalHealth Act in our overall inspection of the service.

We do not give a rating for Mental Capacity Act or Mental Health Act, however we do use our findings to determine theoverall rating for the service.

Further information about findings in relation to the Mental Capacity Act and Mental Health Act can be found later inthis report.

SpirSpiree NottinghamNottingham HospitHospitalalQuality Report

Tollerton Lane,Tollerton,NottinghamshireNG12 4GATel: 0115 937 7800Website: www.spirehealthcare.com

Date of inspection visit: 5 to 6 February 2018Date of publication: 01/06/2018

1 Spire Nottingham Hospital Quality Report 01/06/2018

Letter from the Chief Inspector of Hospitals

Spire Nottingham Hospital is operated by Spire Healthcare Limited. The hospital opened on 29 April 2017. It is a newpurpose built independent healthcare hospital in Nottingham, Nottinghamshire. The hospital has 42 beds. Facilitiesinclude four operating theatres, one of which is a hybrid theatre, a day case theatre suite, a five-bed level three intensivecare unit (currently this is not operational), chemotherapy suite and X-ray, outpatient and diagnostic facilities.( A hybridtheatre is equipped with advanced medical imaging devices. These devices enable minimally-invasive surgery.)

The hospital currently provides surgery, and outpatients and diagnostic imaging. We inspected surgery, and outpatientand diagnostic facilities.

We inspected this service using our comprehensive inspection methodology. We carried out an announced inspectionon 5 and 6 February 2018.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are theysafe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’performance against each key question as outstanding, good, requires improvement or inadequate.

Throughout the inspection, we took account of what people told us and how the provider understood and compliedwith the Mental Capacity Act 2005.

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

Services we rate

We rated this hospital as outstanding overall, and we rated safe, effective and caring as good. We rated responsive andwell-led as outstanding, this was because:

• People were respected as individuals and supported to be involved in their care. There was a strong focus onmaintaining the privacy and dignity of patients. Patients’ feedback about the quality of care and their experiencewas overwhelmingly positive.

• Patients could access care and treatment promptly at a time that suited them.

• Complaints were taken seriously and were investigated and responded to within agreed timescales. Changes to theservice were made as a result of complaints.

• The hospital management team worked collaboratively to ensure the needs of the local population were met. Themanagement team were proactive in developing services, such as the progression of introducing new serviceswhen it was safe to do so.

• The vision and values were understood and well embedded in staff’s daily work. Staff felt supported by a leadershipteam that inspired them and who were credible and visible. Staff were proud to work at the hospital and there werehigh levels of satisfaction across all staff groups. Staff felt involved in the running of the hospital and wereencouraged to suggest ideas for improvement.

• A safe and high quality service was assured through robust governance structures that proactively reviewedperformance, identified areas of risk or emerging concern and made arrangements to mitigate these risks and driveimprovement.

• There were innovative approaches to gather feedback from patients and actions to improve services were made asa result of such information.

Summary of findings


• Data demonstrated a good track record in safety. There were clearly defined systems to report, investigate andlearn from incidents and when things went wrong, and the duty of candour was enacted.

• There were sufficient numbers of staff with the necessary skills, experience and qualifications to meet patients’needs. There was a programme of mandatory training in key safety areas, which all staff completed, and systems forchecking staff competencies and for identifying and meeting staff’s training needs.

• There were systems and process for recognising and reporting potential abuse, for preventing and controllinginfection and for managing medicines which were consistently applied by staff.

• Care was planned and delivered in line with current standards and best practice. There were audit arrangements toprovide assurance of this and systems to review new guidance and oversee its implementation.

• Patients had access to a full range of health care professionals who worked together as an integrated team to meetpatients’ needs. Staff could access patients’ records and other clinical information when it was required. Therewere systems to follow up patients after discharge and to liaise with their GPs.

• Patients consented to their treatment in line with relevant legislation, including those who may lack capacity tomake decisions for themselves.

Following this inspection, we told the provider it should make some improvements, even though a regulation had notbeen breached, to help improve the service.

Professor Edward Baker

Chief Inspector of Hospitals

Overall summary

Spire Nottingham Hospital is operated by SpireHealthcare Limited. The hospital opened on 29 April 2017.It is a new purpose built independent healthcare hospitalin Nottingham, Nottinghamshire. Spire NottinghamHospital is situated south of Nottingham city centre; itopened almost two years after work started on theproject. A full project team including engineering,pharmacy, pathology, IT, logistics, purchasing,recruitment and training supported the SeniorManagement Team in getting the hospital ready foropening. A majority of the consultants who havepractising privileges at the hospital are from the localNHS hospital trust. The hospital’s main specialties areorthopaedics, spinal surgery, urology, gynaecology,general surgery, plastic surgery, ophthalmology, ENT, oralsurgery, gastroenterology and breast surgery. SpireNottingham Hospital is the only hospital in the regionwith a hybrid theatre.

The hospital primarily serves the communities of theNottinghamshire, Lincoln and North Leicestershire areas.It also accepts patient referrals from outside these areas.

Services are provided to NHS patients, and self-fundedpatients who may be insured or who self-pay to cover thecosts of their treatment.

The hospital currently provides services to adults only. Itstopped providing children’s and young people’s servicesin October 2017.It offers outpatient, day case andinpatient services for a range of specialities includingorthopaedics, ophthalmology, gynaecology, urology, ear,cosmetic and general surgery. Additional services offeredon an outpatient basis include rheumatology,dermatology and cardiology. These services aresupported by on-site physiotherapy and diagnosticimaging departments.

The hospital has been registered with the CQC to carryout the following regulated activities since April 2017:

• Surgical Procedures

• Treatment of disease, disorder or injury

• Diagnostic and screening services

• Services in slimming clinics

Summary of findings


• Family Planning Services

The hospital has had a registered manager and adesignated controlled drugs accountable officer (CDAO)in post since registration in April 2017. Spire HealthcareLimited has a nominated individual.

This was the hospital’s first inspection since opening.There were no special reviews or investigations of thehospital ongoing by the CQC at any time during the ninemonths since opening.

Summary of findings


Our judgements about each of the main services

Service Rating Summary of each main service

Surgery

Outstanding –

Surgery was the main activity of the hospital.Where our findings on surgery also apply to otherservices, we do not repeat the information butcross-refer to the surgery section.We rated this service as outstanding because patientswere protected from abuse and avoidable harm andreceived care and treatment that reflected bestpractice guidance from competent staff.Patients were treated as partners in their care, andvalued as individuals which protected their dignity andprivacy.Patients’ feedback was overwhelmingly positive.Services were tailored to individual needs and therewas flexibility to ensure patients’ choices andpreferences were respected.The management team were focused on the deliveryof safe and effective care, and there were robustgovernance arrangements used to drive serviceimprovement.All staff showed an appreciation of the hospital’svalues and this was demonstrated in their daily work.

Outpatientsanddiagnosticimaging

Outstanding –

We rated this service as outstanding because peoplewere protected from avoidable harm and abuse andthere were systems for reporting and learning fromsafety incidents.Patients received care and treatment that was basedon current national guidelines from staff who werecompetent to do their jobs.Patients were valued as individuals and their dignitywas truly respected. Feedback from patients wasunfailingly positive.Patients could access care and treatment in a timelyway and there was flexibility around timing ofappointments. The individual needs of patients wererecognised and arrangements made to meet them.The leadership was robust and visible, with a focus onproviding a safe service that met the needs of thepatients.

Summary of findings


There were robust governance arrangements that gaveadequate assurance and which drove improvement.Staff demonstrated the organisation's values throughtheir work.

Summary of findings


Contents

PageSummary of this inspectionBackground to Spire Nottingham Hospital 9

Our inspection team 9

Information about Spire Nottingham Hospital 9

The five questions we ask about services and what we found 12

Detailed findings from this inspectionOverview of ratings 16

Outstanding practice 57

Areas for improvement 57

Summary of findings


Spire Nottingham Hospital

Services we looked atSurgery; Outpatients and diagnostic imaging.

Outstanding –


Background to Spire Nottingham Hospital

Spire Nottingham Hospital is operated by SpireHealthcare Limited. The hospital opened on 29 April 2017.It is a new purpose built independent healthcare hospitalin Nottingham, Nottinghamshire. Spire NottinghamHospital is situated south of Nottingham city centre; itopened almost two years after work started on theproject. A full project team including engineering,pharmacy, pathology, IT, logistics, purchasing,recruitment and training supported the SeniorManagement Team in getting the hospital ready foropening. A majority of the consultants who havepractising privileges at the hospital are from the localNHS hospital trust. The hospital’s main specialties areorthopaedics, spinal surgery, urology, gynaecology,general surgery, plastic surgery, ophthalmology, ENT, oralsurgery, gastroenterology and breast surgery. SpireNottingham Hospital is the only hospital in the regionwith a hybrid theatre.

The hospital primarily serves the communities of theNottinghamshire, Lincoln and North Leicestershire areas.It also accepts patient referrals from outside these areas.

Services are provided to NHS patients, and self-fundedpatients who may be insured or who self-pay to cover thecosts of their treatment.

The hospital currently provides services to adults only. Itstopped providing children’s and young people’s servicesin October 2017.It offers outpatient, day case and

inpatient services for a range of specialities includingorthopaedics, ophthalmology, gynaecology, urology, ear,cosmetic and general surgery. Additional services offeredon an outpatient basis include rheumatology,dermatology and cardiology. These services aresupported by on-site physiotherapy and diagnosticimaging departments.

The hospital has been registered with the CQC to carryout the following regulated activities since April 2017:

• Surgical Procedures

• Treatment of disease, disorder or injury

• Diagnostic and screening services

• Services in slimming clinics

• Family Planning Services

The hospital has had a registered manager and adesignated controlled drugs accountable officer (CDAO)in post since registration in April 2017. Spire HealthcareLimited has a nominated individual.

This was the hospital’s first inspection since opening.There were no special reviews or investigations of thehospital ongoing by the CQC at any time during the ninemonths since opening.

Our inspection team

The team that inspected the service comprised of YinNaing inspection manager,three other CQC inspectors,and two specialist advisors with expertise in surgery andoutpatient services. The inspection team was overseen byCarolyn Jenkinson, Head of Hospital Inspection.

Information about Spire Nottingham Hospital

The main service provided is inpatient surgery, andoutpatient services. The hospital has two wards with 42beds in total. However, currently only Hazel ward (20

beds) is in use. Patients are cared for in single, en-suiterooms which means there is no mixed genderaccommodation. The ward treats both day case and

Summaryofthisinspection

Summary of this inspection


overnight patients and can provide extended recoverycare level one as required. There are four operatingtheatres, one of which is a hybrid theatre. All four theatresprovide laminar flow (a system of circulating filtered air,this system reduces the risk of airborne contamination).Endoscopy services are also provided although these arenot Joint Advisory Group on gastrointestinal endoscopy(JAG) accredited currently due to not being open 12months.

There is a separate outpatient department (20 rooms)including a plaster room, a gynaecology treatment room,ear, nose and throat treatment room, cardiologyassessment room, pre-operative assessment room, threefurther treatment rooms, ophthalmic examination room,prayer room/quiet room, multiple large and small waitingareas with beverage facilities, GP room, clean and dirtyutility rooms. The physiotherapy service has eightindividual treatment rooms and a large gym with exerciseand weight machines, free weights, Pilate’s area andvisual training feedback systems. An imaging departmentwhich provides 3 Tesla MRI (indicator of magneticstrength), 128 slice dual source CT(higher resolution andspeed ), fluoroscopy (an x-ray procedure that makes itpossible to see internal organs in motion) and plain filmX-ray, changing rooms, multiple reporting areas, ultrasound rooms and a digital mammography room. Thehospital has its own pharmacy, pathology and sterileservices unit. The hospital also has a six podchemotherapy unit and a five bedded critical care unitwhich are not currently operational. Currently thehospital does not treat patients under the age of 18 years.However as patient numbers increase and the businessdevelops it is envisaged that all areas will be used andpatients under the age of 18 will be offered treatments.

We carried out an announced inspection visit on the 5and 6 February 2017. During this inspection, we visitedthe ward, theatres, imaging and outpatientsdepartments. We also visited the clinical support services.We spoke with 48 members of staff including; registerednurses, healthcare assistants, reception staff, medicalstaff, operating department practitioners, and seniormanagers. We spoke with 14 patients and two relatives.We also received 52 ‘tell us about your care’ commentcards which patients had completed prior to ourinspection and 10 Spire comment cards. During ourinspection, we reviewed 20 sets of patient records and 12sets of personnel files.

Activity (April 2017- November 2017)

• In the reporting period April 2017- November 2017there were 371 inpatient and day case episodes ofcare recorded at the hospital; of these 18% wereNHS-funded and 82% other funded.

• Six percent of all NHS-funded patients and 35% of allother funded patients stayed overnight at thehospital during the same reporting period.

• There were 2,524 outpatient total attendances in thereporting period; of these one percent wereNHS-funded and 99% were other funded.

Staffing

There are 137 medical staff with practising privilegesincluding surgeons, anaesthetists, and radiologists.Two regular resident medical officers (RMOs) areemployed under a contract with an external agencyworking a seven days on duty, seven days off rota.

The hospital employed 36.4 full-time equivalent(FTE) registered nurses, 16.3 care assistants andoperating department practitioners, and 80.7 FTEother staff as well as having its own bank staff.

Track record on safety (April 2017- November 2017)

• There were no reported never events.

• A total of 129 clinical incidents were reported. Insurgery, 99 clinical incidents were reported of which82 were graded as causing no harm, six as low harm,and 11 as moderate harm. In outpatients anddiagnostic imaging 30 clinical incidents werereported.

• No serious injuries were reported.

• No reported deaths.

• No incidences of healthcare associatedMeticillin-resistant Staphylococcus aureus (MRSA)reported.

• No incidences of healthcare associatedMeticillin-sensitive staphylococcus aureus (MSSA)reported.

• No incidences of healthcare associated Clostridiumdifficile (C.difficile) reported.




• No incidences of healthcare associated Escherichiacoli (E-Coli) bacteraemia reported.

• One incident of hospital acquired venousthromboembolism (VTE) or pulmonary embolism(PE) reported. (This was reported to CQC by theprovider in December 2017 as part of the providers’requirements to report incidents resulting in patientharm.)

• Eleven complaints were received by the hospital, butnone were received by the CQC. No complaints werereferred to the Parliamentary Health ServicesOmbudsman or the Independent Healthcare SectorComplaints adjudication service.

External Accreditation

Currently no accreditations are held as the hospitalhas not been open 12 months. However applicationfor SGS Accreditation for Sterile Services Departmentand Joint Advisory Group on GastrointestinalEndoscopy (JAG) are in progress.

Services provided at the hospital under servicelevel agreement:

• Resident Medical Officer

• Critical Care Transfer

• Supply of Blood and Blood Components

• EIDO Healthcare LTD supply of patient information

• Medical Gases Provision

• Medical Equipment Servicing

• Laundry and Linen Services

• Pathology

• Translation/interpreting Services.




The five questions we ask about services and what we found

We always ask the following five questions of services.

Are services safe?We rated safe as good because:

• There was an open incident reporting culture within thehospital, and an embedded process for staff to learn fromincidents. All staff demonstrated an understanding of the dutyof candour and the principles behind this.

• The hospital monitored safety through a clinical scorecard with47 clinical indicators. The scorecard was used forbenchmarking against other Spire hospitals and to identifyareas for improvement.

• Staff were knowledgeable about safeguarding processes andwhat constitutes abuse.

• There were processes in place to manage a deterioratingpatient and staff spoke confidently on steps they would take tomanage a patient. Staff used a national early warning scoringsystem to aid identification of a deteriorating patient.

• There were sufficient numbers of staff with the necessary skills,experience and qualifications to meet patients’ needs. Theywere supported by a programme of mandatory training in keysafety areas. There were simulation exercises that kept staffskills current.

• Equipment was serviced and visibly clean and processes werein place to ensure all items were well maintained.

• The environment was fit for purpose and visibly clean and tidy.We observed good levels of infection prevention and controlpractice throughout the department.

However, we also found the following issues that the serviceprovider needs to improve:

• Documentation was not always completed in line withprofessional standards.

Good –––

Are services effective?We rated effective as good because:

• Policies, procedures and guidelines were up to date and basedon National Institute for Health and Care Excellence (NICE)guidelines, relevant regulations and legislation.

• Quality improvements were made as a result of audits and thehospital benchmarked its performance against other Spirehospitals.

Good –––




• Patients received appropriate pain control and food and drinkthat met their needs and preferences.

• Staff worked collaboratively as part of a multi-professionalteam to meet patients’ needs. There were systems thatdemonstrated staff were competent to undertake their jobs andto develop their skills or to manage under-performance.

• There was effective multidisciplinary team working throughoutthe department and with other departments in the hospital.

• Staff had regular development meetings with their departmentmanager, and were encouraged to develop their roles further.Information provided by the hospital showed 100% of staff hadbeen appraised.

• Staff could access information they needed to provide care andtreatment in a timely manner.

• The physiotherapy department had started to collate patientoutcome data. This information was used locally to developand improve treatment plans for patients.

• Staff demonstrated an effective knowledge of the consentprocess and we observed staff gaining consent in accordancewith local policy and professional standards.

Are services caring?We rated caring as good because:

• Patients were always treated with dignity, respect andcompassion. This was reflected in the feedback received frompatients who told us staff were very caring.

• Patients received information in a way which they understoodand felt involved in their care. Patients were always given theopportunity to ask staff questions, and patients felt comfortabledoing so.

• Feedback from patients and relatives was consistentlyextremely positive, and patients told us they would recommendthe department to their friends and family.

• Staff provided patients and those close to them with emotionalsupport; all staff were sympathetic to anxious or distressedpatients.

Good –––

Are services responsive?We rated responsive as outstanding because:

• Hospital managers had worked with the local community andlocal commissioning groups to plan and deliver services tomeet the needs of local people.

Outstanding –




• There was a proactive approach to meeting the individualneeds of patients. Staff in the outpatient department hadworked hard to ensure the needs of patients living withdementia were taken into consideration.

• Staff on the ward had put together a dementia box. Relatives orcarers could stay overnight to reduce anxiety for patients livingwith dementia.

• There were one-stop clinics available for some specialitiesincluding breast care and basal cell carcinoma to minimise thenumber of attendances to the department. Staff were lookingto provide more one-stop clinics in other specialities.

• Staff were encouraged to resolve complaints and concernslocally, which was reflected in the low numbers of formalcomplaints made against the service.

• Patient complaints and concerns were managed according tothe hospital policy. Complainants were kept informed of theprogress and could discuss their complaint face to face if theywished.

• Complaints were investigated thoroughly, analysed for trendsand themes. We saw learning identified and shared to improveservice quality.

• The diagnostic imaging department ensured a quick turnaround on the reporting of procedures. Time taken for reportingwas between two and three days.

• Services were planned and delivered in a way that met theneeds of the local population. On the day appointments couldbe provided for patients with the required referral paperwork,as well as a range of appointment times for those who workedduring the week.

• Patients could access services easily; appointments wereflexible and waiting times short. Appointments and proceduresoccurred on time and patients were kept informed of next stepsthroughout the care pathway.

.

Are services well-led?We rated well-led as outstanding because:

• The hospital had a clear vision and strategy which was realisticand was reflected through team and individual staff memberobjectives.

• Staff understood the vision and strategy and their role incontributing towards it.

Outstanding –




• There was a clear governance structure, which all members ofstaff were aware of and involved in. There was evidence ofinformation escalated from local level governance meetingsand information cascaded from top-level governance meetings.

• Staff were extremely positive about their local leaders and feltthey were supported and appreciated. This positivity alsoextended to the executive level of leadership, who wereextremely visible and approachable.

• The morale amongst the departments was very high and stafffelt proud to work within their departments and as part of thehospital.

• Departments had their own risk registers, which fed into thehospital risk register. Managers had clear visibility of their ownrisks and were knowledgeable about the mitigating actionstaken.

• A reward and recognition scheme was in place for staff, staffcould also be nominated for the annual Spire Healthcare awardscheme.

• Staff from the outpatient and diagnostic imaging had receivedall three ‘inspiring people’ awards, which have so far beenawarded by the hospital.

• Staff felt well informed and involved in the development of thedepartments, and within the development of the hospital.

• Up to date policies and procedures were in place to supportstaff in the delivery of safe and effective care.

• Robust procedures were in place for the granting of practisingprivileges to consultants.

• There was a culture of openness and honesty supported by awhistle blowing policy and freedom to speak up guardian.

• The hospital prioritised engagement with staff, patients and thepublic. Comments and suggestions were taken seriously andwe saw evidence of resulting changes.

• Managers were open to innovative ideas and constantly strivedfor quality improvement. Plans were in place to increasepatient numbers and ensure sustainability.

• Information was used to improve quality, we saw manyexamples of where this had taken place.




Overview of ratings

Our ratings for this location are:

Safe Effective Caring Responsive Well-led Overall

Surgery Good Good Good

Outpatients anddiagnostic imaging Good Not rated Good

Overall Good Good Good

Detailed findings from this inspection


Safe Good –––

Effective Good –––

Caring Good –––

Responsive Outstanding –

Well-led Outstanding –

Are surgery services safe?

Good –––

Incidents

• The hospital had systems in place to monitor safety,lessons were learned and improvements made whenthings went wrong. The hospital policy stated thatincidents should be reported through the hospitalelectronic reporting system. All the staff we spoke withtold us they were encouraged to report incidents.

• There were no reported never events related to surgeryin the period from April 2017 to November 2017. Neverevents are serious incidents that are wholly preventableas guidance or safety recommendations that providestrong systemic protective barriers are available at anational level and should have been implemented by allhealthcare providers.

• During the reporting period,(April 2017- November2017), 99 incidents were reported, 11 of moderate harm,six of low harm and 82 of no harm, this indicated thatstaff were following the reporting procedure describedin the hospital incident reporting policy.

• The hospital used an electronic incident reportingsystem; staff we spoke with were able to describe theincident management process and told us that learningidentified following incident investigation was feedbackthrough team meetings, emails and the hospital safetybulletin. We saw safety bulletins displayed on noticeboards throughout the hospital.

• We saw an example of learning from an incident.Following an incident of moderate harm related to a

piece of equipment in theatre. A full investigation hadbeen completed to identify how the error occurred andhow to prevent a recurrence. Changes had been madeto the storage of sterile and non-sterile equipment as aresult of this incident. All theatre staff we spoke withwere aware of the incident and the changes that hadbeen made to prevent a recurrence.

• We saw that root cause analysis (RCA) investigationswere completed as part of the investigation of incidents.The theatre incident was completed appropriately on astandard template. An action log showed all actions hadbeen completed.

• The provider had achieved 82% of incidentinvestigations completed within 45 days, which wasbetter than the organisation’s target of 80%.

Duty of candour

• Regulation 20 of the Health and Social Care Act 2008(Regulated activities) regulations 2014 was introducedin November 2014. The duty of candour is a regulatoryduty that relates to openness and transparency andrequires providers of health and social care services tonotify patients (or other relevant persons) of certain‘notifiable safety incidents’ and provide reasonablesupport to that person.

• The hospital had a duty of candour policy. We asked anumber of staff, both clinical and non-clinical, abouttheir understanding of duty of candour and all staff wereable to give examples of how this would be applied.Their responses reflected an approach of openness andtransparency.

Surgery

Surgery

Outstanding –


• The policy contained a flow chart showing theescalation to candour and a record of notification. Thehospital’s electronic reporting system included promptsto ensure duty of candour obligations were undertaken,which we saw.

• We saw two examples of incidents when duty ofcandour had been exercised appropriately.

Clinical Quality Dashboard

• The hospital monitored safety through a quarterlyclinical scorecard. The scorecard reported on 47 clinicalindicators such as pain scores, complaints, infectioncontrol and pressure ulcer incidence.

• The scorecard was completed by all the hospitals in theSpire Healthcare organisation which meant that thehospitals could benchmark against each other.

• All staff we spoke with were aware of the score card andunderstood its benefits; we saw the 2017 quarter threescore card displayed on notice boards. The providermonitored incidences of venous thromboembolism(VTE, which is a formation of blood clots in the vein),pressure ulcers and falls.

• The score card was red, amber, green (RAG) rated, greenratings meant the hospital was performing at or abovetarget for the indicator. Spire Nottingham Hospital wasgreen for 34 indicators, amber for six indicators, red fortwo indicators and no rating for three indicators.Overall,the hospital was performing at or above target level; thetwo red ratings were connected to patient reportedoutcome measures and were due to low patientnumbers.

• The scorecard was discussed at head of departmentmeetings and analysed for areas of improvement. Thiswas then fed back to the local teams.

Cleanliness, infection control and hygiene

• Reliable systems were in place to prevent and protectpeople from healthcare associated infections.

• There was an infection prevention and control (IPC) leadin place supported by an IPC committee, which wasresponsible for ensuring services were delivered inaccordance with the hospital control of infectionmanual.

• We reviewed the prevention and control of infectionmanual November 2015, which included procedures tofollow covering all aspects of IPC and reference to otherassociated policies such as MRSA, management ofwaste and food hygiene.

• Infection prevention and control was included inmandatory training. Compliance with IPC training was100% in the reporting period. Against a target of 95%.

• All areas we inspected were visibly clean and cleaningschedules were displayed, complete and up to date.

• Patient rooms were dust free and all fabrics in the roomswere wipeable in line with hospital building note (HBN)00/09. The flooring was laminate with coved edges inline with HBN 00/10 part a (flooring).

• Cleaning materials and equipment were colour coded,which meant that staff knew which piece of equipmentshould be used in which area to prevent crosscontamination.

• The service had not participated in the patient ledassessment of the care environment (PLACE) audit in2017, as the hospital had not been open for theminimum required period. However, they had alreadyengaged with the process and were on the auditprogramme for 2018. PLACE audits look at a variety ofareas, which patients feel are essential to maintain highstandards, cleanliness of the environment is an elementof these audits.

• Systems were in place for the segregation of waste, binswere colour coded and clearly marked so clinical anddomestic waste was disposed of correctly. Staff coulddescribe appropriate segregation of waste. This was inline with the Department of Health (DH) TechnicalMemorandum (HTM) 07-01, control of substancehazardous to health and Health and Safety at Workregulations. The clinical waste unit was checked andseen to be secured.

• Special kits were available to clean spills of blood andblood stained fluid.

• We saw evidence of regular tap flushing within thedepartments, which was in line with the requirements ofhealth technical memorandum (HTM) 04-01 the control

Surgery

Surgery

Outstanding –


of Legionella, hygiene, safe hot water, cold water anddrinking water: part A. These records were electronicand reviewed regularly by the responsible person for thewater system as part of the water safety group.

• Pathology samples were sealed in plastic envelopes andtransported to the pathology laboratory in bagsspecifically designed to carry samples, we observedsamples being received in the pathology lab accordingto the infection control policy.

• We inspected 13 pieces of ward equipment includingintravenous fluid pumps and blood pressureequipment, all were visibly clean and had ‘I am clean’stickers attached to them so staff knew they had beencleaned and were ready for use.

• All staff were bare below the elbows and complied withthe hospital uniform policy. We observed staff followingbest practice for hand washing; patients told us thatstaff washed their hands before and after care andtreatments.

• Hand hygiene audits were performed and resultsincluded on the hospital clinical scorecard, the mostrecent audit result was 96% compliance against a targetof 95%.

• As all patient rooms were single occupancy staff wereable to isolate patients who were at increased risk ofspreading infection and those who were at risk ofdeveloping an infection. Patient rooms were deepcleaned following occupation by patients carrying aninfectious disease.

• Staff in theatres wore suitable clothing for the operatingenvironment and we observed theatre staff preparingfor a surgical procedure and noted the surgical scrubwas performed according to the hospital infectioncontrol policy.

• Patients were prepared for theatre according to NationalInstitute for Health and Care Excellence clinicalguideline 74, surgical site infection prevention andtreatment. Staff described how they would preparepatients and we saw the pre-theatre patient check listbeing completed in the operating theatre.

• Procedures for avoiding and monitoring a surgical sitefor infection were included in the IPC manual. Weobserved staff in theatres following handdecontamination procedures, putting on sterile gownsand gloves and using antiseptic skin preparation.

• There were no surgical site infections resulting fromsurgery in the reporting period April 2017 to November2017.

• There had been no cases of Meticillin-resistantStaphylococcus aureus (MRSA), Meticillin- sensitiveStaphylococcus aureus (MSSA) or Clostridium difficile inthe reporting period April 2017 to November 2017.

• Surgical patients were routinely screened for Meticillinresistant staphylococcus aureus (MRSA) and Meticillinsensitive staphylococcus aureus (MSSA) prior to surgicalprocedures. We saw evidence of this in patient recordswe reviewed. MRSA is a type of bacterial infection and isresistant to many antibiotics. MSSA is a type of bacteriain the same family as MRSA but is more easily treated.

• Disposable surgical instruments were available forpatients carrying Creutzfeldt – Jakob disease (CJD). CJDcan be transmitted through brain tissue and spinal cordfluid.

• We visited the endoscopy suite which was not jointadvisory group (JAG) accredited as it had been openless than a year. We observed the decontaminationprocess of endoscopes and saw leak tests performed onall scopes after cleaning. This was compliant with HTM01/06 decontamination of flexible endoscopy. We saw atracking process was in place and this was documentedwithin the patients' notes. This made it possible to trackwhich endoscope had been used for each patient.Disposable sheaths were available for endoscopes usedon patients carrying infectious diseases.

• Disposable gloves and aprons were readily available inthe areas we inspected as was hand sanitising gel. Weobserved staff using this equipment whilst caring forpatients.

• A care pathway was in place for urinary catheterisationand venous cannulation. Staff told us that plannedurinary catheterisation usually took place in the sterileoperating theatre environment.

• An aseptic non-touch technique, (ANTT) was followedfor urinary catheterisation and cannulation. We

Surgery

Surgery

Outstanding –


observed this taking place in the operating theatre.(ANTT is a standardised approach to performing anaseptic technique for invasive procedures, reducing therisk of a healthcare acquired infection (HCAI).

Environment and equipment

• The building was locked at night and access was by anintercom system monitored by the security guard.

• The wards and theatre department were located on thefirst floor and clearly signposted for patients to find. Themain hospital doors were open for patients to walkthrough and be greeted at reception, however all wardand treatment areas were only accessible to staffthrough a card system. All doors were accessible to staffthrough a card system. Additional safety measures werein place once in one of the procedure rooms as a lockingsystem had been implemented to prevent patientsgoing back into a procedure room once they had left.

• Staff told us they had ample equipment to care for andtreat people and that all equipment was regularlyserviced and well maintained. The theatre manager toldus that they had been able to request additionalequipment for the operating theatre and it had beengranted.

• Servicing of large items of equipment in the hospitalwas under service level agreements with the companywho provided the equipment. All items had details ofservice date on them and dated for next service. Stafftold us if equipment failed, the processes in placeallowed swift response and replacement if necessarywhilst being repaired.

• Equipment in the areas we inspected had beenpurchased new for the hospital, we inspected 20 piecesof electrical equipment around the hospital and all werewithin their scheduled service date.

• All equipment in the department had evidence of indate electrical safety tests.

• We saw completed risk assessments of products underthe Control of Substances Hazardous to Health (COSHH)Regulations 2002, and we found all items were storedappropriately.

• All patient rooms were single occupancy with an ensuitebathroom. Nurse call systems and emergency buzzerswere by the bed and in the bathroom, patients told usstaff encouraged them to use the call system and thatstaff responded quickly to the call.

• The emergency and resuscitation trolleys we inspectedon the ward and in theatre had been checked regularly,we saw the equipment lists and daily check lists hadbeen signed according to the hospital resuscitationpolicy and was in line with the Resuscitation Councilguidelines.

• In theatres, we saw the Association of Anaesthetists ofGreat Britain and Ireland safety guidelines ‘SafeManagement of Anaesthetic related equipment’ (2009)was being adhered to. Anaesthetic equipment wasbeing checked on a regular basis with appropriatelogbooks being kept and we saw evidence of thesebeing completed.

• We saw that theatres and anaesthetic rooms were wellorganised, dust free and single use items such assyringes and needles were readily available.

• We saw that both theatres had difficult intubationtrolleys that were compliant with the Association ofAnaesthetist of Great Britain and Ireland (AAGBI) anddifficult airway society standard. The trolleys were setup in line with those in the local NHS trust, as themajority of the anaesthetists worked at that hospital;this would ensure familiarity with equipment andimprove safety for the patient.

• One of the operating theatres was a hybrid operatingtheatre. A is a surgical that is equipped with advancedmedical imaging devices which enableminimally-invasive surgery.

• There was a recording system in place to allow thedetails of surgical implants such as hip and breastprosthesis to be provided to the implants registry. Wesaw staff recording the information in the operatingtheatre. The registers enable individuals to be traced inthe event of product recall.

• Staff described to us the process they would follow toreport faulty equipment to the Medicines andHealthcare Regulatory Agency (MHRA) and we saw howthe hospital shared safety alerts with staff through themonthly safety update bulletin and team meetings.

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• The hospital had a sterile services department on site;staff told us the turnaround time for sterilisingequipment was about two hours, which meant thatsterile surgical equipment was always available.

Medicines

• A comprehensive medicines management policy was inplace, which covered obtaining, prescribing, recording,handling, storage, security, administration and disposalof medicines. Staff we spoke with were familiar with thepolicy and aware of their roles in managing medicinessafely.

• There was an onsite pharmacy with a team of four staff.Pharmacy staff visited the wards daily and checkedmedicines stocks on the ward weekly. Pharmacy staffwere on call in the out of hours period.

• The pharmacy team had produced a pharmacycommunication folder for ward staff to support themwith medicines management and keep them informedof any changes relating to pharmacy supplies orservices.

• During their daily visit to the ward pharmacy staffchecked individual patient medication forreconciliation. The aim of medicines reconciliation is toensure that medicines prescribed on admissioncorrespond to those that the patient was taking beforeadmission.

• The medicines management policy also described thecircumstances when patients could administer theirown medication following safety checks and accordingto a set of criteria.

• We checked the medicines storage on the ward and inthe operating theatre. Controlled drugs were storedcorrectly and checked every day; we checked 12individual medicines and all were stored correctly andwithin their expiry dates. (Some prescription medicinesare controlled under the Misuse of Drugs legislation(and subsequent amendments). These medicines areclassified as controlled drugs.)

• We checked the medicines trolley on the ward, whichwas locked and secured to the wall. Staff told us and weobserved that during the medicines rounds they worered ‘do not disturb’ tabards so staff and other peopleknew not to distract them from medicinesadministration.

• The temperature of the medicines fridges and the bloodfridges was monitored remotely and any variation intemperature outside of the recommended range wasreported immediately to pharmacy staff to investigate.The pharmacist and pathologist also monitored theblood fridges daily. During our inspection we saw thesigned daily check logs.

• Appropriate medicines were stored on the resuscitationand emergency trolley including anaphylactic shockmedicines. Anaphylactic shock is an extreme and lifethreatening allergic reaction. In the patient records wereviewed, we saw that allergies were recorded.

• Medical gases were stored safely; oxygen was pipedthroughout the hospital including patient rooms.Oxygen cylinders on the emergency trolleys we checkedhad adequate levels of oxygen within them and werewithin the expiry date.

• In the event that antibiotics needed to be prescribed,microbiology protocols were accessible on the hospitalintranet. The resident medical officer told us they wouldrefer to the protocols if they needed to prescribeantibiotics.

• Only one cytotoxic medicine was stored in thepharmacy, we saw that a risk assessment had beencompleted for the safe handling of this medicine.Cytotoxic medicines contain chemicals, which are toxic.

• Medicines were discussed with patients on discharge.Patients requiring anticoagulant injections followingsurgery were shown how to administer the injectionsthemselves and given an information leaflet and sharpsbin to take home.

• The pharmacy team received drug alerts from theMedicines and Healthcare products Regulatory Agency(MHRA) these were shared with staff through themonthly safety update bulletin.

• The pharmacy team were proactive in supportingnursing and medical staff with the correct use ofmedicines. In November 2017 we saw an advisory sheetproduced by the pharmacy team on co prescribing oflaxatives with opioid medications.

Records

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• Patient records were managed in line with the hospitalinformation lifecycle management and patients’ recordspolicy; staff attended annual information governancetraining. We saw staff managing patient records inaccordance with the Data Protection Act 1998.

• Records were stored securely in locked areas and onlyaccessible to nursing and medical staff. Patient recordfiles contained all relevant care and treatmentdocumentation in one place. All patient records werestored on site for easy accessibility.

• We reviewed 10 sets of patient records and saw thatthey were complete and up to date, most were easilylegible. However, in two sets of records, doctors’signatures were unreadable and did not provide acontact number. ‘Generic Medical Record KeepingStandards’ Royal College of Physicians 2009 state thatevery entry in the medical record should be dated,timed (24 hour clock), legible and signed by the personmaking the entry. The name and designation of theperson making the entry should be legibly printedagainst their signature. Deletions and alterations shouldbe countersigned, dated and timed. (Generic MedicalRecord Keeping Standards). As a result of this feedbackduring our inspection, the hospital senior teaminformed all medical staff of the need to adhere to the2009 standards for documentation.

• All relevant sections of the pre-operative assessmentdocumentation were completed including a range ofpre-operative risk assessments such as the AmericanSociety of Anaesthesiologists (ASA) Grade (a systemused for assessing the fitness of a patient beforesurgery) venous thromboembolism risk assessment andbleeding risk assessment.

Safeguarding

• Reliable systems, processes and practices were in placeto keep people safe and safeguarded from harm.

• Information provided by the hospital prior to ourinspection demonstrated 100% of all staff hadcompleted safeguarding adults training and 98.9% of allstaff had completed safeguarding children trainingagainst a target of 95%. Staff we spoke with all told usthey had completed all aspects of their safeguardingtraining, including safeguarding children level threetraining.

• All staff were trained to level two safeguardingprocesses, heads of departments, including the HospitalDirector, and a core of clinical staff were trained to levelthree. The Head of Clinical Services, who was thesafeguarding lead, is trained to level four.

• We reviewed the safeguarding procedure for childrenand young people June 2017 which was based oncurrent best practice guidance and the Intercollegiate(2014) Safeguarding children and young people: Rolesand competences for healthcare.

• Staff we spoke with were able to describe asafeguarding concern and the process they wouldfollow to ensure it was dealt with appropriatelyincluding referral to local safeguarding teams. Posterswere displayed throughout the hospital with contactdetails and information for safeguarding concerns.There was a hospital wide process for documentation toflag if a patient was vulnerable or had different needs.However, staff we spoke with were unsure if there was aflagging system but at the time of the inspection thehospital had not provided care and treatment for anypatient who was living with dementia, had a learningdisabilities or other cognitive impairment.

• We did see the policy for safeguarding vulnerable adultswhich included information related to planning andassessing care for vulnerable adults with carers andfamily where independence is not possible.

• The safeguarding adults policy also containedinformation about the government’s Prevent Strategy,part of the government’s counter terrorism strategywhich aims to stop people becoming terrorists orsupporting terrorism. This was also included within thesafeguarding training.

• We saw evidence, including a root cause analysis andaction plan, of where administration staff had raised anadult safeguarding concern after contact from amember of the public. Action included positivefeedback to the administration team on followingsafeguarding procedures appropriately.

• All staff involved in the care of patients had in datedisclosure and barring service (DBS) certificates in placeand we saw evidence of this in the staff records wereviewed.

Mandatory training

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• Staff received effective mandatory training in safetysystems. The target for mandatory training was 95%.Records showed 99% of staff had attended all requiredmandatory training in 2017. Records showed 89% ofstaff had attended mandatory training in the reportingperiod. There were eight topics; safeguarding adults,safeguarding children, fire safety, health and safety,infection control, manual handling, compassion inpractice and equality and diversity.

• Specific training on sepsis recognition was included inthe acute illness management training.

• We saw that staff compliance with mandatory trainingwas discussed at departmental meetings. Compliancewas also seen to be discussed when an appraisal wascompleted.

• Records for storing information on mandatory trainingwere stored on an electronic system. We also sawoptional role specific training was recorded for example;the nurses would complete safe transfusion dependingon where they worked. All records for mandatory andoptional training were stored electronically. We saw thatreports were run monthly to check staff mandatorytraining completion rates.

• Staff told us mandatory training was a mixture of onlinetraining and face to face. Staff told us they were giventime to complete the training at work and we saw thelearning zone in the ward area which had computersavailable for the staff to do their online training.

• We saw evidence that the doctors employed by anexternal agency (resident medical officers), completedall required mandatory training.

• Mandatory training for practising privileges consultantswas completed via their employing NHS trust andchecked / updated by Spire Nottingham Hospital.

Assessing and responding to patient risk (theatres,ward care and post-operative care)

• We observed patients being assessed, monitored andcared for safely and were assured that systems were inplace to remove and reduce the level of risk to patients.

The American Society of Anaesthesiologists (ASA) used agrading system of one to six, which determines thefitness of patients. Grade one patients were normallyhealthy patients, and grade two patients had mild

disease, for example well controlled mild asthma. Onlypatients that are ASA grade one or two had theiroperations undertaken at Spire Nottingham Hospital toensure the hospital had the resources to meet theirneeds. ASA 3 graded patients could be considered forsurgery at the hospital but only following amultidisciplinary team assessment where it was in thebest interests of the patient.

• All patients underwent pre assessment and if there wereany concerns about the patient’s suitability this wasdiscussed with the anaesthetist.

• Patients were accepted for treatment following a preassessment consultation and according to the SpireNottingham Adult Elective Surgical Admission Criteria.The hospital cared for level zero patients but was staffedand equipped to manage level one patients if required.Level zero patients are patients whose needs can bemet through normal ward care in an acute hospital;level one patients are those at risk of their conditiondeteriorating and need additional advice and supportfrom a critical care team.

• Most elective surgical procedures had a care pathway inplace (92 in all). The pre assessment process was clearlydescribed in each care pathway. We reviewed the carepathway for replacement of a hip joint. Clinical riskassessments included ASA score, vital signs, urinalysis,Waterlow score to assess the risk of pressure sores,thrombosis risk assessment, bleeding risk assessmentand falls risk assessment.

• Female patients were informed that a pregnancy testmay be required on admission to reduce any risk to anunborn foetus in the case of patients who were notaware they were pregnant.

• All patients over the age of 75 years completed anabbreviated mental test score for dementia screening.All patients screening positive for dementia then wenton to be fully risk assessed to make sure theyunderstood and had mental capacity to make aninformed consent decision about their treatment.

• Cardiac patients were assessed by the cardiac nursespecialist in line with British Cardiovascular Societyguidance. The resident medical officer and the

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resuscitation lead were informed when cardiac patientswere undertaking exercise tests to ensure that in theevent of sudden patient deterioration resuscitation andlife support procedures could be administered swiftly.

• All patients had a physiotherapy assessment followingtheir surgery to make sure they were not developing apost-operative chest infection and to check they wereable to mobilise.

• The World Health Organisation (WHO) ‘five steps to safersurgery checklist’ (WHO checklist) is a system to safelyrecord and manage each stage of a patient’s journeyfrom the ward through to the anaesthetic and operatingroom to recovery and discharge from theatre.

• The ‘five steps to safer surgery checklist’ was used in theoperating theatre, and the cardiac catheter lab. Weobserved it being completed correctly in the operatingtheatre.

• The quarter three report of surgical safety checklistaudit of the notes demonstrated a compliance with theWHO checklist of 100%. Senior managers told us that ifany members of staff were not compliant with doing theappropriate checks that would be discussed with themand in the case of consultants not being compliant, thiswould be reported to the Medical Advisory Committee(MAC).

• Systems were in place to identify and manage patientswhose condition was deteriorating.The frequency ofroutine observations, such as pulse and temperature,were dependant on what treatment the patient hadundergone.

• All staff in the department had completed immediatelife support (ILS) training and paediatric basic lifesupport training. Registered staff had also completed anacute illness management (AIM) course to aid them inthe recognition and treatment of a deteriorating patient.Unregistered staff were also undergoing specific AIMtraining for their role. This training included themanagement of sepsis.

• The national early warning score (NEWS) was used fordeteriorating patients plus a sepsis-screening tool. Earlywarning scores have been developed to enable earlyrecognition of a patient’s worsening condition bygrading the severity of their condition and promptingnursing staff to get a medical review at specific trigger

points. This included patients experiencing signs ofdelirium during their stay in the hospital would beescalated as per the escalation procedure fordeteriorating patients

• Staff showed us a folder containing information andinstructions about what to do in the case of adeteriorating patient which included managing extremeblood loss and transferring the patient to anotherhospital. Documentation included an SBAR handoversheet and a checklist. SBAR stands for situation,background, assessment and recommendation and is arecognised briefing model used in clinical settings; itensures all the relevant information is available toestablish the best course of action for the patient.

• The hospital kept four units of O negative blood on site;O negative blood can be given to any patients in anemergency regardless of their blood group.

• A service level agreement was in place with a local NHSacute hospital for the transfer of patients who needed ahigher level of care. We saw an incident report and stafftold us of an example of a patient who was transferredsuccessfully to an NHS hospital according to theagreement.

• The resident medical officer (RMO) was available torespond to any patient concerns. Guidance on when itwas appropriate for nursing staff to call the RMO wasoutlined in the RMO handbook. The patient’s consultantor nominated deputy could be contacted at any time ifthe RMO had any urgent concerns. Staff told us it wasvery easy to contact the anaesthetist or consultant ifneeded.

• When patients were discharged home ward staffcontacted them by telephone the following day to checkhow they were feeling and to answer any queries.Patients were also supplied with contact numbers foruse throughout a 24 hour period should they have anyconcerns or worries.

Nursing and support staffing

• Staffing and skill mix was planned and reviewed so thatpatients received safe care and treatment.

• Ward staffing was planned using an adapted version ofthe Shelford nursing care tool, which is a tool thatcalculates safe nurse staffing levels. Nursing staff told usthe tool was updated daily and adjustments were made

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to the nurse rota if necessary. We saw from the staffingrota and the staff on duty at the time of our inspectionthat actual staffing levels matched planned staffinglevels.

• Two members of staff with intermediate life supportskills were on duty at each shift, we saw this clearlymarked on the staffing rota in line with the hospital’sresuscitation policy.

• Staffing in the operating theatres followed theAssociation for Perioperative Practice recommendationsand during our time in the operating theatre weobserved the correct level of staff in attendance. Thetheatre manager told us that the theatre team wasselected depending on the type of operation beingperformed, for example a member of staff withexperience in spinal surgery would be selected forspinal operations.

• In the other areas of the hospital we visited we sawthere were adequate numbers of support staff on dutyincluding the pharmacy, physiotherapy department,pathology laboratory, domestic and catering staff.

• The provider did not use agency staff but did have ateam of bank staff who worked regularly at the hospital;bank staff had the same training and induction aspermanent staff.Bank staff had to work regularly at thehospital to maintain their position on the bank; thismeant that bank staff were up to date and familiar withthe policies, procedures and working practices at thehospital.

• Staff handovers took place between shifts, in theoperating theatre and between the resident medicalofficers. We observed a multi-disciplinary handover onthe ward during which each patient’s care, treatmentand progress was discussed. Staff told us the handoverswere thorough and meant they had all the informationthey needed to care for patients.

Medical staffing

• Consultants retained 24 hour responsibility for theirpatients. Consultants with practising privileges wereonly appointed if they lived within 45 minutes of thehospital and we saw in the Medical Advisory Committee

meeting minutes where some consultants had not beenaccepted because they lived too far away. This meantthat consultants working at the hospital could attendquickly if needed.

• A resident medical officer (RMO) was on site throughoutthe 24-hour period. Two RMOs worked on a weekly rota.RMOs were allocated a bedroom on the ward and hadaccess to the restaurant and food preparation areas.The RMOs were supplied through a private provider ofmedical services. In the event of an RMO being unable toattend, work arrangements were in place for anotherRMO to be in place within four hours. The patient’sconsultant or anaesthetist provided emergency coveruntil the replacement RMO was in place. Thisarrangement could also be activated if the on duty RMOhad been working for a prolonged period without anysleep.

• Anaesthetists stayed at the hospital until all patientswere fully conscious and had returned to the wardfollowing surgery; this meant they were available to dealwith any emergencies in the immediate post-operativeperiod. All RMOs held a current advanced life support(ALS) certificate.

• The RMO attended the daily multi-disciplinary wardmeeting and gave a detailed handover to the next RMOwho was taking over the duty.

• We observed consultants discussing patient care andtreatment with nursing staff and the RMO.

Emergency awareness and training

• The hospital had anticipated risks and made plans.

• We saw evidence of regular scenario training for clinicalemergencies such as cardiac arrest, anaphylaxis andmajor haemorrhage. We saw evidence of these trainingexercises, feedback from them and learning for the staff.Staff told us that they found the scenario trainingvaluable as it enabled them to keep their skills up todate.

• The hospital had practised a scenario where a patientrequired emergency admission to an acute hospital.They involved the local NHS ambulance service andNHS acute hospital so they would become familiar withthe location and layout of the hospital.

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• Fire drills were carried out monthly including use of theevacuation slide. Fire wardens were clearly identified bywearing a red badge. A fire warden was available oneach shift on the ward and in theatre.

• Emergency generators were tested monthly, on averagethe emergency generator took 15 seconds tore-establish power to the hospital. Operating theatreequipment had uninterrupted power supply systems inplace which were also tested monthly. This meant thatin the event of total power failure systems were in placeto make sure care and treatment was not affected.

• Pathology had practised retrieval of blood productsfrom the local NHS hospital should more supplies berequired in an emergency.

• Staff were aware of the business continuity plan whichcould be accessed on the hospital’s internal computersystem. This contained action cards, information on keyholders and evidence of annual desktop exercises. Acopy of this policy was also kept behind the receptiondesk in the outpatient department, which meant ifrequired this was easily accessible by staff.

Are surgery services effective?

Good –––

Evidence-based care and treatment

• From the policies and procedures we reviewed we sawthat care and treatment was delivered in line withlegislation, standards and evidence based practice. Staffwere familiar with policies and procedures and had tosign to say they had read, understood and would delivercare and treatment in line with them.

• Staff were informed about new guidance through thesafety update bulletin and we saw in the December 2017bulletin a list of the latest National Institute for Healthand Care Excellence (NICE) guidance.

• From our observations of care and the patient recordswe reviewed we saw examples of NICE clinicalguidelines (CG) being implemented such as CG50, careof the deteriorating patient and CG51, sepsis

recognition. We also witnessed procedures in thecardiac catheter lab following British CardiovascularSociety and British Society of Echocardiographyrecommendations and guidance.

• The hospital had a comprehensive audit schedule inplace with audits planned across a 12 month periodcovering all clinical areas, environmental issues andcustomer relations.

• The hospital had not reached the threshold forbenchmarking against national and NHS audits due tolow patient numbers and not yet being open for 12months.

• Clinical indicators such as venous thromboembolismassessment compliance, national early warning scoredocumentation, infection control, consent procedures,patient satisfaction and staff training were measured.Managers told us that when hospital heads ofdepartments met they discussed the clinical scorecardand shared best practice with each other.

• We saw evidence of where practice had been changedas a result of audit. For example the pharmacy team hadidentified from an audit of their intervention log thatlaxatives were not being routinely prescribed withopioid medication, they subsequently produced anadvisory sheet for nursing and medical staff on coprescribing of laxatives and opioid medications.

• Staff and managers were aware of the Royal College ofSurgeons, standards for cosmetic surgery and we sawevidence of where the standards had beenimplemented. For instance in the patient records wereviewed the two week cooling off period had beenexplained and documented.

• The hospital submitted information to the breast andcosmetic implant registry and the national joint registry.We saw staff in the operating theatre logging implantdetails to be submitted to the registry.

Pain relief

• Pain was assessed and managed effectively. Patientswere asked about pain in the pre assessmentconsultation. Anticipatory pain relief was prescribed andwe saw this in the patient records we reviewed andbeing administered in the operating theatre.

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• Pain was measured using a pain score of 0 – 4 where 0 isno pain and 4 is worst pain possible. The five patientswe spoke with told us that nurses frequently checkedand asked if they were comfortable and pain relievingmedicines were administered quickly without anyproblem.

• Post-operative nausea was assessed using a nauseascore, and anticipatory anti-emetics were alsoprescribed.

• Pain and medicines management was a standingagenda item on the medicine and pain managementcommittee meeting and any issues were then passedthrough to the clinical governance committee.

Nutrition and hydration

• Food was prepared on site in the hospital kitchen by ateam of chefs and met the nutritional requirements ofpatients, staff and visitors to the hospital.

• The hospital menu was compiled in consultation with anutritional dietitian. Patients were able to choose from avariety of meals. The chef told us that they oftenresponded to special requests from patients; Patientswere complimentary about the food provided and onepatient told us the food was ‘equivalent to that of a fivestar hotel.’

• A member of the catering team attended themulti-disciplinary ward round which identified patientswith special dietary requirements. This information wasalso displayed on a notice board in the kitchen.

• Patients requiring a general anaesthetic were fastedaccording to the Association of Anaesthetists of GreatBritain and Ireland (AAGBI) guidelines. Fasting timeswere clearly communicated for each patient at the dailyward briefing and staff handovers.

• In the theatre department there was discussion aboutcompliance to theatre starve times in line with nationalguidance and scorecard key performance indicators(KPIs). The most recent results showed the hospital hadrecorded 65% compliance against a target of 60%.

• Anticipatory medicines were prescribed to managepost-operative nausea and vomiting, we saw evidencein the patient records we reviewed.

• The hospital had dietetic services available two days perweek but could contact a dietitian at other times ifurgent dietary advice was needed.

• Patients’ diet and nutritional status was covered in thepre assessment phase using the malnutrition universalscreening tool (MUST). MUST is a five step screening toolto identify adults who are malnourished, at risk ofmalnutrition or obese. It also includes managementguidelines which can be used to develop a care planand onward referral to a dietitian if necessarydepending on the score.

Patient outcomes

• The provider monitored treatment outcomes andsubmitted information to the national audits,benchmarking and accreditation schemes. Howeverbecause the hospital had not been operating for morethan 12 months and patient numbers were low, therehad been no return on the outcome information.

• Patients having hip replacements, knee replacements,hernia repairs and cataract operations were sentinformation about the patient reported outcomemeasures (PROMs) survey with their appointment letter.Patients happy to take part in the survey could completeit as part of their pre assessment consultation or on lineat home via ‘My Clinical Outcomes.’ Patients werereminded through ‘My Clinical Outcomes’ three to sixmonths following their operation to update the PROMssurvey.

• The Head of Clinical Services told us that preparation forvarious national accreditation schemes was on going,for example, the endoscopy suite was working towardsbeing Joint Advisory Group on GastrointestinalEndoscopy (JAG) compliant.

• The hospital had begun the process for submittinginformation to the Private Healthcare InformationNetwork (PHIN). PHIN publishes independentinformation to help patients make better treatmentchoices.

• Plans were in place for benchmarking consultants’performance but at the time of our inspection patientnumbers were too low for the information to bemeaningful.

• The hospital was collecting Quality-PROMS for patientshaving cosmetic surgery. Quality PROMS measure

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patient satisfaction with the outcomes of somecosmetic surgery procedures for example, eye lidsurgery, breast surgery and nasal surgery. However dueto low numbers of patients meaningful data wasunavailable.

• Out of 68 inpatient attendances there were three (4.4%)unplanned transfers to other hospitals, one readmissionwithin 28 days of discharge and one unplanned returnto the operating theatre.

Competent staff

• Staff maintained their skills and competencies in avariety of ways in order to deliver effective care andtreatment. Robust recruitment processes were in place,which meant that staff with the right qualifications andexperience were appointed. Staff told us that theprovider arranged additional training in a variety oftopics and they could request specific training throughtheir line managers.

• We saw new training and development opportunitiesadvertised in the December 2017 safety update bulletinand instructions for staff on how to access the training,this included information governance training andBritish Oxygen Company (BOC) training for medicalgases.

• The human resource department monitoredprofessional registrations and when registrations werenearing renewal reminders were sent to head ofdepartments to follow up with individual staff.

• All qualified nursing staff had attended training forintermediate life support and national early warningscores. Other training courses were being provided bythe hospital such as acute illness management andblood transfusions. Acute illness management trainingalso included recognition and management of sepsisand was refreshed every two years.

• Catering staff we spoke with told us they completedfood hygiene standards training and had attendedtraining events delivered by a dietitian.

• The majority of consultants working at the hospitalpractised in NHS hospitals; effective processes were inplace to grant practising privileges to those consultantsapplying to practise at the hospital. A few consultants

did not practice in NHS hospitals, Spire Healthcareprovided a responsible officer to these consultants tomake sure they were fulfilling the requirements forrevalidation.

• In all six consultant personnel files we reviewed detailsof the individual’s scope of practice, CV and trainingrecord were complete and up to date. We saw evidenceof monthly checks being run on the electronic HRsystem which showed any lapses with indemnity cover,General Medical Council (GMC) registration andappraisal information. Consultants were alerted of anyinformation that was out of date and consultantpractising privileges would be suspended if not actedupon promptly. The chair of the MAC was informed ofany such issues.

• We saw all consultants who worked at the hospital hadthe correct pre-employment checks completed in orderto be granted practising privileges. All applications forpractising privileges went to the hospital director andwere discussed with the chair of the MAC and ratified bythe MAC. Qualifications were checked for anyconsultants applying to work at the hospital and theirscope of practice should be the same as their practice intheir employing NHS trust. An example was given ofturning down an application in relation to a surgeon’spatient outcome figures.

• The practising privileges biennial review programme isnow undertaken at 18 months rather than 24 months.These will be reviewed at the MAC meeting. This was arecommendation of an independent review of thegovernance arrangements at Spire Hospitals, completedin 2014.

• A consultant directory was available to patients, whichgave the names of consultants working at the hospitaland their speciality. The hospital had plans to publishconsultant performance data once patient numbers hadincreased.

• Staff we spoke with told us that they had regularmeetings with their line managers and an annualappraisal meeting. In the staff personnel files wereviewed we saw that annual appraisal meetings hadtaken place for all staff who had worked at the hospitalfor longer than six months. The hospital reported that all(100%) of ward and operating theatre staff had receivedan appraisal within the last 12 months.

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• Case reviews of complex cases would take place at themedical advisory committee (MAC); however thehospital had not managed any patients in this categorysince it opened.

Multidisciplinary working

• We observed effective team working in all areas of thehospital, multi-disciplinary team meetings, handoversand briefings took place regularly to ensure effectivecare and treatment was delivered to the patient.

• We joined the ward multidisciplinary meeting, whichinvolved nursing staff, the resident medical officer(RMO), pharmacy staff, physiotherapy staff and cateringstaff. A thorough update was given for all the patients onthe ward including discharge plans, dischargemedicines, special dietary requirements and allergies.The meeting was participatory and each member of theteam was clear about their role in the care andtreatment of the patient. Relatives and carers were alsomentioned if relevant.

• We also observed the operating theatre briefing whichtook part at the beginning of the day. The briefingincluded staffing roles and the theatre cases for the day,ward staff also attended this briefing.

• We also joined the head of department daily briefingwhich received feedback from all of the hospitalbriefings to ensure there was a full overview of patientsafety. An on call head of service would also beinformed of any concerns at weekends and out of hours.

• Patients, staff and the RMO knew who was ultimatelyresponsible for the care of the patient.We observedhandovers between the consultants, anaesthetist andthe resident medical officer.

• An escalation procedure was in place, which describedclearly the action nursing, and medical staff should takein the case of a deteriorating patient or a patientshowing signs of sepsis.

• Ward staff liaised with relatives and carers, with theconsent of the patient, to keep them up to date withpatient progress and discharge plans.

• Discharge planning began once the patient wasadmitted to hospital, plans were discussed with allmembers of the multidisciplinary team (MDT) soarrangements such as take home medicines, follow up

appointments and physiotherapy sessions were in placeon the day of discharge. Discharge information wasdocumented in the GP discharge letter which wasposted to the GP on the day of discharge.

Seven-day services

• Systems were in place to ensure that all services couldbe available in the out of hour’s period.

• Radiology, theatre staff and pharmacy staff were on callduring the out of hour’s periods; these were weekends,evenings, nights and bank holidays.

• Physiotherapists provided a seven day service forpatients requiring physiotherapy at the weekend andwere on call at other times.

• Blood tests could be analysed out of hours if needed.Staff told us pathology staff could usually get to thehospital within 15 minutes. Microbiology tests werecarried out at the Spire Healthcare hub in Manchester,specimens were collected twice a day from the SpireNottingham Hospital.

• Contact information about out of hours, on call serviceswas included in the registered medical officerhandbook. The RMO was onsite and available 24 hours aday. For complex matters and further advice andsupport the RMO told us they could contact consultantsand that when they had cause to do this they had foundit very straightforward.

• We saw consultants provided details of coverarrangements for when they were not available whenobtaining practising privileges. This was documentedand kept on record on the ward as well as in theirpersonnel files.

Access to information

• Staff had access to all the information they needed todeliver effective care and treatment.

• Patient records were predominantly paper based andstored on site at the hospital. This meant that it waseasy to request patient records and they were quicklyavailable. Consultants did not take patient records outof the hospital.

• Discharge letters for GPs were printed and posted on theday of discharge; patients told us that their GP had

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received information from the hospital the day afterthey had been discharged. GP discharge letters includedfull details of medication and any further treatment thepatient required, for example physiotherapy.

• GPs were able to contact the hospital through thehospital switchboard and if necessary could request tospeak to the patient’s consultant. Ward staff told us theyhad taken phone calls from GPs in the out of hour’speriod and had transferred calls to the RMO.

Consent, Mental Capacity Act and Deprivation ofLiberty Safeguards

• The provider had a consent policy in place, which wasbased on guidance issued by the Department of Health.This included guidance for staff on obtaining validconsent and details on the Mental Capacity Act, 2005(MCA) guidance.

• Staff were aware of their responsibilities under the MCA,2005 and deprivation of liberty safeguards (DoLs) andwere able to describe the arrangements that were inplace should the legislation need to be applied. Trainingon DoLs and the MCA was part of the mandatorytraining.

• Staff were aware of the Mental Capacity Act 2005 and ifany concerns about a patient’s capacity to consent wereidentified in the pre assessment consultation thesewould be discussed with the patient’s consultant andthe clinical lead.

• We found that patient’s consent to care and treatmentwas sought in line with legislation and staff understoodthe relevant consent and decision making requirementsincluding the Mental Health Act.

• Detailed information was given to patients to enablethem to make an informed decision about care andtreatments. The Spire Healthcare website containeddetailed information on all procedures carried out bytheir hospitals.Information packs were given to patientsprior to their first appointment. Risks and complicationswere explained during the consultation phase and wesaw where these conversations had been documentedin the patient records we reviewed. Patients told us thatdoctors and nurses spent time explaining proceduresand answering questions.

• Patients undergoing cosmetic surgery were given a twoweek cooling off period. This meant that they had time

to reflect on the information they had been given andchange their minds if they wished. It also meant theywere able to give an informed consent on the day of theoperation.

• Patients undergoing breast augmentation requiringprosthetic implants also gave documented consent tobe included in the breast implant registry. We sawevidence of this in two of the patient records wereviewed

Are surgery services caring?

Good –––

Compassionate care

• From the interactions we observed between staff,patients and their relatives, care and treatment wasdelivered with kindness, dignity, respect andcompassion. Staff understood the importance ofmaintaining patient confidentiality.

• The October 2017 score for the Friends and Family Test(FFT) was 98%, this meant that 98% of the patients whocompleted the friends and family test survey answeredyes to the question ‘Would you recommend this serviceto friends and family?’

• Patients were nursed in single rooms; we observed staffknocking before they entered. In the operating theatre,we saw staff taking care to maintain a patient’s privacyduring surgical procedures. There were separate areasfor males and females in the endoscopy suite.

• We saw notices displayed about the availability ofchaperones, one patient told us they had requested achaperone and someone was available straight away.

• From the November 2017 inpatient satisfaction report,100% of respondents said they were satisfied with thecare and attention they received from nurses and 100%of respondents said they were treated with compassionand respect at all times.

• Staff understood and respected patient’s personal,cultural, social and religious needs. Social and homecircumstances were discussed at the pre assessment

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consultation. The hospital had a multi faith prayer roomand a designated hospital chaplain. All patients wereasked about their faith, culture and beliefs as part of thepre assessment process.

• Patients told us they were encouraged to wear dayclothes the day after their treatment and sit out of bedat meal times. The physiotherapist told us that patientswere supported to become mobile as soon as possiblefollowing surgery.

• Staff told us they spent time with patients and theirrelatives to understand their concerns and answerquestions. Patients told us that staff were ‘wonderful.’One member of staff told us they had recognised that apatient’s relative was looking anxious and took time totalk with them and put them at ease.

• We saw staff responding promptly when patients wereexperiencing pain or discomfort and patients told usnurse always responded quickly to the call bell.

Understanding and involvement of patients and thoseclose to them

• During our inspection we saw that staff involvedpatients, and if appropriate relatives and carers, in theircare and treatment planning.

• Patients told us that staff introduced themselves,explained what care they were going to give and alwayschecked they understood all aspects of their care duringtheir experience at the hospital.

• All the patients we spoke with told us they had plenty ofinformation about the procedures they were going toundertake and about the cost. Patients said there wereno hidden costs and that final payments had been whatthey expected.

• Visiting times were fully flexible which made it easy forrelatives and friends to visit. With the consent of thepatient relatives and carers were involved in careplanning and kept up to date with the patient’sprogress. There were facilities for relatives or carers tostay overnight if necessary. At the time of our inspection,the husband of an overseas patient had been allowed tostay in the room next to his wife. We saw at themulti-disciplinary meeting relatives were involved indischarge planning.

• From the November 2017 inpatient satisfaction report,patients scored between 94% - 100% to the question‘Were you involved as much as you wanted to be indecisions about your care and treatment?’

• We were told the hospital provided free meals topartners who wanted to come and eat with their friendor loved one whilst in hospital. This has been as a resultof a patient who had expressed anxiety about theirrelative while they were in hospital. As a result of thisfeedback, they provided their relative with free meals sothey could eat together.

Emotional support

• The hospital had adequate services in place to ensurethat patients and those close to them receivedemotional support if needed.

• Patients told us that staff were always there to offer ‘anarm around the shoulder’ if needed and staff told usthey were would always spend extra time with patientsor relatives if they appeared upset at any time.

• The hospital had introduced clinical nurse specialists insome areas for example in cancer care and breast care.Clinical nurse specialists were able to offer additionalemotional support or refer on to psychological servicesif necessary.

• There was a designated hospital chaplain; staff couldarrange a visit by the chaplain at the patient’s request.We saw posters displayed with details of the chaplainand contact information.

• Staff attended ‘Breaking bad news’ training whichcovered the emotional aspects of patient care insensitive situations.

The hospital supports the emotional and social needs ofpatients and allows, on occasions, a relative to stay inthe Hospital, providing a bedroom and meals for thispurpose.

Are surgery services responsive?

Outstanding –

Service planning and delivery to meet the needs oflocal people

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• Spire Hospital Nottingham is an independenthealthcare facility treating mainly self-funded andself-referred patients offering a wide range of specialtiesand consultants.Hospital managers have pro-activelyengaged with the local population, including GP’stoincrease understanding and awareness of the hospitaland in order to work in partnership to deliver locallyidentified services. For example, the hospital wasdeveloping falls prevention classes at the request of thelocal community.

• The hospital also worked with local commissioninggroups to support the NHS with waiting list initiatives,for example in 2017, the provider carried outtonsillectomy operations via an NHS service levelagreement.

• GP training events were delivered at the hospital; thisalso gave local GPs an opportunity to discuss theservices available at the hospital.

• Services at the hospital were provided flexibly in apurpose built environment to suit the needs of thepatient and using high specification, sophisticatedequipment. Pre assessment consultations were alsoavailable in the evening and at weekends.

• Patient wellbeing was integral to the planning of thenew hospital and an extensive outdoor area has beendeveloped to allow patients to spend time outside in aprotected environment with their families.This includedan outdoor play area, water features and amplecomfortable seating.

• The hospital had a dedicated coffee and sandwich shopfor patients and relatives which was designed to be in acentral location of the hospital . When procuring theatresurgical instruments prior to opening, the hospitalarranged meetings between consultants and suppliersto ensure that the equipment provided at SpireNottingham was hand-picked by the surgeons to matchtheir preferences and wherever possible the equipmentthey were familiar with in their NHS Trust employer toensure continuity of care.

• A yoga class was developed in the physiotherapydepartment which is available to patients and staff. Thiswas developed as a direct result of patient feedbackthat this service would benefit patient’s recovery.

Access and flow

• Patients could access care and treatment in a timelyway. Patients were referred to the hospital by their GP,consultant or could refer themselves. Patients we spokewith told us that appointments were flexible, quick andcould be changed easily.

• The provider sent appointment reminders by textmessage, patients who did not attend for theirappointment were contacted by the bookings team tofind out why and book another appointment ifnecessary.

• Three NHS patients waited on average eight weeks fromreferral to treatment; the NHS waiting list target is 18weeks.

• During our inspection, we observed that procedureswere carried out on time and patients were keptinformed of next steps throughout their stay in hospital.

• Once patients had seen their consultant and the preassessment nurse, a date was agreed for admission tothe hospital for treatment. There were clear exclusioncriteria for patient with complex medical conditions.Patients completed a health questionnaire in which theywere asked to declare any medical conditions and thepre assessment nurse also recorded the patient’s pastmedical history.

• This meant that patients who were at risk ofcomplications or deteriorating medical conditions werenot accepted for treatment at the hospital.

• The hospital only accepted patients for planned surgicaloperations. In the reporting period April 2017 toNovember 2017 three patients had unplanned returnsto theatre for further treatment.

• Discharge letters were posted to the patient’s GP on theday of discharge.

• One patient’s procedure was cancelled for non-clinicalreasons in the reporting period April 2017 to November2017 but this patient was offered another appointmentwithin 28 days of the cancelled appointment, which waswithin recommended timescales.

Meeting people’s individual needs

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• Staff had access to a translation and interpretationservice for patients whose first language was notEnglish. This process had access to translation serviceon the telephone or could invite interpreters to attendappointments in person.

• All departments also had access to British SignLanguage (BSL) interpreters for patients who used signlanguage to communicate with others.

• The hospital was a new building with free parking andeasy access for people who use wheelchairs or were lessable bodied. Signs were in the car park remindingpatients and visitors that should they need assistancegetting from their car into the hospital they should callthe number provided.

• Throughout the hospital we observed that services hadtaken account of the needs of different people includingvulnerable persons.

• Access to all areas of the hospital were wheelchairaccessible, we saw hearing loops at reception areas. Ahearing loop is a special type of sound system for use bypeople with hearing aids

• We saw hospital information and leaflets written indifferent languages. Interpreting services were availableand staff were discouraged from using friends andfamily to interpret.

• Staff told us that if patients needed information indifferent languages this could be arranged, we sawpatient notices displayed in different languages.

• Information was available on the Spire Healthcare website, patients were sent an information pack prior totheir first visit to the hospital and additional morespecific information leaflets were given at the preassessment consultation. Patients were also givenfurther information on discharge includingpost-operative instructions.

• Staff on the ward had completed dementia training andthere was a nominated dementia champion for theward.

• A dementia pathway was in place, patients over 75 yearsof age were screened for dementia using theAbbreviated Mental Test Score. If the test indicated thepatient may be living with dementia their GP wasinformed and ward staff if they were admitted to thehospital.

• Ward staff showed us a dementia box they had createdfor patients living with dementia. It contained items thatwould make the patient’s stay in hospital easier such assimple signs and a calendar clock.

• Carers or relatives were encouraged to stay in hospitalto reduce anxiety in patients living with dementia orlearning disability.The ward had a folding bed that couldbe made up in the patient’s bedroom.

• Free Wi-Fi was provided for patients, visitors and staff.

• The Spire Nottingham Hospital’s adult elective surgicaladmission criteria meant it was unlikely that patientswith complex medical needs were treated at thehospital due to the increased risk of complicationsduring and after surgery. However, all patients wereassessed individually including those living withdementia.

• The hospital had specialised bariatric equipment tocare for and treat bariatric patients (who have a BMI(Body Mass Index) exceeding a healthy range) and wesaw electronic hoists ready for use.

Learning from complaints and concerns

• Patient’s concerns and complaints were taken seriously,complainants were informed of the progress of thecomplaint investigation and learning identified wasshared widely.

• In the reporting period April 2017 to November 2017,there were 11 complaints. Complaints were managed bythe complaints co coordinator and reviewed by thehospital director and head of clinical services. We sawthat complaints had been managed in line with thehospital complaints policy, all but one had beenresponded to within the correct timescales.Complainants had access to the hospital director andhead of clinical services if they wished to discuss theircomplaint in a face-to-face setting.

• The provider monitored complaints for trends andthemes and learning from complaints was shared withstaff through the safety update bulletin and with thewider Spire Healthcare community.

• We saw where actions and shared learning contributedto the improvement of care quality for the patient suchas promptness in answering telephone calls frompatients and practice around anti embolism stockings.

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• Patients told us they would feel comfortable raisingconcerns or making a complaint. We saw ‘Please talk tous’ leaflets which described the complaints process topatients and action the patient could take if they werenot satisfied with the response, such as contacting theParliamentary Health Services Ombudsman or theIndependent Healthcare Sector Complaintsadjudication service.

Are surgery services well-led?

Outstanding –

Vision and strategy for this core service

• The provider had a clear vision ‘to be the first choice forindependent healthcare in the Nottinghamshire andsurrounding community’ and five strategic objectives for2018. The five strategic objectives for 2018 were: toreceive outstanding from the CQC, get it right first time,believe in our people, celebrate patient satisfaction andbe innovative to enhance the patient experience andfinally deliver revenue and regrowth in line with theirannual operational plan.

• The strategic objectives were developed by the seniormanagement team and heads of department whilsttaking in to account responses from the hospital staffand consultant satisfaction surveys.

• Quality and safety was a top priority for the hospital andthis was reflected in the objectives. One objective was to‘get it right first time- ensure processes are ingrained todeliver efficient services.’ For example in theatres and onthe ward ’ensure patient safety is at the forefront ofeverything we do by adhering to national guidelines,policies and clinical best practice.’

• We saw the objectives reflected in department teamstrategies and in individual staff appraisals. Objectiveswere realistic and contributed to the overall strategy.

• The senior management team told us they had engagedand listened to staff to ensure their voice was heardthroughout the development of the strategy.

• All staff we spoke with were aware of and felt involved inthe vision and strategic objectives and understood howthese related to their individual performance.

• All staff we spoke with told us they were proud ofworking at Spire Nottingham Hospital and the visionsand values were displayed in clinical areas.

• New staff told us they were made aware of the provider’svision and values at induction and this was reinforcedthrough the appraisal programme. Staff wereencouraged to demonstrate the values through theirbehaviours.

• Staff spoke with overwhelming pride in how theyprovided care for patients. Staff talked about theirdedication and commitment of teams to provide thebest patient experience.

• There was a clear action plan towards the strategicobjectives and a planned review to monitor progressduring 2018.

Governance, risk management and qualitymeasurement (and service overall if this is the mainservice provided)

• There was an effective governance framework in thehospital, which gave robust assurance about the qualityand safety of services. The provider held meetingsthrough which governance issues were addressed. Themeetings included the Medical Advisory Committee(MAC), Heads of Department (HOD), Clinical Audit andEffectiveness and Clinical Governance Committee. Wesaw the hospital committee structure organisation chartfor 2018 and it was clear which committees were activeand who chaired each meeting.

• The hospital had a clinical scorecard that hadkeyperformance indicators (KPIs) that werereportedquarterly. Results were benchmarked andtrackedagainst group performance targets. Staff toldusthis was used for quality improvement. Wesawevidence at Clinical Governance anddepartmentalmeetings that results were discussed.

• All staff were aware of the clinical scorecard which had anumber of key performance indicators related to patientsafety. The scorecard was seen to be displayed in allclinical areas visible to staff.

• There was strong engagement with consultantsworkingat the hospital. As this was a new hospital, theMAC had to start from the beginning, which was a firstfor Spire Healthcare. A core team were approached priorto the hospital opening and an interim MAC was

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developed. This became a full MAC in November 2017and was seen to haverepresentation from differentclinical specialties. The senior team and the MAC chairwere very proud of how this team had evolved over themonths leading up to the development of a full MAC.

• Mostconsultants worked at the local NHS hospital. TheMAC chair and the Hospital Director had close links tothe local NHS hospital medical director to ensure openlines of communication. were reviews of consultantpractice to ensure thatthe consultants were workingwithin their own scope ofexpertise.

• Effective systems were in place for granting practisingprivileges to consultants. All applications to practice atthe hospital were reviewed by the hospital medicaladvisory committee (MAC). We saw evidence of this inthe minutes of the MAC meetings we reviewed. Wereviewed six sets of consultant personnel files, allcontained evidence of the appropriate checks requiredby regulation including medical indemnity insuranceand appraisals. Practising privileges were suspended ifthe consultant did not practise regularly at the hospital.

• There was a nominated consultant (MAC chair)whosupported the Clinical Governance Committee andalsosat on the MAC, the minutes showed they supportedthefeedback of any governance issues to the MAC. Thisperson also had direct access to all hospital policy andprocess documents in order that if any communicationor changes were made they would be immediatelyinformed.

• The Clinical Governance Committee metquarterly.Regular agenda items included incidents,keyperformance indicators, clinical audit plan,patientsafety, patients’ experience and the risk register.

• Reviewing incidents was a standard agenda item on thequarterly clinical governance committee meeting andwe saw evidence of this from meeting minutes. Thesenior team explained to us and we saw evidence ofdiscussion concerning trends of incidents and plannedaction to be taken. We saw all incidents were reviewedby committee members monthly and summarisedquarterly at the meeting.

• Learning wasshared across the other hospitals in theorganisation, an organisation wide incident reviewworking group reviewed all incidents to identify sharedlearning.

• All incidents were categorised by location and type andthis was reviewed by the senior management team andreported onto the governance committee and medicaladvisory committee (MAC). Near miss incidents werealso reviewed and discussed.

• The children’s and young person’s service wassuspendedin October 2017 in order to ensure all staffhad therequired training to enable this service tocontinue. Wesaw this was discussed and minuted at theClinicalGovernance and MAC committee demonstratinga goodgovernance process. This demonstrated thehospitalleadership team made decisions based on theneed toprovide safe services of good quality, even if theymayhave negative commercial consequences. This wasalso demonstrated in the slow build up andintroduction of other services within the hospital forexample intensive care utilisation and chemotherapytreatments.

• There was a wide range of audits carried out inthehospital and these were seen to be reviewed attheClinical Audit and Effectiveness Group, which in turnfedthrough to the Clinical Governance CommitteeandHODs meeting. Patient safety was seen to be anagendaitem for all committees. There was a regularaudit planat the hospital and we saw they were up todate with theplan.

• Information was two way and key points were includedin the safety update bulletin for staff. This meant thatstaff at all levels had a clear picture of quality andperformance across the hospital.

• We reviewed the hospital governance report for quarterthree 2017. The report was based on the Care QualityCommission five domains of safe, effective, caring,responsive and well led. It was a comprehensivedocument highlighting to all members of staff forexample, the levels of activity, any changes in activity,new consultants, safety information including trends ofincidentsand safety alerts.

• Policies and procedures were in place to support staff tocarry out their duties safely and effectively and newpolicy information was included in the monthly safetyupdate bulletin.

• The hospital maintained a risk register, risks were red,amber, green (RAG) rated, mitigating actions andcontrols were described in the risk register. There were

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no risks rated red – the highest risk rating. We discussedrisks with the department heads, the risks theydescribed for their departments were commensuratewith the risks identified on the risk register.

• All staff we spoke with were aware of the risk register. Wesaw that all incidents, risks and complaints were loggedand managed on the hospital’s electronic reportingsystem.

• Managers told us they were compliant with nationalsafety standards for invasive procedures as the hospitalfully adhered to the national Spire standards for surgicalsafety known as LocSSIP’s.

• The hospital had a named infection control andprevention lead in post and an annual programme ofInfection Prevention for 2018, which outlined actionsrequired to reduce the risk of health care associatedinfection.

Leadership / culture of service related to this coreservice

• The senior team and heads of department at thishospital were mostly recruited prior to the hospitalopening. They were able to develop as a new team andwork collaboratively together to develop thefoundations of the hospital since its inception.

• As a group, they had recruited teams and developed theservices to provide quality safe care for patients. We sawevidence throughout our inspection of how the teamhad used their skills and knowledge to capably lead thishospital from the planning stage to a functioninghospital.

• The senior team had identified that they werecontinuing that growth and development throughsharing and learning between teams across the hospital.

• The MAC had a new but stable membership and ourdiscussions showed there was open communicationwith the hospital senior management team. Thisdemonstrated a shared focus on delivering goodgovernance and quality patient care.

• Staff were full of praise for the senior managementteam. Staff told us they regularly saw the hospitaldirector and head of clinical services in their

departments. All members of the senior team were seento be approachable. Many members of staff told us ‘thatthe fact that the hospital director and clinical leadsknew their names meant a lot to them.’

• There was clear leadership, and staff knew theirreporting responsibilities and took ownership of theirown working areas. Staff were seen to be sharing ideasand between teams and working together to gain anunderstanding of each other’s roles as the servicesdeveloped. This was evident in relation to staff on theward understanding of booking procedures andadministration protocols in order to answer patient’squestions or access the right person for them to speakto.

• During our inspection, leaders were visible in alldepartments we inspected; staff knew the seniormanagers, referred to them by name and told us theywere very friendly and approachable. We observed staffand leaders interacting, leaders’ mannerisms towardstaff were appreciative and supportive.

• From the conversations we had with staff and seniormanagers, the data we reviewed and the action plansand learning identified, it was clear that leaders couldrecognise challenges to good quality care and identifyactions to address them.

• There was a culture of openness and honesty, this wasevident from the incident reporting process, complaintsprocess and the way the hospital marketed its services.

• A whistle blowing policy, duty of candour policy andappointment of two freedom to speak up guardianssupported staff to be open and honest. Staff told us theyattended duty of candour training and described to usthe principles of duty of candour.

• Staff told us they felt respected and valued. All staff weregiven a Spire Healthcare welcome handbook onappointment which contained all the information theyneeded to carry out their roles effectively includinguniform policy and details of the employee assistanceprogramme.

• Local managers we spoke with told us there was aprocedure in place for the management of poorperformance but to date they had not needed to use it.

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• The senior team had identified and addressed someareas of poor performance and staff problems .Theywere dealt with and we were assured by how this wasresolved to ensure staff did not feel intimidated and thatpatients were kept safe.

• There was an overall emphasis on safety and qualitythroughout the hospital from the quality of the foodprovided to the procedures and checks in place toensure patient safety.

Public and staff engagement

• The hospital actively engaged with staff and the publicby a variety of communication methods. They took onboard comments and suggestions and actedaccordingly to address issues. We saw minutes from amonthly ‘believe in our people meeting’; representativesof all staff grades attended these meetings in order toreview new ideas for development across the hospital.For example as the teams were all new it was discussedhow to ensure staff developed an insight into otherdepartments of the hospital.

• An annual staff survey took place which translated in toan action plan which was shared with staff. We saw the‘You said/we did’ action plan displayed on noticeboards. Staff had asked for more information onhospital performance and other key issues so inresponse, managers had implemented additionalcommunication methods.They also held a ‘Believe inour people’ group made up of representatives fromeach department who could raise concerns or makesuggestions on behalf of other members of staff.

• Staff told us they could raise concerns with senior staffor line managers, or the freedom to speak guardian.Posters were displayed in prominent areas with detailsof the freedom to speak guardian. Staff were also awareof the hospital whistle blowing policy; 94% of staffanswered positively to ‘I am aware of Spire HealthCare’spolicy on whistleblowing.’

• In the hospital consultant survey, 79% of consultantsrated the service as excellent or good. This placed thehospital fourth out of 39 hospitals in the SpireHealthcare group.

• Feedback from the most recent patient survey showedthat patients felt they had ’information overload’ at the

time of discharge. In response, ward staff introduced afollow up phone call with the patient the day afterdischarge to check if the patient was happy withdischarge instructions.

• The hospital also took part in the net promoter score.The net promoter score is a management tool used togauge the loyalty of an organisation’s customerrelationships. During 2017, patients gave the hospital a90% net promoter score.

• In June 2017, the hospital held a public open day, whichwas well attended by the local community.Feedbackwas collected and as a result, the physiotherapydepartment planned a weekly Pilate’s class and weredeveloping falls prevention classes. The hospital hadalso welcomed visits from the local U3A (University ofthe third age) and Rotary club groups.

Innovation, improvement and sustainability (localand service level if this is the main core service)

• One of the five strategic objectives was to deliverrevenue growth and ensure sustainability. Seniormanagers had plans in place to increase patientnumbers and make services more attractive to thepublic by re opening paediatric services, offeringappointments in 24 hours, providing one stop shopservices, providing one total cost for all procedures andsupporting NHS waiting list initiatives.

• Staff and managers looked for continuous improvementby learning from incidents and complaints,implementing new evidence based practice andresponding to feedback from patients and otherstakeholders.

• Staff used information to proactively improve patientcare. For example, a pain management group hadstarted to meet to review pain management throughoutthe patient journey, including audit of patient recordsand analysing patient feedback. One result of thismeeting was to identify a pain specialist for SpireNottingham Hospital and arrange pain managementtraining.

• The provider ran a staff reward scheme called ‘InspiringPeople.’ Nominations were received from all hospital

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staff and each month one member of staff was selectedto receive a gift voucher in appreciation of what theyhad achieved.Staff could also nominate colleagues tothe annual Spire Healthcare award scheme.

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Safe Good –––

Effective Not sufficient evidence to rate –––

Caring Good –––

Responsive Outstanding –

Well-led Outstanding –

Are outpatients and diagnostic imagingservices safe?

Good –––

Incidents

• There were no never events reported for the servicefrom April 2017 to November 2017. Never events areserious incidents that are entirely preventable asguidance, or safety recommendations providing strongsystemic protective barriers, are available at a nationallevel, and should have been implemented by allhealthcare providers.

• There were no serious incidents reported for the servicefrom April 2017 to November 2017. Serious incidents areevents in health care where there is potential forlearning or the consequences are so significant that theywarrant using additional resources to mount acomprehensive response.

• The service recorded 40 incidents from April 2017 toNovember 2017. Thirty of these incidents were definedas clinical incidents and 10 were recorded asnon-clinical incidents. Staff told us the main themesbehind the incidents reported in the department wereadministration errors and errors in labelling specimens.Learning from the incidents had taken place andmeasures implemented to prevent further incidents.

• All staff we spoke with had a good understanding of theincident reporting process. All staff had completed andsubmitted an incident form and had feedback followingincidents they had submitted.

• There was a good learning from incidents culture withinthe service. Staff were not only aware of incidentsreported locally in their own department, but alsowithin the hospital and provider wide incidents. Staffdiscussed relevant incidents at team meetings andidentified any potential learning for their department.

• Under the Ionising Radiation (Medical Exposures)Regulations (IR (ME) R) 2017, providers are required tosubmit notifications of exposures ‘much greater thanintended’ to the CQC. We received no notifications fromApril 2017 to November 2017. Staff in the diagnosticimaging department had a clear understanding of whata reportable incident was.

• Senior staff had recently completed root cause analysis(RCA) training to develop their skills when it came toincident investigation. At the time of our inspection,they had not been required to complete a RCA of anyincidents, which happened in their department.

• Regulation 20 of the Health and Social Care Act 2008(Regulated Activities) Regulations 2014 is a regulation,which was introduced in November 2014. The duty ofcandour is a regulatory duty that relates to opennessand transparency and requires providers of health andsocial care services to notify patients (or other relevantpersons) of certain ‘notifiable safety incidents’ andprovide reasonable support to that person. The duty ofcandour regulation only applies to incidents wheresevere or moderate harm to a patient has occurred.

• Staff we spoke with had an understanding of the duty ofcandour process and the need for being open andhonest with patients when errors occur. Senior staffmembers were able to confidently explain the processthey would undertake if they needed to implement the


Outpatients and diagnosticimaging

Outstanding –


duty of candour following an incident, which met therequirements, however at the time of our inspection,they had not needed to do this. Staff did howeverdiscuss an incident, which occurred in a different servicewhere the duty of candour was implemented.

For our detailed findings on incidents, please see the safesection in the surgery report.

Cleanliness, infection control and hygiene

• All areas of the outpatient and diagnostic imagingdepartments we visited were visibly clean and tidy.Environmental audits were conducted by the infectionprevention and control (IPC) lead. Results from theaudits conducted in November 2017 showed an average94% compliance with requirements for nine areasaudited. All areas audited where clinical care andtreatment was provided demonstrated 100%compliance. Areas which demonstrated the lowestcompliance (82-93%) were administration areas, waitingareas and the dirty utility room. Staff told us actions hadbeen taken in response to these results and compliancehad now improved.

• The service had not participated in the patient ledassessment of the care environment (PLACE) audit in2017, as the hospital had not been open for theminimum required period. However, they had alreadyengaged with the process and were on the auditprogramme for 2018. PLACE audits look at a variety ofareas, which patients feel are essential to maintain highstandards, cleanliness of the environment is an elementof these audits.

• Housekeeping staff understood their responsibilities,cleaning frequency and standards. There were cleaningschedules in all areas and staff had signed when areashad been cleaned. Housekeeping staff were responsiblefor cleaning all areas in the outpatient and diagnosticimaging department, except the MRI scanning room.The lead radiographer for MRI was responsible for thecleaning of this room and had access to the appropriateresources to enable them to do this.

• There were handwashing facilities within the clinicalenvironment and staff had access to hand sanitiser atpoint of care. We observed staff performing handdecontamination in accordance with the World HealthOrganisation (WHO) five moments for hand hygiene. Wealso observed hand hygiene promotional posters to

support compliance with hand hygiene. All sinksobserved in the department were compliant with HealthBuilding Note (HBN) 00-09: infection control in the builtenvironment.

• Patients and relatives were also encouraged todecontaminate their hands when entering thedepartment. Hand sanitiser was available in publicareas and waiting rooms for patients and relatives touse as required. We also observed hand sanitiserdispensers, which were aimed at children who visitedthe department. These were decorated in a way toencourage them to use them, as well as being at aheight, which made it easy for them to use.

• The department regularly conducted hand hygieneaudits. Information provided before the inspectiondemonstrated 100% compliance. These audits alsoincluded whether staff were bare below the elbow inaccordance with national and local policy. All staff weobserved during our inspection were bare below theelbow.

• Staff had access to personal protective equipment (PPE)in all areas of the outpatient and diagnostic imagingdepartment to protect themselves and patients duringcare and treatment. We saw evidence of this in usethroughout the clinic.

• We saw evidence of regular tap flushing within thedepartments, which was in line with the requirements ofhealth technical memorandum (HTM) 04-01 the controlof Legionella, hygiene, safe hot water, cold water anddrinking water: part A. These records were electronicand reviewed regularly by the responsible person for thewater system as part of the water safety group.

• There were wipes available for decontaminatingequipment after use in all areas of outpatients anddiagnostic imaging. There was also a well-embeddedprocess in place using the green ‘I am clean’ stickers toidentify when items of equipment were decontaminatedand ready to be used on another patient. We observedstaff decontaminating equipment after patient use withthe wipes provided.

• The outpatient department used endoscopes (aninstrument used to examine organs or body cavities)during some procedures. The decontaminationprocesses used for these endoscopes was in line withHealth Technical Memorandum (HTM) 01-06:



Outstanding –


decontamination of flexible endoscopes. Staffimmediately wiped equipment post procedure withspecific wipes before being placed in a container with acover to identify it had been used and sent to theendoscopy department for more in-depthdecontamination and specific tests for functionality. Anaudit of these endoscopes was completed in January2018; this demonstrated 100% compliance with thecleaning process.

• The departments mainly used single use items forprocedures. On the rare occasions equipment usedrequired sterilisation, staff placed items back into theircontainers (trays) and transported them to the onsitesterile services department for reprocessing.

• Staff told us all areas of the outpatient and diagnosticimaging departments had received a deep clean as partof the hospital deep clean programme. We saw acertificate in one area, which provided details of thedeep clean, which had been completed.

• Staff were aware of additional precautions to take in theevent of an infectious patient arriving in thedepartment; however, we were informed it was unlikelythat a patient with an infectious disease such astuberculosis (TB) or influenza would attendappointments at the hospital. Staff from the outpatientdepartment were involved in the peer vaccinationprogramme (influenza vaccination) for the entirehospital. Staff told us uptake at the hospital was over70%.

• Information provided before the inspection showed100% of all the staff at this hospital had completed theirIPC mandatory training. Staff from the outpatients anddiagnostic imaging departments told us all the staff,except a new member of staff and a regular bankmember of staff, had completed their IPC training.

• All areas in the outpatient and diagnostic imagingdepartment had disposable curtains. These were intactand dated and staff knew the process for replacingthem.

• In the event of a body fluid spillage in the departments,all areas had immediate access to body fluid spill kits.

• There was an IPC link practitioner within both theoutpatients and diagnostic imaging departments. Theyliaised regularly with the lead IPC nurse for the hospitaland facilitated audits and additional training asrequired.

Environment and equipment

• The outpatient and diagnostic imaging department waslocated on the ground floor and clearly signposted forpatients to find. The main outpatient doors were openfor patients to walk through, however all consulting andtreatment rooms were only accessible to staff through acard system. The diagnostic imaging departmentrequired patients to use a call bell to gain entry. Alldoors were accessible to staff through a card system.Additional safety measures were in place once in one ofthe procedure rooms as a locking system had beenimplemented to prevent patients going back into aprocedure room once they had left, preventingaccidental exposures to radiation.

• At the time of our inspection there were threeresuscitation trolleys in the department. One waslocated in the diagnostic imaging department, one inmain outpatients and one in the cardiology room wherea higher risk of cardiac arrest was perceived due to thenature of procedures and tests conducted in this room.All trolleys had regular checks when the departmentwas open and items were in date. All trolleys were cleanand free of additional items and had standardisedequipment on them. All trolleys had tamper proof sealson them.

• Within the diagnostic imaging department, there was amagnetic resonance imaging (MRI) scanner,computerised tomography (CT) scanner, plain x-rayequipment, fluoroscopy, ultrasound scanningequipment and mammography equipment.

• Servicing of large items of equipment in the departmentwas under service level agreements with the companywho provided the equipment. All items had details ofservice date on them and dated for next service. Stafftold us if equipment failed, the processes in placeallowed swift response and replacement if necessarywhilst being repaired.

• All equipment in the department had evidence of indate electrical safety tests.



Outstanding –


• Lead aprons were available in the diagnostic imagingdepartment. They were stored correctly on hangers andthere was evidence of regular checks of these. Wereviewed these aprons and found them to be in a goodstate of repair. Staff had monitoring devices on them tomonitor their exposure to radiation.

• The diagnostic imaging department displayedappropriate signs to indicate the risks from x-rays inaccordance with the ionising radiation (medicalexposure) regulations (IR (ME) R) 2017 and the Healthand Safety (Safety Signs and Signals) Regulations 1996.We also observed signs in the department to indicatethe additional risk to women who were pregnant. In thearea where the magnetic resonance imaging (MRI)equipment was located, there were signs to indicate thedangers associated with this and prohibition signs. Thestrength of the MRI scanner was clearly displayed on thesigns. This practice was in line with the Medicines andHealthcare Products Regulatory Agency (MHRA) safetyguidelines for magnetic resonance imaging equipmentin clinical use 2015.

• Within the room where the MRI scanner was located, weobserved equipment such as waste bins with labels onthem to show they were ‘MR safe’. This meant theseitems were safe to remain in the room when the magnetwas operational as they were safe and not at risk ofbecoming a projectile (an item pulled at force across aroom due to the magnet). Items in the department,which could not be in the room with the MRI scannerwhen in use, were labelled ‘MR unsafe’. The MRI leadtold us they inspected the room at the beginning of theday to ensure no MRI unsafe items had been left in theroom accidentally. If staff were unsure about equipmentand could not assure themselves they could safely be inthe room with the MRI, these were considered as MRunsafe. This was in line with MHRA safety guidelines formagnetic resonance imaging equipment in clinical use2015.

• All areas of the department had completed assessmentsof products under the Control of Substances Hazardousto Health (COSHH) Regulations 2002, and we found allitems were stored appropriately.

• Staff regularly conducted quality assurance checks of allequipment and recorded this. During a morning huddle

in the diagnostic imaging department, the staff memberleading the huddle informed the rest of the team aboutan item of equipment that had failed the qualityassurance checks that morning and the action taken.

• We reviewed a random selection of consumableproducts including blood-sampling bottles, clinicalswabs, dressings, intravenous fluids and airwaysupporting products. All items were in date and theoutside packaging intact.

• In the outpatient department, there was bariatricequipment available including therapy couches andchairs. Staff were aware of the safe loads for these itemsand they were in a good state of repair. Bariatric patientshave a BMI (Body Mass Index) exceeding a healthy range.

• There was an anti-gravity treadmill available in thephysiotherapy department for patient treatment andrehabilitation. Patients using this piece of equipmentwere required to put on a special running suit. Staff toldus the company that provided the equipment regularlyreplaced these and provided a comprehensivedecontamination service, as well as servicing theequipment.

• We observed staff correctly segregated clinical anddomestic waste. Waste bins provided for thedepartment were enclosed and foot operated. Sharpsbins were correctly assembled and below the fill line.The management and disposal of sharps and waste wascompleted in accordance with policy.

Medicines

• Both outpatients and the diagnostic imagingdepartment had safe systems in place for ordering,storing and administering medicines and contrastmediums in compliance with the hospital policymanagement of medicines in Spire Healthcare, dated2016.

• No controlled drugs (CDs) or cytotoxic medicines werekept or administered in the outpatient department. CDsare medicines liable for misuse that require specialmanagement and cytotoxic medicines are medicineswhich contain chemicals which are toxic to cells,preventing replication and growth and may be used totreat cancer.

• Medicines in outpatients were stored in lockedcupboards and refrigerators, within locked rooms. The



Outstanding –


rooms were only accessible to staff through a cardsystem, and only registered staff held the keys to thecupboards and refrigerators. We reviewed a selection ofmedicines in the department and found all items werein date.

• We found all medicine refrigerators were locked at thetime of our inspection. The staff in the pharmacydepartment monitored refrigerator temperaturesremotely. If there were any concerns, they would informstaff in the outpatients department immediately.

• Contrast medium was securely stored in the CTdesignated room within the diagnostic imagingdepartment. When required, contrast was prescribed forpatients and administered in accordance to hospitalpolicy.

• The outpatient service used their own provider specificprescriptions for patients. Staff kept these in lockedcupboards, within a locked room and had a recordingsystem in place, which indicated when a prescriptionhad been issued. This was in line with best practiceguidance from NHS Protect: security of prescriptionforms 2013. The pharmacy department completedregular audits on prescriptions and the traceability ofthe used prescriptions. The department scored 100%compliance in the most recent audit.

• There was an anaphylaxis kit in the outpatientdepartment. This was provided by the pharmacydepartment and in a tamper proof container. All staffwere aware of the kit’s location; however, we did notobserve any evidence of staff checking this piece ofequipment.

• There was a corporate antimicrobial policy in place atthis hospital, which all departments followed. Staff alsotold us the consultant microbiologist who providedadvice was from a local NHS acute hospital, it wastherefore acceptable for staff to follow advice from theconsultant microbiologist on antimicrobial prescribingwhich would be based on the local NHS acute policy.

• We had concerns that this could lead to conflictingdecisions about antimicrobial prescribing and raisedthis with the hospital management. An examplediscussed with them was around antimicrobialprescribing and administration for sepsis. The SpireHealthcare corporate policy advised to administer analternative antimicrobial from what the local NHS acute

hospital administered. On review, of the policy section10 stated ‘that for guidance on antibiotic choice eachhospital should follow local guidance’. We were assuredthis was not a significant risk for the provider.

Records

• The hospital had an on-site medical records store,which was located at the end of the hospitaladministration corridor. Only staff who worked inmedical records had access to the department, otherstaff members would be allowed in by medical recordsstaff. This ensured the security of the records held in thedepartment. At the time of our inspection, all records ofpatients seen at the hospital were stored in thisdepartment. There were plans in place to eventuallystore old files in off-site storage, but this was not apriority at the time of our inspection.

• From April 2017 to November 2017 there were nopatients seen in the outpatient department withouttheir full patient records being available. This was downto strict policies in place over the security of patientrecords. Staff were not permitted to take records off-site.

• During our inspection, we did not observe any patientrecords left unattended. However, the medical recordsstaff did inform us there had been one incident wherethis had happened. An incident form was completedfollowing this and lessons had since been learnt.

• Hospital policy in place ensured all members of staffplaced patient records in sealable wallets whentransporting notes, even if this was from one room tothe next room. This ensured confidentiality wasmaintained and no items could accidentally beseparated from the notes. All staff members tookrecords security very seriously, the medical recordssupervisor ensured staff adhered to correct policies,which were in line with the Data Protection Act 1998.

• We reviewed 10 sets of patient records and found theycontained referral letters, results of any diagnostic tests,appropriate pre-operative assessment checks includingvenous thromboembolism (VTE) assessment andcontemporaneous notes. However, in all of the recordsreviewed, we found documentation was not alwayscompleted in line with professional standards, as the



Outstanding –


clinician did not always sign at the end of notes, and didnot print their name or enter their professionalregistration number. In 50% of the notes we reviewed,we also found the notes were not legible.

• A documentation audit conducted by the providershowed 90% compliance with the standards auditedagainst. Areas that received a negative response were inrelation to clinicians not signing their entry.

• We raised this with the hospital director at the time ofour inspection and a daily spot check audit ofconsultant documentation was implemented. A letterwas sent to all medical staff outlining what wasrequired.

• All images from scans and x-rays were stored on apatient archiving communication system (PACS). Onlyauthorised staff could access these through a passwordsystem.

Assessing and responding to risk

• Local policies in the diagnostic imaging departmentfollowed the national guidance and standards inrelation to the identification and prevention of contrastrelated acute kidney injury. Staff told us they had notexperienced any cases of this since the hospital opened.

• All staff in the diagnostic imaging department hadcompleted basic life support and paediatric basic lifesupport training. Staff were knowledgeable about thesteps to take in the event of a patient deteriorating inthe department.

• Until recently, the diagnostic imaging department hadtwo resuscitation trolleys, but one had recently beenremoved. Staff were aware of this decision, however atthe time of our inspection had not assessed the impactthis would have as the department was divided into twomain areas with many card-operated doors in between.During our time on-site, the lead for the department riskassessed this and provided results to the inspectionteam to demonstrate there was no risk associated withthis.

• All staff in the outpatients department had completedimmediate life support training and paediatric basic lifesupport training. Registered staff had also completed an

acute illness management (AIM) course to assist them inthe recognition and treatment of a deteriorating patient.The lead for the department had also sourced an AIMcourse for the unregistered member of staff.

• All patients had a set of baseline observationsperformed during pre-assessment appointments.Nursing staff used the national early warning scoringsystem (NEWS), to record routine physiologicalobservations such as blood pressure, temperature, andheart rate. NEWS was used to monitor patients and toprompt support from medical staff when required. Ifstaff had concerns about a patient’s status, furtherobservations and NEWS calculations would beconducted. If staff had concerns, they would contact theresident medical officer (RMO) to come and review thepatient.

• In the event of a cardiac arrest, there was a hospitalarrest team on site, which would be bleeped to attend.Staff knew the process to summon this support bydialling ‘2222.’ Within the department, there was a visualand audible emergency buzzer system to identify wherethe emergency was located. Staff told us for the areas,which were not immediately visible, the bleep systemused for the cardiac arrest team also showed thelocation of the emergency to help direct the team.

• The hospital arrest team regularly practised arrestscenarios. Staff from the diagnostic imaging departmenttold us about an arrest scenario involving the MRIscanner. Staff told us this had gone well and ensuredstaff and patient safety at all times. The first step to anarrest in an MRI scanner was to safely remove thepatient from the scanner to an area that was safe toresuscitate a patient.

• There was an embedded process in place to transferdeteriorating patients to the local acute NHS trust. Stafftold us about an incident where a patient wastransferred out from the outpatient department andrequired immediate treatment at the local NHS hospital.Although the patient had not deteriorated during theirtime in the department, during their appointment staffhad identified a serious life threatening condition. Stafftold us this process had gone smoothly at the time,although a review of the incident had identified areasfor improvement.



Outstanding –


• Staff told us they had not undergone any specific sepsistraining to assist them to identify and treat patientssuffering from sepsis. However, staff told us they wouldtreat any deteriorating patient in the same way andwould request the RMO to assist in the emergency. Theprovider confirmed sepsis training was included in theacute illness management (AIM) course which all staffcompleted. Records showed all staff had undertakenthis training.

• Staff completed WHO ‘Five Steps to Safer Surgery’surgical checklists in the outpatient department forpatients who underwent a minor procedure. TheNational Patient Safety Agency (NPSA) issued a patientsafety alert recommending that all providers of surgicalcare use the WHO surgical safety checklist. This wasincorporated into the ‘Five Steps to Safer Surgery’, whichincluded pre-list briefings, the steps of the WHO surgicalsafety checklist and post-list debriefings in oneframework. The checklist focused the whole team onthe safety of practices before, during and after aprocedure. Staff had started to audit the use of thesechecklists, however there were only seven to audit atthe time of our inspection, which did not give the leadfor the department enough information about whetherthis process was embedded.

• Staff in the diagnostic imaging department used theWHO surgical safety checklists during some proceduresthey conducted. Information received showed thecompliance with the checklists were improving from91% in January 2018 to 100% so far for the month ofFebruary 2018.

• There was a radiation protection advisor (RPA) availableto the diagnostic imaging department, contactable byphone or email. Onsite there was a team of threeradiation protection supervisors (RPS) to ensure all staffwere adhering to local rules.

Safeguarding

• Staff in the outpatient and diagnostic imagingdepartments demonstrated a good awareness of thesafeguarding policy, and what actions to take if theysuspect a vulnerable adult or child requiredsafeguarding.

• All staff were able to identify who the lead forsafeguarding was at the hospital. The outpatient

manager was one of the safeguarding leads for thehospital. The diagnostic imaging manager had allocateda member of staff as the lead for safeguarding within thedepartment.

• Information provided by the hospital prior to ourinspection demonstrated 100% of all staff hadcompleted safeguarding adults training and 98.9% of allstaff had completed safeguarding children trainingagainst a target of 95%. Staff we spoke with all told usthey had completed all aspects of their safeguardingtraining, including safeguarding children level threetraining.

• There had been no reported safeguarding concernsfrom outpatients or diagnostic imaging departments.Staff were however aware of a safeguarding which hadrecently occurred at the hospital.

• Staff within the outpatients department had completedfemale genital mutilation (FGM) training as part of theirsafeguarding training. Although the hospital did notprovide a paediatric service, staff were aware of theirresponsibilities to report concerns. One area of risk staffhad identified was through gynaecology clinics where adiscovery of an adult female having undergone FGMwho may have female children themselves. At the timeof our inspection, there had been no requirements toreport concerns.

• We saw information regarding domestic abuse andother safeguarding concerns displayed in theoutpatients department waiting area, which was clearlyvisible to patients using the department. Within thisinformation displayed was a range of confidentialtelephone numbers for patients to take away if theyrequired this.

Mandatory training

• All staff in the department were required to completefire safety, health and safety, infection control,safeguarding children and adult training, manualhandling, compassion in practice, equality and diversity,Mental Capacity Act training and controlled drugstraining. Mandatory training mainly consisted ofelectronic training, with some face-to-face training.



Outstanding –


• Information submitted by the provider showed 100%compliance with most modules. The only modules notto have 100% compliance were health and safety (99.4%compliance) and safeguarding children (98.9%compliance).

For our detailed findings on mandatory training please, seethe safe section in the surgery report.

Nursing staffing

• There was sufficient staff with the qualifications, skillsand experience to meet the needs of the patients in theoutpatient and diagnostic imaging department.

• The outpatient department had one manager, oneoutpatient sister, one pre-assessment sister, threeregistered nurses and one healthcare assistant. Therewas currently one registered nurse on the bank staff andone in the recruitment process.

• Information provided before the inspection showedagency and bank usage was minimal. From April 2017 toNovember 2017 all months apart from September 2017recorded a zero bank and agency usage. In September2017, there was a 2% agency and bank usage.

• The outpatient department had not used agency coversince they opened and the diagnostic imagingdepartment had only used agency once. Bothdepartments had access to an agency, but preferred touse regular bank staff where they could to cover duties.

• The diagnostic imaging department had one manager,eight radiographers and one healthcare assistant. Therewere an additional three radiographers on the banksystem who could cover cardiac cases, mammographyclinics and general radiographer duties.

• When a cardiology clinic was running, staffing for thisincluded a lead cardiology nurse and cardiacphysiologist. These were additional staffing to theoutpatient and diagnostics imaging departmentstaffing.

• Staffing for the outpatient department was calculatedusing a tool adapted from the Shelford Staffing tool.This determined requirement against activity. Duringour inspection, one day had one outpatient sister, oneregistered nurse and one healthcare assistant on duty.The next day had one outpatient sister, three registered

nurses (staggered through the day) and one healthcareassistant on duty. The outpatient manager workedMonday to Friday, 9am to 5pm and covered anyadditional requirements.

• There were no staff members on long-term sickness inthe outpatient or diagnostic imaging department. In theeventuality of short notice sickness, cover throughregular staff or bank staff was usually found.

Medical staffing

• The hospital employed over 137 consultants onpractising privileges, most of whom were employed atthe local NHS acute trust. There was a group ofconsultants who regularly provided clinics in theoutpatient department.

• The hospital employed 14 radiologists on practisingprivileges. These radiologists worked on a rota for thediagnostic imaging department.

• Consultants provided their availability well in advanceto the administration department so clinics could bescheduled.

• There was a resident medical officer (RMO) employed atthe hospital. Their main duties expected them to coverthe ward setting; however staff told us they couldrequest the RMO to assist them if required.

• There were no medical staff on long-term sickness in theoutpatient or diagnostic imaging department.

Emergency awareness and training

• All staff in the outpatient and diagnostic imagingdepartment had completed fire safety training whichincluded practical fire evacuation scenarios.

• Staff were aware of backup generators being installed atthis hospital and the engineering team were responsiblefor testing these every month.Staff were aware of amajor incident and business continuity plan, whichcontained details of what all departments, should do inthe event of an emergency.

• For our detailed findings on emergency awareness andtraining please see the safe section in the surgery report.

Are outpatients and diagnostic imagingservices effective?



Outstanding –


Not sufficient evidence to rate –––

Evidence-based care and treatment

• The department followed corporate policies andprocedures, which were accessible on the hospital’sintranet. We saw these referenced the National Institutefor Health and Care Excellence (NICE), relevantregulations and legislation and evidence-based bestpractice guidance.

• Staff in the diagnostic imaging department had recentlyreviewed the corporate policy in light of the new ionisingradiation (medical exposure) regulations (IR (ME) R)2017 regulations. The lead for the department, who wasa member of the national Spire Diagnostic Imagingsteering Group, told us this work had been shared withthe Spire Healthcare corporate team who reviewpolicies and was being implemented into this policy.

• Staff provided evidence-based care and treatment inline with standards from the Society of CardiologicalScience and Technology (SCST). We observed staff usingthe Bruce protocol (also known as an exercise tolerancetest or stress test) for assessing patients with suspectedheart disease.

• All departments conducted a planned programme ofclinical and non-clinical audits. These results werediscussed locally at individual department meetings aswell as hospital wide governance meetings. Results ofthese audits were published on the internal dashboard.Results of these audits showed they were mainlymeeting the targets within the outpatient anddiagnostic imaging departments.

For our detailed findings on evidence-based care andtreatment, please see the effective section in the surgeryreport.

Pain relief

• Staff in the physiotherapy department provided patientswith chronic pain management classes. These classeswere provided with oversight of a pain managementspecialist consultant and pain specialist nurse.

• Patients undergoing any minor procedure in theoutpatients and diagnostic imaging department rarely

required analgesia (pain relief) during their procedure.Procedures were usually conducted under localanaesthetic. If patients did require analgesia, theconsultant in charge of their care could prescribe this.

Nutrition and hydration

• All patients attending the outpatient department hadaccess to a tea and coffee machine, which was free ofcharge. There was also a coffee shop in the immediatevicinity of the department.

Patient outcomes

• Staff in the physiotherapy department completedpatient reported outcome measures (PROMs) andpatient reported experience measures (PREMs) forpatients receiving care and treatment. This involvedpatients completing assessments of their healthoutcomes and their functional level, as well as theirexperience of receiving healthcare. Ultimately theresults from these assessments helped staff to look atcare and treatment they provided and where necessary,alter treatment plans to improve patients’ experiences.

• At the time of our inspection, the hospital had notcollated enough data on PROMs and PREMs to enablethem to benchmark their clinical performance againstother providers, therefore staff used these results locallyto improve patient experience.

• A patient dose audit had not yet been undertaken at thislocation, as the hospital has not been open for 12months. However, a recent radiation protection advisoraudit was completed and identified staff from thediagnostic imaging department were using the NationalDiagnostic Reference Levels (NDRLs) and recording thedose area product. A full patient dose audit wasscheduled for later in 2018.

• At the time of our inspection, there were noaccreditation schemes in place in any of thedepartments. The hospital had plans in place toparticipate in accreditation schemes once they met thethreshold for how long they had been operating.

For our detailed findings on patient outcomes, please seethe effective section in the surgery report.

Competent staff

• All staff had completed an induction programme whenthey joined the hospital. We saw evidence of completed



Outstanding –


induction competencies in staff competency files. Stafftold us since they had completed the inductionprogramme, they had fedback to the hospitalmanagement on how this could be improved and thishad resulted in a new document for new starters.

• All staff who worked at Spire Nottingham Hospitalcompleted the same induction programme. Thisincluded employed staff, staff on practising privilegesand bank staff.

• Information provided before our inspection showed100% of staff within the outpatient and diagnosticimaging department had received an appraisal. Stafftold us these had been meaningful and helped toidentify a personal plan for development for the yearahead. Staff also had regular one-to-one meetings withtheir department leads, which also gave them theopportunity to discuss areas for development.

• Staff told us they felt supported to develop their rolesfurther by accessing external training. We heard aboutseveral examples where staff had or were in the processof attending further training, supported by the hospitalto develop and enhance their current roles.

• We observed examples where staff had been supportedto complete additional training and had evidence ofassessed competency in both the outpatientdepartment, where staff had been trained to use theplaster cast removal equipment, and in diagnosticimaging where staff had undergone a cannulationcourse.

• When the hospital first opened, staff in all departmentswere required to complete competency training on allequipment within their departments. The company whosupplied the equipment mainly provided this and wesaw evidence to demonstrate staff competency.Department leads told us, for future staff joining thedepartments, this competency training would beprovided by staff members who were equipmentchampions for the departments. If there was a largeincrease in staff in the departments, they wouldconsider requesting the companies to return to providecompetency training.

• Staff from the diagnostic imaging department regularlyorganised ‘in house training’ for staff to increase

knowledge and awareness on imaging related topics aswell as clinical conditions. This training was opened upto staff from all departments and feedback from staffwas that it was well received.

• Department leads reviewed and monitored professionalregistration for staff where this applied. Staff weresupported to meet the registration renewal process andrevalidation process required by relevant professionalbodies.

• There was a corporate policy in place to manage staffwith variable performance. At the time of our inspection,department leads told us they had not had to use thisprocess with staff members currently employed, butwere aware of the policy if they required this.

For our detailed findings on competent staff please see theeffective section in the surgery report.

Multidisciplinary working

• All staff without exception told us there was goodinternal multidisciplinary team (MDT) working at thishospital. All staff told us this had developed during theinitial phase of getting the hospital ‘up and running’ inthe first place.

• The outpatient department had nurse specialists inoncology and cardiology. Although they had specificclinics, which they would participate in, they alsoworked as part of the larger outpatient team to ensureholistic patient care was provided.

• There was a one-stop breast care clinic provided by thediagnostic imaging department. This service was led bythe radiography lead for mammography and aradiologist who specialised in breast care. Patientsattended for a consultation with a consultant,mammography and ultrasound. Staff would takebiopsies if there was a clinical indication and send to theSpire Healthcare hub laboratories in Manchester. Due tothe success of this clinic, the lead for the departmentwas looking into setting up a similar process for patientswith testicular concerns.

• Staff from this hospital worked closely with a localconsultant microbiologist who provided advice forpatients displaying signs of infection or who had clinicalresults of colonisation from an organism. The lead nurse



Outstanding –


for infection prevention and control had engaged withthem to ensure a close working relationship and hadcommunicated with them several times about tasksrequiring a microbiologist input.

• Staff in medical records and administration/bookingsdepartment told us there was a good workingrelationship with all departments in the hospital. Thisensured patients attending the hospital had a positiveexperience, which was timely and professional.

For our detailed findings on multidisciplinary working,please see the effective section in the surgery report.

Seven-day services

• There were no typical seven-day services availablewithin the outpatient and diagnostic imagingdepartment. Staff in the diagnostic imaging departmentwas however, on an on-call rota to provide out of hoursservices to ward patients if required.

• The diagnostic imaging department did not offer openaccess for computerised tomography (CT) or magneticresonance imaging (MRI) scans from GPs, however therewas the ability for GPs to contact the department toarrange short notice appointments.

For our detailed findings on seven-day services please seethe effective section in the surgery report.

Access to information

• Staff in the diagnostic imaging department had accessto the electronic system (picture archiving andcommunication system) which stored all images andreports.

• The outpatient department had recently started to sendout letters to patient’s GPs through an electronic system.Information is sent immediately after the patient’sappointment without delay. The lead for thedepartment had monitored the implementation of thisnew system to ensure it was efficient.

• Only staff from medical records had the authority toestablish a new set of patient records. This ensuredthere were no unnecessary duplications and security ofthe records.

• Pathology reported verbally if there were any resultswhich were abnormal as well as providing a paperversion of the results to keep in the patient’s records.

• There was a process in place to request relevant clinicalinformation from alternative hospitals for patientsattending this hospital. Staff in medical records wouldensure these were saved in the patient’s records.

• Hospital policies, procedure and guidelines were storedelectronically. All staff had access to these documents.Department leads also kept paper copies of somepolicies, which staff could access if required. An exampleof this was the major incident policy, which was kept inoutpatient’s reception.

Consent, Mental Capacity Act and Deprivation ofLiberty Safeguards

• The hospital had corporate policies for consentprocedures as well as a deprivation of liberty safeguardspolicy. Both of these policies were in date and staff wereaware of them.

• Staff had a good understanding on the requirements forconsent. Information provided by the hospital showedon a recent audit, 86% of consent forms were compliantwith audit requirements. This was below the hospitalstarget of 95% compliance.

• During our inspection, we observed some positiveexamples of staff gaining consent from patients beforeprocedures. This also included asking a patient forconsent for a member of the inspection team to bepresent during a procedure.

• Information received from the hospital showed 100% ofstaff that required Mental Capacity Act 2005 training,had completed it (46 staff). This had also been providedto all health care assistants. All staff we spoke withdemonstrated good understanding of the MentalCapacity Act 2005 and what to do if they had concernsabout a patient’s capacity to provide consent totreatment. At the time of our inspection, staff told usthey had not had concerns about a patient’s capacity orprovided care and treatment for a patient under adeprivation of liberty safeguard.

Are outpatients and diagnostic imagingservices caring?

Good –––

Compassionate care



Outstanding –


• We reviewed nine CQC comment cards and ten SpireHealthcare patient satisfaction cards for the outpatientand diagnostic imaging departments, most of whichwere positive. Comments received included ‘veryprompt, efficient and professional care’, ‘staff were verycaring and professional’ and ‘excellent care, I cannotfind any fault.’ There was one comment card, whichhighlighted that a patient was disappointed due to alengthy wait with no explanation.

• We spoke with six patients and two relatives during ourinspection. All feedback received was extremely positiveand praised staff for the way they treated them.Comments made by patients and relatives included“wonderful staff”, “very attentive”, “fantastic treatment”and “five star care and treatment.”

• The service had adapted their own patient satisfactionforms from the NHS Friends and Family Test (FTT), whichasked patients if they would recommend the service totheir close friends and family. Results provided by theservice for December 2017 showed 97% of patientswould recommend the service to their friends andfamily. Of the 3% who would not recommend theservice, responses included additional informationbefore appointments about directions to the hospital,layout of the hospital, parking arrangements at thehospital and information about bus routes wasrequired.

• There was a Spire Healthcare corporate chaperonepolicy in place dated April 2016. We observed signsaround all departments informing patients about theirright to a chaperone during their consultation andtreatment. In each consultation room, there was astamp for staff to use in patient notes to formally recorddetails of a chaperone if patients required one.Alternatively, staff documented if patients refused achaperone.

• We observed all staff treating patients with dignity,respect and compassion. Staff ensured curtains weredrawn when patients changed for any treatments orinvestigations, and any gowns used by patients werefastened appropriately.

• All investigation rooms in the diagnostic imagingdepartment had individual, lockable changing rooms,which ensured privacy, and dignity was maintained.Staff knocked and waited to enter when collecting thepatient for their investigation.

• Receptionists made a concerted effort to maintainconfidentiality by lowering their voices when speakingwith patients at the desk. Rooms where patient care wasconducted were appropriately sound proof andconversations could not be overheard.

• We observed staff introducing themselves to patientsand explaining their role during our inspection. This wasin line with the recommendations in the NationalInstitute for Health and Care Excellence (NICE) qualitystandards for patient experiences in healthcare.

Understanding and involvement of patients and thoseclose to them

• We saw staff taking the time to explain all the details oftheir care and treatment to patients and encouragedthem to be partners in their care. Staff communicatedwith patients in a manner they understood. We saw staffinvolving patients during a scanning procedure,ensuring they were comfortable, but also indicating howmuch longer they would be.

• Staff made sure patients had the opportunity to askquestions about their care and treatment during andafter their consultation. Patients told us they feltcomfortable and confident when asking staff for furtherinformation about their care and treatment.

• Patients told us they had received adequate amounts ofinformation prior to their appointments, whichprepared them for what to expect during theirappointment. This was reflected in informationprovided by the hospital, which showed in December2017, 95% of the patients said the information receivedprior to their appointments was ‘excellent’ or ‘verygood.’

• Patients were encouraged to contact the outpatient anddiagnostic imaging departments following theirappointments if they had any concerns about their careand treatment, or if they had further queries.



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• Staff encouraged relatives and those close to them to, tobe involved in the patients care and treatment. Theyalso ensured they understood the information givenduring their appointments and gave them theopportunity to ask questions.

• Information about costings was provided to patientsduring the booking process and confirmation sent outwith appointment letters. We did not observe anydiscussions taking place between patients and staffabout costs. However, staff told us if they were askedquestions about costs, they would handle themfactually, but respectfully and tactfully.

Emotional support

• Staff told us they had clinics, where difficult and lifechanging news could be provided to a patient. Toenable them to deliver the highest standard ofemotional support, all staff members had attended‘breaking bad news’ training. Staff told us of cases wherethey had used this training to support patients and theirrelatives.

• There were clinical nurse specialists in oncology andcardiology who provided emotional support to patientswith specific diagnoses. The specialist oncology nursetold us they liked to offer ‘open appointments’ topatients who required her service to ensure theemotional support was provided.

• There was a quiet room available in the outpatientdepartment where staff would take patients if they hadreceived concerning or difficult news at anappointment. This enabled them to comfort them ifthey required it, but also maintaining their privacy anddignity. We did not observe any patients requiringadditional staff support during our inspection, howeverstaff told us about an experience where the quiet roomwas used to comfort a patient.

Are outpatients and diagnostic imagingservices responsive?

Outstanding –

Service planning and delivery to meet the needs oflocal people

• The majority of patients who attended the outpatientand diagnostic imaging department were self-fundedpatients. Staff in the bookings and administrationdepartment had recently started to arrangeappointments for NHS patients, although these were invery low numbers at the time of our inspection.

• The service offered patients appointments in theoutpatient department in the evenings and weekends.Outpatient appointments were available Monday toFriday between 7.30am and 9pm. Appointments werealso available on Saturday between 8am and 4pm.Clinical assessments were also offered to patientsthrough a telephone consultation if deemedappropriate. These arrangements accommodatedpatients who had commitments during the workingweek.

• All departments were located on the ground floor anddeveloped to meet the needs and demands of patients.The environments had been developed in line withrelevant health building notes to ensure compliancewith recommended standards. There were three mainwaiting areas in use in the outpatient department.Patients were directed to the waiting area, which wasclosest to the consulting room they required.

• In one of the waiting areas in the outpatientdepartment, there was a small selection of children’stoys for children who accompanied adult patients.These were wipeable and in good condition.

• The physiotherapy department was open Monday toFriday between 8am and 8pm. They also offered a dropin physiotherapy session between 6pm and 8pm everyMonday. This service was aimed at ensuring patients(particularly sports patients who had picked up injuriesat the weekend) could access a rapid accessmusculoskeletal physiotherapy appointment in a timelymanner. The patient did not need to wait for a prebooked appointment enabling faster diagnosis andaccess to imaging on onward management.

• The diagnostic imaging department was open Mondayto Friday between 8am and 8pm. A full range of serviceswas available between these times, with the one stopbreast clinic operating in the evenings. There was noroutine provision of diagnostic imaging servicesavailable at the weekends.



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• Free car parking was available at the hospital, with alarge number of spaces available to meet current andfuture needs. There was signage available directingpatients to the main reception, and clear signage to alldepartments once in the hospital.

• Transport for patients was an important issue, whichstaff took into consideration. Staff in the outpatientdepartment helped patients if they needed to arrangetransport home, including arranging taxis for patients.

• When planning the hospital bus routes were taken intoconsideration and stops were added by the localcouncil at the hospital entrance. Unfortunately since theopening of the hospital the route has been reduced bythe council.

• The physiotherapy department had identified arequirement for classes, which included falls preventioneducation. This was in response to engaging with localcommunities and listening to patient feedback. Theseclasses were combined with general keep fit andwell-being classes.

• Staff from the physiotherapy department had alsoidentified a local gap in ‘high end functional’physiotherapy with elite athletes. Service levelagreements (SLAs) had been arranged to provide arange of services to professional athletes at thislocation.

• The service identified there was a proportion of patientstravelling significant distance to the hospital. Inresponse to this, they developed ‘one-stop clinics’ forbreast care and basal cell carcinoma. This ensuredpatients had consultations, investigations andprocedures during one appointment at the hospital.These clinics were well received and the service wasnow looking at other one-stop clinics.

• At the time of out inspection, the majority of patientswere self-funded or insured patients. Appointmentswere offered to meet the needs of the patient, wherepossible at times that met their needs. For the few NHSpatients who had started to use the services at thehospital, they were able to access the ‘choose and book’appointment system.

Access and flow

• Prior to our inspection, the service had not seen manyNHS patients since they had been open. The service had

recently started to have a small number of NHS patientsreferred for outpatient and diagnostic imagingappointments. Therefore, there was no data availablefor waiting times or referral to treatment times for thisservice.

• The service intended to see all patients within 15minutes of their appointments. If there wereunavoidable delays in the department, staff wouldinform patients on their arrival and keep them updatedon any further delays. During our inspection, all clinicswere running on time and patients were aware of this.We saw signs in all departments informing patients tospeak with staff if they had been waiting for longer than15 minutes.

• The outpatient department audited the time patientswaited once they arrived in the department forappointments. When the department first opened, therehad been reoccurring issues with delayedappointments; however, recent results showed allpatients were called in for their appointments promptly.

• We asked staff about the ‘did not attend’ (DNA)appointment process. Not all clinical staff were aware ofit or if there was a process in place, however they told usthe administration staff would manage this process.Administration staff confirmed there was a DNA processin place for those who failed to turn up or cancelledtheir appointments at short notice. A courtesy callwould be made to ensure the patient was safe, and analternative appointment time offered. There wascurrently no maximum time patients could DNA beforethey were no longer offered an appointment at thehospital.

• The hospital also used text messages to remondpatients of their appointment.At the time of ourinspection, all departments commented on the lowaccess and flow they currently experienced. However, itwas acknowledged there had been a steady increasemonth by month since the hospital had opened. Theoutpatient manager told us the department wascurrently running at approximately 43% capacity, andthe physiotherapy department were also currentlyrunning a similar capacity.

• On the day appointments could be accommodated forpatients who contacted the hospital directly, as long asall referral paperwork had been completed. Staff in the



Outstanding –


diagnostic imaging department could not complete anyprocedures without a copy of the request form. Therewas also a system in place in the outpatientsdepartment for patients to return for wound reviews ifthey had recently had surgery and had concerns.

• The diagnostic imaging department had provisions inplace to ensure all procedures were reported on in atimely manner. The lead for the department told us thecurrent reporting times were two days for patientsunder an insurance company and three days for allother patients. There was a policy in place for urgentreporting of unexpected and significant findings. All staffwere aware of this policy and how to escalate concerns.

Meeting people’s individual needs

• Staff had access to a translation and interpretationservice for patients whose first language was notEnglish. This process had access to translation serviceon the telephone or could invite interpreters to attendappointments in person.

• All departments also had access to British SignLanguage (BSL) interpreters for patients who used signlanguage to communicate with others.

• A member of staff from the outpatient department hadcompleted the required training to become a dementiachampion. They had produced a box (forget me not box)for the department with items in them which wereconsidered as ‘dementia friendly.’ This meant the itemswithin them would reduce potential anxiety, stress andfrustration in a patient who was living with dementia ifthey attended for an appointment. Items within the boxwere ‘twiddlemuffs’ (double-sided knitted muffs withvarious soft items attached both inside and out), apictorial pain chart, pictorial reminiscence cards andadapted cutlery and crockery.

• As well as a forget me not box of useful items, there wasalso a resource folder available for staff members to usewhich also had the contact numbers and details of localservices which could support patients living withdementia and their relatives.

• The dementia champion in the outpatient departmenthad also tried to adapt the environment to make it more

dementia friendly through the introduction of signs andwall mounted clocks, which had large faces and font onthem to make it easier for patients living with dementiato read.

• The pictorial pain chart was also used to meet the needsof other patients including those with learningdisabilities and other disabilities where communicationwas difficult. Staff told us it was important to beprepared to meet the needs of patients in alleventualities; however, at the time of our inspection,they had not provided care and treatment for patientswith any learning disabilities, living with dementia orother cognitive impairments.

• At the time of our inspection, the department did nothave a learning disabilities specialist who they could goto for advice on how to meet the needs of the individual.There was a resource file in the outpatients department,which contained useful national advice telephone linesand information for healthcare professionals on how tomeet the needs of a patient with learning disabilities.Staff told us they would encourage any relatives, friendsor carers to attend any appointments with the patient.

• There was a multi-faith room located in the outpatientdepartment, which was available to all patients whoused the hospital. The staff in the department hadorganised this room and had sourced the equipmentwithin this. We saw religious texts from differentreligions located in this room, as well as bibles forchildren and religious texts in large print for those withvisual impairments. There were washing facilitiesavailable for those who required them, and wipeableprayer mats.

• The outpatient department had a hearing loop systemin place for patients who had hearing impairments. Thiscould also be moved around the department to meetthe needs of the patient with hearing impairments.

• We saw a large library of patient information leaflets inthe outpatient department. These covered a range ofdifferent health needs from cancer related issues towomen’s health requirements and heart diseaseinformation. We also saw these leaflets in differentlanguages and different font sizes. Staff told us leafletsin languages not currently provided could also besourced if required.



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• The outpatients department had basic bariatricequipment in place including a couch and treatmentchair; however, they intended to improve the facilitiesavailable for bariatric patients as the needs of thehospital grew.

• Patient wellbeing was integral to the planning of thenew hospital and an extensive outdoor area has beendeveloped to allow patients to spend time outside in aprotected environment with their families.This includedan outdoor play area, water features and amplecomfortable seating.

• The hospital had a dedicated coffee and sandwich shopfor patients and relatives which was designed to be in acentral location of the hospital .

Learning from complaints and concerns

• All staff we spoke with were aware of the complaintsprocess at the hospital. Staff told us where possible;they would try to resolve any concerns and complaintsat a local level before escalating this. As a result of this,no complaints had been forwarded to the IndependentSector Complaints Adjudication Service orParliamentary and Health Service Ombudsmen.

• Department leads were knowledgeable about theircomplaints rate and had been involved in the handlingof complaints. Complaints and incidents were a regularagenda items on all team meetings, and staff were keento identify any potential learning from them. Leads alsorecorded compliments received from patients, and wesaw examples of this in the outpatients department.

• Information received prior to the inspection showedthere were 11 complaints received at the hospitalbetween April 2017 and November 2017. Of these, fourcomplaints included the outpatients and diagnosticimaging services provided at this location. There weretwo complaints, which identified lateness ofappointments as the key theme, one that identified afollow up error, and the other complaint identifiedunhappiness with the outpatient departmentappointment booking process. All complaints wereresolved at the first level.

• Staff in all areas demonstrated a positive attitudetowards complaints, and welcomed feedback frompatients as they had a genuine interest in improving the

department. We observed one patient raise a minorconcern with a member of staff at the end of anappointment. Staff encouraged the patient to raise thisformally so action could be taken to rectify this.

Are outpatients and diagnostic imagingservices well-led?

Outstanding –

Vision and strategy for this core service

• The hospital vision was to be recognised as the firstchoice for independent healthcare in Nottinghamshireand the surrounding area. This vision was displayedeverywhere and all staff identified this as being theirown vision too.

• There was no separate vision or strategy for this coreservice; however, staff were committed to the overallvision of the hospital. Department leads were taskedwith business targets by the Senior Management Teamto raise the profile of the hospital.

• The Senior Management Team had engaged withmembers from all departments to develop five keyobjectives, which all staff will base their own personalobjectives around. Staff were keen to help take thesekey objectives forward and had already volunteered toparticipate in working groups. One of the key objectives,which all staff discussed, was around growing theservices they provided and maximising the capacity ofclinics. Staff told us they had discussed ideas locally andhad even been to staff forums to discuss ideas with theSenior Management Team.

For our detailed findings on vision and strategy for this coreservice please see the well-led section in the surgeryreport.

Governance, risk management and qualitymeasurement

• Leads from the outpatient and diagnostic imagingdepartments contributed to the overarching governanceof the hospital and attended regular governancemeetings. This ensured information was escalated fromthe department level and information cascaded fromthe executive level. All staff commented on how theywere well appraised of important governance issues.



Outstanding –


• The outpatient and diagnostic imaging departmentboth had a local risk register which department leadsmaintained. This was reviewed regularly at teammeetings and new risks added if identified, or removedif no longer an issue. Staff told us they also discussedwhether risks required escalating to the hospital riskregister. We reviewed the hospital risk register and foundtwo risks, which had been escalated from the local riskregisters due to requiring executive oversight of these.These risks reflected the top concerns of thedepartment leads.

• In response to the largest risk in the outpatientdepartment (mislabelling of specimens), the lead hadimplemented a safety cross initiative which identifieddays which had passed where no further incidents hadoccurred. This was a local way of monitoring whethermitigating actions were effective in reducing the riskfrom reoccurring.

• The diagnostic imaging department had organisedradiation protection committee meetings to take placeon a regular basis. This was to ensure that all clinicalprocedures and supporting activities undertaken werein accordance with legislation and regulations. Theradiation protection advisor and three local radiationprotection supervisors regularly engaged about safetypractices within the department and any importantinformation from these engagements was cascaded tothe rest of the department. Any areas of concern fromany meetings or engagement activities were escalatedto the hospital clinical governance meetings.

• The hospital had implemented a clinical scorecard tomonitor performance and quality on key indicators. Theoutpatient and diagnostic imaging departmentsinputted into this scorecard and used the results todrive quality improvement. At the time of inspection,there were areas on the scorecard that required furtherdevelopment once the hospital had been opened for alonger duration and more information could be collatedfor this.

• The physiotherapy department had locallyimplemented patient reported outcome and experiencemeasures for quality measurement and patientoutcome measurement.

• Departments were engaged with local audits, howeverat the time of inspection there was little participation in

national audits due to the low patient numbers andrelatively new operational status of the hospital. Staffmonitored quality internally at present and addressedareas of low compliance.

• Staff in the outpatients department were aware of thenational safety standards for invasive procedures(NatSSIPs) and how these impacted on theirdepartment. Spire Healthcare had developed their ownlocal safety standards for invasive procedures (LocSSIPs)which the hospital was using with no variation.Therewere clear policies in place to support these.

For our detailed findings on governance, risk managementand quality measurement for this core service please seethe well-led section in the surgery report.

Leadership and culture of service

• Staff from all departments spoke overwhelminglypositive about their clinical leads for the departments.Staff told us their managers were extremely visible, veryknowledgeable about their roles and responsibilitiesand approachable. Staff also told us clinical leads werevery encouraging of staff and wanted them to developtheir own roles and responsibilities.

• The positivity extended beyond local leadership, andincluded the leadership of the Senior ManagementTeam. Staff told us they regularly saw the hospitaldirector and head of clinical services in theirdepartments. They told us the Senior managementteam were visible, competent and enthusiastic leaderswho strived to provide the best service for patients,whilst creating a positive working environment for staff.They regularly communicated updates about thehospital and all staff felt they would be welcome toapproach them individually if they had concerns.

• All staff told us they felt valued and appreciated at thishospital. Local leaders would regularly thank them fortheir hard work and sent messages of their thanks tothem. Executive staff also extended their appreciation tothe staff and showed a genuine interest in staffwell-being. One staff member told us this was the onlyhospital they had ever worked at where the hospitaldirector knew their name. Other staff members agreedwith this and told us things like that made them reallyfeel valued.



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• There was a positive culture in all departments. Staffenjoyed working at the hospital and in their respectivedepartments. The majority of staff had been at thehospital since it had opened, and had worked hard todevelop the departments into the functioningdepartments they were at the time of inspection. Stafffelt immensely proud of what they, as individuals andteams, had achieved.

• We observed high standards of team working in alldepartments within this core service. Staff workedcollaboratively, constructively and quickly to deliver ahigh standard of care for patients.

• There was an open and honest culture within alldepartments. Staff were open and honest with patientsif issues occurred during their care and treatment. Weobserved staff implementing this during our inspectionafter a patient attended an appointment with the wrongconsultant.

• The open and honest culture extended to beyondinteractions with patients. Staff were encouraged tospeak up about concerns if they had them without fearof reprisal. There was a policy in place to support staffwho spoke up about concerns as well as two freedom tospeak up guardians recently appointed.

Public and staff engagement

• The hospital had implemented the ‘you said, we did’initiative, which demonstrated prompt responses toissues raised by patients. Examples from the mostrecent feedback received included not enough signagefor the way out of departments and the environment ona whole appeared very cold and unwelcoming. Actionstaken against these included additional way out signageordered for the outpatients department and morepatient information boards and local art to be installedin all areas.

• Staff in the outpatient and diagnostic imagingdepartment had specific surveys in place to gatherpatient feedback about the quality of service provided.This was monitored on the clinical scorecard andquarterly reports produced. The most recent feedbackwas mainly positive; however, it was acknowledged thatresponse rates were still relatively low.

• Staff from all departments related to this core servicehad participated in the hospital’s staff survey. Althougha full report had not been completed at the time ofinspection, some headlines from findings included staffsatisfaction in regards to whistleblowing and ability toraise concerns, good team working and prioritising highquality care. All these aspects scored 88% and above forstaff satisfaction.

• Staff engagement was a key factor at this hospital.Members of staff from all departments in this coreservice had voluntarily joined the ‘believing in ourpeople’ forum. This forum discusses staff feedback andworks on potential solutions to any issues identified.Representatives provided feedback to theirdepartments on actions taken, which we were told wasuseful and important to demonstrate their views andopinions were taken seriously.

• The hospital had an awards scheme in place called‘inspiring people awards.’ At the end of 2017, three ofthese awards had been issued to staff for recognition ingoing the extra mile. All three of these awards had goneto staff form the outpatients and diagnostic imagingdepartment. All staff within these departments wereproud of the recognition their colleagues had received.

For our detailed findings on public and staff engagementfor this core service please see the well-led section in thesurgery report.

Innovation, improvement and sustainability

• At the time of our inspection, the hospital had not beenopen a full year. In this time, staff from the outpatientand diagnostic imaging departments had worked hardto improve the environments they were operating in.Staff told us they had taken the departments from‘empty shells’ to the fully functioning departments weinspected. Staff continued to look for opportunities toimprove the workings of their department as well as thequality of care they provided patients.

• Department leads for all areas covered in this coreservice had targets set to improve the business side oftheir services, which in turn the provider hopes willimprove the hospital and sustainability of the servicesprovided.



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Outstanding practice

• The provider monitored safety through a clinicalscorecard with 47 clinical indicators. The scorecardwas used for benchmarking against other SpireHealthcare hospitals and to identify areas forimprovement.

• One of the operating theatres was a hybrid operatingtheatre. A hybrid operating theatre is a surgicaltheatre that is equipped with advanced medicalimaging devices which enable minimally-invasivesurgery.

• In June 2017, the provider held a public open daywhich was well attended by the local community.Feedback was collected and as a result, thephysiotherapy department planned a weekly Pilate’sclass and were developing falls prevention classes.The hospital had also welcomed visits from the localU3A and Rotary club groups

• The provision of one-stop clinics for breast care andbasal cell carcinoma had proved very successful and

efficient. This prevents patients having to attendseveral appointments, which may inconveniencethem and provides them with relevant information ina timely manner.

• Staff from the outpatient department had createdthe multi-faith room, which was accessible to allpatients and staff who attend the hospital. There hadbeen consideration into not only multiple faiths, butalso the requirements of users (for example visuallyimpaired and age of the user).

• The dementia champion in the outpatientsdepartment had proactively created a ‘forget me not’box, which contained items useful for patients livingwith dementia. There had also been work completedwithin the environment to make it suitable forpatients living with dementia.

• The provider had appointed two staff members tofulfil the freedom to speak up guardian role for thehospital staff.

Areas for improvement

Action the provider SHOULD take to improve

• The hospital should ensure all documentation inpatient records meets the required professionalstandards.

Outstandingpracticeandareasforimprovement

Outstanding practice and areasfor improvement


spire nottingham hospital newapproachcomprehensive report … · 2020. 4. 21. ·...

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