Spire Bushey Hospital NewApproachComprehensive Report … · 2020. 2. 2. · LetterfromtheChiefInspectorofHospitals Wecarriedoutanannouncedinspectionon26and27July,12September2016and13December2016,withan

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

Ratings

Overall rating for this location Good –––

Are services safe? Requires improvement –––

Are services effective? Good –––

Are services caring? Good –––

Are services responsive? Good –––

Are services well-led? Good –––

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 BusheBusheyy HospitHospitalalQuality Report

Spire Bushey HospitalHeathbourne RoadBusheyHertfordshireWD23 1RDTel: 020 8901 5526Website: www.spirehealthcare.com/bushey

Date of inspection visit: 26 and 27 July 2016, 4August 2016, 12 September 2016, 13 December 2016Date of publication: 09/01/2018

1 Spire Bushey Hospital Quality Report 09/01/2018

Letter from the Chief Inspector of Hospitals

We carried out an announced inspection on 26 and 27 July, 12 September 2016 and 13 December 2016, with anunannounced inspection on 4 August 2016.

Our key findings were as follows:

We rated the hospital as good overall.

Safe was rated as requires improvement in surgery and outpatients and good in medical care. Effective, caring,responsive and well-led, were rated as good overall.

The termination of pregnancy service was inspected but not rated.

Are services safe at this hospital?

• Not all staff who had responsibility for potentially assessing, planning, intervening and evaluating children’s carewere trained to level three in children’s safeguarding, but the hospital had an action plan to improve compliance.

• There were no registered nurses (child branch) available when children attended the hospital.• Not all HSA1 forms had a reason for termination documented, in line with legislation.• Not all patient records had evidence that a HSA4 form had been completed and sent to the Department of Health

chief medical officer within 14 days to comply with the Abortion Act 1967.• Staff were encouraged to report incidents and were aware of the duty of candour regulation. There was evidence of

learning from incidents and complaints and effective processes were in place to reduce risk.• Medical notes for nurse’s clinics in outpatients were not always available for staff who were treating patients in the

department.• Staffing levels ensured the needs of patients were met. There was little use of bank and agency staff.• There was access to appropriate equipment to provide safe care and treatment.• The environment was visibly clean and there were systems in place to maintain the safety of equipment used across

clinical areas. The hospital used the; ‘I am clean’ stickers to indicate that equipment had been cleaned.• Systems were in place for the prescribing, storage and administration medications.• Staffing levels were appropriate to the needs of the clinical areas and flexed according to the demands of the service,

ensuring flexibility to meet patient demands.• There were clear escalation processes in place, which included escalating to the resident medical officer (RMO) and

the patient’s consultant.• Safeguarding systems were in place and staff knew how to respond to safeguarding concerns.

Are services effective at this hospital?

• Care and treatment was delivered in line with evidence based-guidance.• Policies were accessible, current and reflected professional guidelines. The hospital monitored adherence to policies

with the use of local audits.• Screening for sexually transmitted diseases did not happen within the termination of pregnancy service. There were

no processes in place for patient referral to obtain screening. This does not comply with national guidance.• We found that audits carried out in the termination of pregnancy service were not detailed and did not consider all

relevant checks of patient records for compliance with standards.• We did not see evidence of conversations regarding contraception being conducted with patients who had attended

for termination of pregnancy, or whether long acting reversible methods were discussed/offered.• Some patient outcomes were audited and the hospital participated in the Private Hospital Information Network.• Pain was well-managed and pain management was audited.• Patients’ nutritional status was assessed.

Summary of findings


• An induction programme was provided to all new staff.• There was a process in place for checking professional registration.• The Medical Advisory Committee (MAC) ensured consultants were competent to practice and practising privileges

were reviewed annually.• Consultants were on call for 24 hours a day and seven days a week for their inpatients and day case patients. The

hospital employed RMOs who were on site 24 hours a day providing medical cover for patients and clinical support tostaff.

• Most of the time staff were able to access all necessary information to provide effective care.• Staff were aware of their role with to regards to the Mental Capacity Act and Deprivation of Liberty Safeguards and

had received training.• Mental capacity assessments which had been completed for patients with Do Not Attempt Cardio Pulmonary

Resuscitation (DNACPR) orders were not always recorded in patients’ records in line with hospital policy.• Multi-disciplinary teams worked well together to provide effective care. Multi-disciplinary team working included

hospital staff, local acute trusts, clinical commissioning groups and general practitioners.• Staff had received an up to date appraisal and individual training needs had been identified. Staff had the right

qualifications, skills, knowledge and experience to do their job.

Are services caring at this hospital?

• Patients were treated with dignity and respect. Their preferences were taken into account with treatment planningand they were given the time and information required to make informed decisions about their care.

• Feedback from patients and those close to them was positive about the way staff cared for them and the treatmentthey had received.

• The hospital wide Friends and Family survey, which included both NHS and private patients scored consistentlyabove 97%.

• Staff recognised the need to provide patients and their families with emotional support and the hospital had a list ofmulti-faith contact details should patients require these.

• The hospital had a ‘Pink Petals’ peer support group which provided patients with a number of opportunities toaccess links within communities and support and information for individuals.

• Staff told us that if they had to deliver distressing news to a patient or their loved ones this would happen in a singleuse room on a ward or in a consulting room to allow privacy.

• The chemotherapy unit had received the Macmillan Quality Environment Mark (MQEM) which was an assessment ofservices provided for cancer support. Part of the assessment related to having a caring and supportive environmentwhere people can talk in confidence and privacy.

Are services responsive at this hospital?

• Services were planned and delivered in a way that met the needs of the local population. The importance offlexibility, choice and continuity of care was reflected in the services.

• Appointments were scheduled according to the patient’s condition.• Appropriate facilities were provided to meet the needs of patients requiring wheelchair access and a hearing loop

was in place. Telephone interpreters were available to support patients if necessary.• Patients could access the service at times to suit them.• The services had protocols and procedures in place to manage patients with complex needs, including those living

with a learning disability and dementia.• Staff had awareness and had attended training in caring for patients living with dementia.• Information on complaints or how to raise a concern was available for patients.• Complaints and concerns were always taken seriously and responded to in a timely manner. There was evidence of

actions taken to address issues raised in complaints and staff were informed of changes required in response tocomplaints.

Summary of findings


• Patients received and had access to appropriate written information about their condition and treatment.• There were toys and books available in the waiting areas specifically for children when they attended outpatients,

physiotherapy or diagnostics appointments. These had been renewed during the inspection as we found some weredirty and damaged.

Are services well led at this hospital?

• There was no clear governance process in place to manage the termination of pregnancy services. The audits wereunreliable and there was some non–compliance with the Abortion Act 1967.

• The hospital had a vision and a set of values. The hospital also had a clear corporate governance structure and aclinical governance committee that met quarterly to discuss a range of hospital issues.

• There were defined routes for cascading information to hospital staff.• The hospital had a robust risk register.• Senior managers at the hospital were visible, supportive and approachable.• Staff were generally proud to work at the hospital and said they felt supported and valued.• Clinical leads had a shared purpose and motivated staff to deliver services and succeed.

We saw an area of outstanding practice including:

• The formulation of the ‘Pink Petals’ support group was inspired by the needs of the local community and provided anaccessible platform for all patients to gain information and support to help them manage their conditions.

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

Importantly, the provider must:

• The hospital must ensure that HSA1 and HSA4 forms are completed in line with the Abortion Act 1967 for all patients.• Meet the requirements for staffing levels for children’s services in accordance with the Royal College of Nursing

standards for clinical professionals and service managers, ‘Defining Staffing Levels for Children and Young People’sServices’, (2013) .

• Ensure there is access to a registered nurse (child branch) available to advise on the management and care andtreatment of children and young people.

• Ensure staff that have responsibility for assessing, planning, intervening and evaluating children’s care, must betrained to level three in safeguarding children.

In addition the provider should:

• Ensure effective governance processes are in place and that termination of pregnancy services audits reports to acommittee to review results and action plans.

• The hospital should ensure that all audits relating to the termination of pregnancy service accurately reflect findingsin patient records.

• The hospital should ensure that it is documented within patient notes following a termination of pregnancy whetherconsent to share information with their GP has been given or declined.

• The hospital should consider installing clinical hand basins in patient bedrooms when refurbishing the departmentin line with latest infection control guidelines.

• Consider the floor covering in consultation rooms and in patient bedrooms which were non-compliant with infectioncontrol guidelines.

• Ensure that MCA capacity assessments are always recorded in line with organisational policy and guidance.• Ensure medical notes are always available for staff who are treating patients in the outpatients department.• Ensure consultants do not bring mobile equipment to use in clinics without being able to evidence how it is cleaned

and maintained.

Summary of findings


Professor Sir Mike RichardsChief Inspector of Hospitals

Summary of findings


Our judgements about each of the main services

Service Rating Summary of each main service

Medicalcare

Good –––

We rated the service as good for safe,effectiveness, caring, responsive and wellled.Staff recognised the importance of raisingconcerns and recording incidents toencourage learning and improve patientcare.We saw that systems and processes were inplace to keep people safe from harm andabuse and where areas for improvementwere identified, this was acted upon.The endoscopy facilities and chemotherapyunit were visibly clean and well organised.Care and treatment was delivered in linewith evidence based guidance.Information about the outcomes ofpatients’ care and treatment was collectedand monitored to identify areas forimprovement and share best practice.There was a programme of local andnational audits conducted to improve care.The endoscopy facilities had startedworking towards gaining national JointAdvisory Group in Gastroenterology (JAG)accreditation.Patients spoke positively about the carethey had received.Mental capacity assessments which werecompleted for patients with Do NotAttempt Cardio Pulmonary Resuscitation(DNACPR) orders were not always recordedin patients’ records in line with hospitalpolicy.Patients were offered support to managetheir treatment and conditions.There was a clear vison and strategy formedical services which all staff were awareof and felt involved in.Staff were constantly striving to improveperformance and find new and innovativeways of working.

Summary of findings


Staff caring for young people did not havethe appropriate level of safeguardingtraining.There was no registered nurse (childbranch) managing the care of youngpeople admitted to the hospital. Inaddition, the hospital did not have accessto registered nurses (child branch) to carefor children and young people.

Surgery

Good –––

We rated the service as requiresimprovement for safe and good foreffectiveness, caring and responsive andwell led. This led to a good rating overall.Patients’ areas were tidy and visibly cleanand staff followed the hospital infectioncontrol policies.Patients were assessed and treated in linewith professional guidance.There were effective arrangements in placeto monitor and manage pain. Patientnutrition and hydration needs were met.Patients were treated with dignity andrespect. Patients complemented staff onthe care they received; they were givenappropriate information about their careand treatment.There was effective and flexible booking insystems that considered patients’ needs.Complaints were acknowledged,investigated and responded to in a timelymanner and information was shared withstaff.The hospital had a clear governancestructure. Information was cascaded to allstaff. The service reviewed and acted onfeedback about the quality of carereceived. There was strong leadership andstaff felt valued.Staff caring for young people did not havethe appropriate level of safeguardingtraining.There was no registered nurse (childbranch) managing the care of young

Summary of findings


people admitted to the hospital. Thehospital did not have access to registerednurses (child branch) to care for childrenand young people.

Outpatientsanddiagnosticimaging

Good –––

We rated the service as requiresimprovement for safe, and good for caringand responsive and well led. Effectivenesswas inspected but not rated.Staff identified and addressed safetyconcerns. Staff were clear with regards tothe process to report incidents and werefully aware of the Duty of Candourregulation.There was good evidence of learning fromincidents.There were good infection controlprocedures in place and the areas wevisited were visibly clean.Staffing levels were appropriate for theservice provision with minimal vacancies.Staff delivered patients’ care andtreatment following local and nationalguidance for best practice.Staff obtained patient consent before careand treatment was given.The hospital management team plannedand delivered services in a way that metthe needs of the local population. Theimportance of flexibility, choice andcontinuity of patient care was reflected inthe services. Patients could access the rightcare at the right time.The imaging department planned anddelivered care and treatment in line withcurrent evidence-based guidance,standards and best practice.Multi-disciplinary teams worked welltogether to provide effective care.Referral to treatment times for NHSpatients, were in line with the nationalaverage and patients could makeappointments easily and quickly whenrequired.Patients were positive about the way stafftreated them in all outpatient anddiagnostic areas.

Summary of findings


Information on how to raise a concern orcomplaint was available for patients. Thehospital complaints lead took complaintsand concerns seriously and responded tothem in a timely manner.Staff had knowledge regarding the visionfor the hospital. There was good staffsatisfaction. Staff felt supported andvalued. There was a strong culture of teamworking across the areas we visited.Staff caring for young people did not havethe appropriate level of safeguardingtraining.There was no registered nurse (childbranch) managing the care of youngpeople attending outpatients. The hospitaldid not have access to registered nurses(child branch) to care for children andyoung people.Clinical hand basins were not provided inconsultation rooms when the hospital wasbuilt. This did not comply with currentHealth and Building Notice (HBN) 009(2013).The flooring in the consultation roomswere not compliant with HBN (2013) 00-10part A.Medical notes were not always available forstaff who were treating patients in thedepartment.

Terminationofpregnancy

Not sufficient evidence to rate –––

The service was inspected but not rated.Staff caring for young people did not havethe appropriate level of safeguardingtraining.There was no registered nurse (childbranch) managing the care of youngpeople admitted to the hospital. Thehospital did not have access to registerednurses (child branch) to care for childrenand young people.There was no evidence that thetermination of pregnancy service wasdiscussed or reviewed at any committeemeeting.

Summary of findings


Not all HSA1 forms had a reason fortermination documented in line withlegislation.Not all patient records had evidence that aHSA4 form had been completed and sent tothe chief medical officer within 14 days tocomply with the Abortion Act 1967.Records did not always contain consistentinformation to demonstrate all aspects ofpatients care or medicines received.There was no screening for sexuallytransmitted diseases in place. There wereno processes in place for patient referral toobtain screening. This does not complywith national guidance.Some records contained errors that hadbeen crossed out but there were no initialsto state who had rectified this error orcrossed the previous content out.Audits did not always accurately reflect theevidence we saw in patient records, thiswas non-compliant with Department ofHealth Required Standard OperatingProcedures (RSOP) and was not alwaysidentified or addressed.Action plans did not always address areasof non-compliance following audits.Patients were protected from abuse andavoidable harm, as staff knew how torecognise untoward incidents andsafeguarding concerns, and report themappropriately. There were arrangements inplace to share and action any identifiedlearning points following incidents.Robust procedures were in place formanaging medicines used in terminations.All staff within the service and pharmacyteam were aware of legislation surroundingmedicines used in terminations.Patients underwent thorough assessmentsprior to any treatment being delivered,with any potential risks documented andexplained to patients.Procedures were in place to ensureeffectiveness of both medical and surgicalterminations; the service had a 0% failurerate.

Summary of findings


Staff understood the need to show careand compassion towards patients who haddecided to undergo a termination, andwere aware of the emotional impact thismay have on patients.Services were easily and readily accessibleto patients, with clinics available at varioustimes throughout the week, including oneweekend day.Clinical audit plans were in place within theservice that were compliant with RSOP.The corporate risk registered identified theappropriate risks relating to the service.There was an inclusive and team-workingculture throughout the service, with a drivefor effective patient care.

Summary of findings


Contents

PageSummary of this inspectionBackground to Spire Bushey Hospital 14

Our inspection team 14

How we carried out this inspection 14

Information about Spire Bushey Hospital 15

The five questions we ask about services and what we found 16

Detailed findings from this inspectionOverview of ratings 17

Outstanding practice 86

Areas for improvement 86

Action we have told the provider to take 87

Summary of findings


Spire Bushey Hospital

Services we looked atMedical care; Surgery; Outpatients & diagnostic imaging; Termination of pregnancy;

SpireBusheyHospital

Good –––


Background to Spire Bushey Hospital

Spire Bushey Hospital is a purpose built private hospitalwhich was opened in 1982. Since then there have been anumber of developments and a significant growth involumes of patients treated year on year. In 2007 a privateequity company called Cinven bought the company fromBUPA Hospitals Ltd, and Spire Healthcare wasestablished. Spire Healthcare became a public limitedcompany when it floated on the London Stock Exchangein July 2014.

The hospital is located close to the M25, and M1 andprovides access to a wide geographical area including;Watford, Hemel Hempstead, St Albans and Harrow.

The hospital has 58 inpatient beds, over two wardsincluding four extended recovery beds.

There are five theatres, three with laminar flow whichincluded an endoscopy suite and a laparoscopic theatre.

There are 20 consulting rooms. Diagnostic imagingfacilities include a 128 slice dual source CT scanner, anewly replaced MRI scanner, digital mammography,ultrasound and x-ray. The physiotherapy department haseight treatment rooms, a hydrotherapy pool and agymnasium.

The hospital undertakes a range of surgical procedures,to patients aged 16 years and over. The hospitalsuspended its inpatient and day case surgical service forchildren under the age of 16 years in January 2016following a review of paediatric services. They provideoutpatient consultations to patients aged from two yearsand over.

There is an off-site Elstree Cancer Centre (ECC), two milesfrom the hospital, which is based in a separate unit. Thisopened in 2010, Spire Bushey’s day-case chemotherapyservices were provided there together with theout-patient telephone appointment team.

There were administration and management staff on site.

The hospital is managed by Spire Healthcare and is partof a network of over 38 hospitals. The hospital providescare for private patients who are either covered by theirinsurance companies or are self-funding. Patients fundedby the NHS, mostly through the NHS referral system canalso be treated at Spire Bushey Hospital.

Our inspection team

Our inspection team was led by:

Inspection Lead: Julie Fraser Inspector, Care QualityCommission

The team of 11 included CQC inspectors and a variety ofspecialists: theatre nurse, consultant surgeon, infectioncontrol nurse specialist, and an oncology nurse specialist.

How we carried out this inspection

Before visiting, we reviewed a range of information weheld about the hospital and each core service.

We carried out an announced inspection visits on 26, 27July and 13 December 2016, an unannounced inspectionon 4 August 2016. We made an additional announcedvisit on 12 September 2016 to review additional medicalnotes for TOP services. We spoke with a range of staff inthe hospital, including nurses, consultants and support

staff. During our inspection we reviewed servicesprovided by Spire Bushey Hospital in the ward, operatingtheatre, outpatients and imaging departments and theElstree Cancer Centre.

During our inspection we spoke with 22 patients, 68 staff,including consultants, who are not directly employed bythe hospital and six family members/carers from all areas

Summaryofthisinspection

Summary of this inspection


of the hospital, including the wards, operating theatreand the outpatient department. We observed howpeople were being cared for and talked with patients andreviewed personal care or treatment records of patients.

To get to the heart of people who use services’ experienceof care, we always ask the following five questions ofevery service and provider:

• Is it safe?• Is it effective?• Is it caring?• Is it responsive to people’s needs?• Is it well-led?

Information about Spire Bushey Hospital

The hospital has 58 inpatient rooms in two main wards,including four extended recovery beds, all with ensuitefacilities. There are five theatres, three with laminar flowwhich includes an endoscopy suite and a laparoscopictheatre.

There are 19 consulting rooms. Diagnostic imagingfacilities include a 128 slice dual source CT scanner, anewly replaced 1.5t MRI scanner, digital mammography,ultrasound and x-ray. The physiotherapy department haseight treatment rooms, a hydrotherapy pool and agymnasium.

Spire Bushey Hospital has an in-house accredited theatresterile services department.

Spire Bushey Hospital provides outpatient and inpatientservice for various specialties to both private and NHSpatients. Outpatient services are provided from the age oftwo years and upwards. The hospital previously carriedout surgical procedures on children aged two years andupwards, but changed its registration in January 2016 toonly admit young people aged 16-18 years and adults forsurgical procedures.

The services include, but are not limited to, orthopaedics,gynaecology, general surgery, urology, ophthalmologyand termination of pregnancy. There were 11,398inpatient and day case surgical procedures carried outfrom April 2015 to March 2016. Of these patients 2,442stayed one or more nights, the rest were day cases and 98were children and young people aged between 2-18years. There were 13 medical terminations of pregnancyand 12 surgical terminations of pregnancy were carriedout from April 2015 to March 2016.

From April 2015 to March 2016, 87,022 people were seenin outpatients, 7,177 were children and young peopleaged between 2-18 years.

The hospital is accredited by all the major private medicalinsurers. From April 2015 to March 2016 around 8% ofpatients having day or in patient treatment were fundedby the NHS, the remaining patients were self-funding orpaid for by their insurance companies.

There are 371 doctors that have practising privileges andtheir individual activity is monitored.

All patients were admitted and treated under the directcare of a consultant and medical care is supported 24hours a day, seven days a week by an onsite residentmedical officer (RMO). Patients are cared for andsupported by registered nurses, care assistants, alliedhealth professionals such as physiotherapists who areemployed by the hospital.

The hospital Accountable Officer for Controlled Drugs(CDs) is the matron.

The hospital has a local contract with a variety of localNHS trusts for blood transfusion services, geneticsservices, and used Spire Healthcare pathology services ina variety of locations within the United Kingdom.

Spire Bushey Hospital has been inspected twice by theCare Quality Commission, once in March 2013 and againin February 2014, with eight of the core standards beingassessed during these inspections. All standards assessedwere found to be compliant. The termination ofpregnancy service was reviewed in March 2012 and allstandards were met.




The five questions we ask about services and what we found

We always ask the following five questions of services.

Are services safe?Start here...

Requires improvement –––

Are services effective?Start here...

Good –––

Are services caring?Start here...

Good –––

Are services responsive?Start here...

Good –––

Are services well-led?Start here...

Good –––




Overview of ratings

Our ratings for this location are:

Safe Effective Caring Responsive Well-led Overall

Medical care Good Good Good Good Good Good

Surgery Requiresimprovement Good Good Good Good Good

Outpatients anddiagnostic imaging

Requiresimprovement Not rated Good Good Good Good

Termination ofpregnancy Not rated Not rated Not rated Not rated Not rated Not rated

Overall Requiresimprovement Good Good Good Good Good

Notes

1. We will rate effectiveness where we have sufficient,robust information which answer the KLOE’s andreflect the prompts.

2. We are doing further work on the aggregation tool forIH. If you have not followed the principles, pleasehighlight the agreed reason determined at NQAG.

Detailed findings from this inspection


Safe Good –––

Effective Good –––

Caring Good –––

Responsive Good –––

Well-led Good –––

Information about the serviceSpire Bushey medical services consist of a day-casechemotherapy treatment for patient aged 18 years andover and endoscopy services for patients aged 16 years andover.

The endoscopy facility is located at the main hospital sitewithin the theatres complex and carries out a variety ofprocedures as day cases including colonoscopy (aninternal investigation of the bowel) and hysteroscopy (aninternal investigation of the uterus). The facilities includesix day case beds on Gade Ward.

The chemotherapy unit is a part of the Elstree Cancer CareCentre and located at shared facilities two miles away fromthe main hospital site. The unit is open Monday to Friday8am – 8pm delivering treatment agreed by the patient’sconsultant oncologist. Treatment provided at thechemotherapy unit is delivered by a team of specialistoncology nurses and overseen by a consultant. The unitconsists of six patient treatment pods, one consulting roomand a treatment room.

All attendances at the chemotherapy unit were patientsaged 18 years and over who were receiving treatmentthrough private medical insurance or self-funded.Endoscopic procedures were available for NHS patients (18years and over), privately funded and self-pay patients aged16 years and over. From April 2015 to March 2016 therewere 1,992 attendances at the chemotherapy unit,1,121endoscopic procedures were carried out on patients agedover 18 years and 10 endoscopic procedures were carriedout on patients aged 16 and 17 years old.

We carried out an announced inspection on 26 and 27 July2016 and an unannounced visit on 4 August 2016. During

our inspection we visited the chemotherapy unit andendoscopy facilities. We spoke with 14 members of staffincluding the lead chemotherapy nurse, theatre manager,administrative and support staff, pharmacists andspecialist care nurses. We received information frompatients who used the service and viewed 10 sets of patientrecords.

Medicalcare

Medical care

Good –––


Summary of findingsOverall, we rated the medical services at Spire Bushey asgood for safe, effective, caring, responsiveness andwell-led, because:

• Performance data showed a good track record onsafety, patients were told when things went wrongand there were systems in place to ensure thatpatients received the correct treatment.

• Staff recognised the importance of raising concernsand recording incidents to encourage learning andimprove patient care.

• We saw that systems and processes were in place tokeep people safe from harm and abuse and whereareas for improvement were identified, this wasacted upon.

• The endoscopy facilities and chemotherapy unitwere visibly clean and well organised.

• Care and treatment was delivered in line withevidence based guidance.

• Information about the outcomes of patients’ careand treatment was collected and monitored toidentify areas for improvement and share bestpractice. There was a programme of local andnational audits conducted to improve care.

• The endoscopy facilities had started working towardsnational Joint Advisory Group in Gastroenterology(JAG) accreditation.

• Patients spoke positively about the care they hadreceived.

• Patients were offered support to manage theirtreatment and conditions.

• There was a clear vison and strategy for medicalservices which all staff were aware of and feltinvolved in.

• Staff were constantly striving to improveperformance and find new and innovative ways ofworking.

• Staff who were responsible for assessing youngpeople’s care in medical services, did not all have thecorrect level of safeguarding training.

• The hospital did not employ or have access to aregistered nurse (child branch) when children oryoung people attended the hospital. This did notcomply with national guidance.

Are medical care services safe?

Good –––

We rated the medical services as good for safe because:

• Performance data showed a good track record in safety.• The service used an electronic system to record all

incidents.• Clinical areas were generally clean and well-organised.

Medical records were maintained accurately andsecurely.

• There were safe systems for the storage and handling ofmedicines.

• Infection control procedures were followed and theservice conducted regular audits.

• The service had a system in place to recognise andrespond to changes in patients’ health.

• There was evidence that patients were told when thingswent wrong and offered an apology.

• Mandatory training was up to date.• The chemotherapy unit had been assessed by the

Macmillan Cancer support charity in November 2015and was awarded the Macmillan Quality EnvironmentMark (MQEM).

However, we also found:

• The service did not follow all of the Department ofHealth (DH) guidance for facilities for inpatients andclinical areas.

• Staff employed by the hospital, who were responsiblefor assessing young people’s care in medical services,did not all have the correct level of safeguardingtraining.

• The hospital did not employ or have access to aregistered nurse (child branch) when children attendedthe hospital. This did not comply with nationalguidance.

Incidents

• Staff understood their responsibilities to raise concernsand record incidents and near misses using thehospital’s electronic reporting system. All staff that wespoke to were able to describe the process of reportingincidents.

Medicalcare

Medical care

Good –––


• From April 2015 to March 2016 there were 333 incidentsreported across the hospital for all services, 217 of theincidents were attributed to surgery and medicine. Eightof the incidents related to the chemotherapy unit andincluded incidents such as spilt anti-cancer treatment.

• Incidents were recorded as clinical and non-clinical andgraded in severity from no or low harm to severe harmor death.

• We saw evidence that all incidents were robustlyinvestigated and there were opportunities for learningthis was discussed with staff and changes made whennecessary. For example, nursing staff on the inpatientwards were able to tell us about the improvements tothe process for assessing the risk of patients falling dueto an incident and there were notices in patients’ roomsencouraging them to call for assistance.

• A clinical governance and risk manager was in place tooversee all incidents within the hospital, alongside thehead of clinical and non-clinical services. Incidents werediscussed at senior management meetings, clinicalgovernance meetings and there were monthly adverseincident meetings. If necessary, an incident would alsobe discussed at speciality meetings including medicinesmanagement committees. Following these meetingsfeedback would then be disseminated to staff within theservice.

• There had been no ‘never events’ reported for thishospital from April 2015 to March 2016. Never events areserious patient safety incidents that should not happenif healthcare providers follow national guidance on howto prevent them. Each never event type has thepotential to cause serious patient harm or death butneither need have happened for an incident to be anever event.

• The Duty of Candour is a regulatory duty that relates toopenness and transparency and requires providers ofhealth and social care services to notify patients (orother relevant persons) of certain notifiable safetyincidents and provide reasonable support to thatperson. Staff were able to discuss the principles of dutyof candour and being open and honest. We sawevidence that patients were offered an apology andreasonable support when things went wrong.

• Incidents which were discussed regularly at medicaladvisory committee (MAC) meetings, clinical governanceand departmental meetings included reviews ofincidents that had resulted in expected or unexpecteddeath to identify trends.

• National patient safety alerts were discussed at clinicalgovernance meetings and we saw evidence that alertswere dealt with appropriately; staff were informedthrough daily briefings and team meetings.

Safety thermometer or equivalent (how does theservice monitor safety and use results)

• The medical services had systems in place to monitorthe number of falls, pressure ulcers, catheter relatedinfections and blood clots (venous thromboembolism,VTE) that occurred for inpatients in line with nationalguidelines.

• Monthly audits were conducted on the wards to checkthe effectiveness of controls put in place to minimise therisk of patients falling or acquiring pressure ulcers. Thisincluded comprehensive risk assessments and trainingto ensure compliance to organisational policies.

• From April 2015 to March 2016, the hospital recordedeight instances of VTE. We saw that there were VTEscreening processes in place and the hospital hadcarried out audits which showed that from April 2015 toMarch 2016 there was 100% compliance to VTEscreening. There had been 14 inpatient falls from April2015 to March 2016. The hospital introduced a numberof ways to help prevent falls, this included staffeducation in completing risk assessments andencouraging patients to call if they needed assistance tomove.

Cleanliness, infection control and hygiene

• The day case unit and chemotherapy unit were visiblyclean and tidy. We saw that cleaning schedules were inplace and housekeeping staff had signed regularlythroughout the day to indicate when the area had beencleaned. There were also ‘I am clean’ stickers onequipment marked with the date they were cleaned.

• There were reliable systems in place to prevent andprotect people from a healthcare associated infection.

• There was an infection prevention and controlcommittee which held regular meetings that wereattended by infection leads from all departments. Wesaw that the committee monitored the infection controlsystems in place and made improvements whenrequired.

Medicalcare

Medical care

Good –––


• Quality indicators for infection control were displayedon the hospital’s clinical scorecard which was on theorganisation’s internal website. Hospitals within theorganisation were able to view all scorecards andcompare their results.

• Infection control audits were conducted on a regularbasis and included adherence to hand hygieneprotocols. We saw that there were posters relating tohand-washing techniques in the wards andchemotherapy unit. Hand hygiene audits for staff wereconducted by hospital employees and patientsattending the hospital. All staff adhered to the arms barebelow the elbow policy.

• From April 2015 to March 2016 hand sanitiser was used19 times per occupied room per day and the hospital’starget was 18. From April 2016 to June 2016, 86% ofpatients who took part in the audit said that they hadseen information relating to handwashing techniquesand 82% of patients reported that staff always sanitisedtheir hands before attending to their dressings orwounds, 2% said sometimes and 8% were unsure.

• The chemotherapy unit infection and prevention controllead conducted infection control audits which were inaddition to those in the hospital infection control plan.Staff told us that they did this because patientsreceiving chemotherapy were susceptible to infectionsas their immune system was compromised by cancertreatment drugs. These included audits relating toaseptic techniques used when inserting catheterdevices for delivering systemic anti-cancer therapy(SACT). We saw that in March and April 2016, staff in thechemotherapy unit achieved 93% compliance toinfection control protocols when managing catheterdevices. Actions from the audit included reminding staffto use specific alcohol wipes at the site of insertion.

• Staff working in endoscopy were able to describe theprecautions taken when seeing patients withcommunicable diseases, this included arranging thetheatre list to see the patient at the end of list whenpossible and following infection control procedures.Staff also told us that they would liaise with theinfection control lead and consultant microbiologist foradvice.

• The Department of Health’s (DH) Health TechnicalMemorandum (HTM) 01-06, provided best practiceguidance on the decontamination of endoscopes. Wesaw that the processes adapted at Spire Bushey were inline with DH recommendations. There was a robust

process in place which ensured that the start ofendoscopic equipment decontamination processstarted immediately at the bedside. The endoscopeswere then transported directly to a dedicateddecontamination area adjacent to the theatre. Theequipment was then tested for integrity and underwenta further manual clean with specialised single usebrushes and equipment before being placed in anendoscopic washer-disinfector. Clean endoscopes wereplaced in sterile trays and transported through a sterilearea to a separate clean area which had a drying unitand then placed in an ultraviolet cupboard andappropriately stored for up to 72 hours.

• From April 2015 to March 2016 there were no reportedincidents of Clostridium.Difficile (C Difficile), MRSA orMethicillin-susceptible Staphylococcus Aureus (MSSA).

• Staff had access to appropriate personal protectiveequipment such as disposable aprons and gloves.

Environment and equipment

• The service had systems in place to ensure thatequipment was maintained and staff knew how to useit; this included training by manufacturers on specialistequipment.

• The hospital followed most of the DH guidance forfacilities for inpatients and clinical areas, for example, inregards to space. The hospital was in the process ofrefurbishing their inpatient rooms as some of thefacilities did not follow DH guidance. The hospital hadidentified that the carpeted rooms did not meet withHealth Building Notice (HBN) 00-10 Part A and hadstarted replacing the carpet with vinyl flooring; this wasdue to be completed by the end of 2016 and was on thehospital’s risk register. We saw that areas that were stillcarpeted underwent a routine monthly deep clean andthere was a record of when additional cleaning hadbeen undertaken due to domestic or clinical spillages.

• The endoscopy decontamination area was compact andstaff told us that there were plans to increase the size.There was one sink in the endoscopy decontaminationarea and this was not in line with DH guidelines,however, there was a separate ‘clean’ and ‘dirty’ area tominimise the risk of cross infection. This was on thehospital risk register and we saw an action plan toincrease the capacity.

• There were systems and arrangements in place tomanage waste which included processes for managingcytotoxic (cytotoxic drugs are used for cancer

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treatments to help prevent growth of cancer cells)spillages. We saw that they had appropriate ‘spillagepacks’ for cytotoxic drugs in the chemotherapy unit.Staff in the chemotherapy unit and pharmacy were ableto describe the process in the event of a spillage and thehospital had a comprehensive policy on the safemanagement of cytotoxic substances.

• We saw that clinical waste was appropriately disposedof and sharps bins were used and stored appropriately.

• The resuscitation trolleys on the wards and in thechemotherapy unit were checked and maintained on adaily and weekly basis and staff told us they wouldhighlight equipment and drugs that were nearing expirydate. However, we noted that some of the equipmentthat should have been stored in sterile packaging wasnot; staff told us that this was so that they would haveeasy access in the event of an emergency. This was notin line with best practice for infection and preventioncontrol and the hospital responded by reviewing all ofthe resuscitation trolleys and ensuring that equipmentwas stored correctly; we saw this on our unannouncedinspection. Staff told us that they had received trainingin how to use the resuscitation equipment.

• In the chemotherapy unit we saw evidence that staffhad received training by manufacturers to use specialistequipment such as syringe drivers (these were used tohelp reduce symptoms such as pain or sickness bydelivering a steady flow of injected medication underthe skin). The senior nurses in charge told us that theyregularly arranged for medical device representatives toattend the unit and deliver bespoke training; we sawrecords that showed that staff had attended thesetraining sessions.

• Equipment was stored appropriately and we witnessedstaff contacting the in house engineers department toremove defective equipment.

• Maintenance of equipment was completed by in houseengineers and manufacturers of specialised equipment.The hospital had policies which defined whichequipment would need to be serviced and repaired inhouse or off site. We saw that there was a clear schedulein place for the maintenance and servicing of allequipment.

• The chemotherapy unit had been assessed by theMacmillan Cancer support charity in November 2015and was awarded the Macmillan Quality EnvironmentMark (MQEM). The MQEM award was an assessment ofservices provided for patients living with cancer, which is

based on an assessment of the environment ensuring itis welcoming and accessible, that patients are treatedwith dignity and respect and are given choices in theircare and treatment. Accreditation standards werereassessed three yearly to ensure continuedcompliance.

• The hospital completed the Patient-Led Assessments ofthe Care Environment (PLACE) in 2016 and received 99%for ‘condition, appearance and maintenance’.

Medicines

• Pharmacy services were available at the main hospitalsite Monday to Friday 8am to 5pm and 8.30am to12.30pm on Saturdays, there was a 24 hour on callservice available seven days a week. The hospital hadrecently opened a dedicated oncology pharmacy at themain site to improve safety and efficiency; there wereplans to relocate the oncology pharmacy closer to thechemotherapy unit.

• There were arrangements in place for safely managingmedicines, including chemotherapy. This includedsystems for obtaining, prescribing, recording, handling,storage and security, dispensing, safe administrationand disposal.

• Nursing staff were aware of the hospital’s policies onmedicines management and the administration ofcontrolled drugs was in line with Nursing and MidwiferyCouncil (NMC) guidelines.

• The hospital conducted regular medicine audits and wesaw that action plans had been devised to improvecompliance to protocols in specific areas. For example,an audit conducted in November 2015 showed that staffwere not always completing documentation in line withthe hospital’s policy when medicines were taken fromthe storage area. An action plan had been developedand included appropriate guidance and mandatoryrequirements being displayed on the front of drugscupboards and ensuring that staff were aware of thepolicy and process through online training and dailybriefings.

• The hospital used medication records to documentmedications prescribed and administered. We reviewedsix sets of medical records and found that these hadbeen completed appropriately and whether the patienthad any allergies was clearly indicated in theappropriate area of the records.

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• Medicines reconciliation was completed by designatednurse practitioners and pharmacy staff. This was aprocess of identifying medicines that patients wereprescribed before admission and reviewing any newlyprescribed drugs to prevent any interactions.

• There were no controlled drugs kept at thechemotherapy unit. Chemotherapy treatments wereprepared by an external provider and delivered to thededicated oncology pharmacy at the main hospital siteand transported to the chemotherapy unit within 24hours. We saw that the hospital had processes in placeto track the transfer and receipt of all chemotherapytreatments. Upon receipt of the treatments staff at theunit secured the medicines in a refrigerator.

• The hospital did not use unlicensed medications but didhave access to medications that were not usuallyavailable on the NHS, for example, specific anti-sicknessmedications used in the chemotherapy unit.

• Patients who received medicines to take home weregiven clear instructions on how to take them and giventhe opportunity to discuss possible side effects.

• We saw that the fridge temperatures were regularlychecked and we witnessed two members of staffchecking a patient’s medication against the patient’smedical record and notes as per the organisation’spolicy.

• In theatres where endoscopic procedures were carriedout controlled drugs were kept in each theatre’s lockedcupboards. Access to the theatres was via a fingerprintentry system and the keys for the controlled drugs wereheld by one member of theatre staff whilst theatreswere open. The keys were stored on the ward in alocked cupboard when theatres were closed, the sisteror senior nurse in charge would hold the keys for thelocked cupboard. There were processes in place to trackand identify who had the keys and we saw thatmedicines management was discussed regularly atdepartmental meetings.

• The hospital had a robust policy, process and guidelinesfor managing the administration of prophylactic andtherapeutic antibiotics. This included regularmonitoring and review as a part of the overall medicinesaudits to ensure that prescribers were followingprotocols.

• We saw that the hospital had a sedation policy whichwas based on American Society of Anaesthesiologists(ASA) and British Society of Gastroenterology (BSG)guidelines; staff in theatres were able to articulate theprocess including emergency situations.

Records

• Patients’ individual care records were managed andstored appropriately. The hospital had a comprehensivepolicy which described how records should becompleted and stored. There was clear guidance onhow information should be recorded and which areas ofthe records had to be filled in, for example, hospitalnumbers and discharge details.

• There were clear systems in place to ensure thatmedical records generated by consultants holdingpractising privileges (the term used for health careprofessionals such as consultants who practised inprivate hospitals) were safely integrated into thehospital’s records for the patients. The process for thiswas clearly defined in the hospital's recordsmanagement policy, which those with practisingprivileges were required to adhere to.

• Records within medical services were paper based andstored in locked areas at the main hospital site and thechemotherapy unit.

• During our inspection we reviewed 10 sets of patient’srecords and found that the admission notes had beenwritten in line with General Medical Council (GMC)guidance. The reasons for admission were clearlydocumented and decisions relating to care pathwaysdocumented. Records for patients receivingchemotherapy treatment were detailed and containedclear information about individual patient medicationregimes and treatment plans.

• The endoscopy service care pathway included amodified version of the World Health Organisation’s(WHO) five steps to safer surgery checklist.

• Notes made by nursing staff were clear, legible anddescribed the care and treatment given to patients inline with NMC guidelines.

Safeguarding

• There were systems and processes in place to keeppatients safeguarded from abuse.

• The hospital had a safeguarding policy for adults andchildren and we saw that flow charts were displayed in

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departments, this included information aboutrecognising women or children at risk of female genitalmutilation in line with national guidelines. Theflowcharts and policies also included the details of thehospital’s safeguarding leads and externalorganisations.

• All hospital staff were required to complete safeguardinglevel one for adults and children as part of theirmandatory training. At the time of our inspection 69% ofnursing staff had completed level two safeguarding forchildren and 72% had completed safeguarding level twofor adults. In theatres, where the endoscopic procedureswere performed, 93% of staff had received safeguardinglevel two for children and 95% had receivedsafeguarding level two for adults. We saw that thehospital had a comprehensive plan to improve thelevels of training and this had been discussed in clinicalgovernance meetings. Clinical staff and consultants hadtraining planned for the future for children’ssafeguarding level three. The aim was to ensure that allclinical staff would complete children’s safeguardinglevel three training. The matron had completedchildren’s safeguarding level three and could offeradvice to staff as required. The matron and OPDManager, who was also the hospital Safeguarding Lead,was planning to complete children’s safeguarding levelfour.

• Nursing staff were able to describe their responsibilitiesand actions if they had concerns that a patient wasvulnerable and at risk of abuse.

• The hospital did not employ or have access to aregistered nurse (child branch) when children attendedthe hospital.

• There were no patients treated at the chemotherapyunit who were aged under 18 and the nursing staff hadreceived adult safeguarding training as part of theirmandatory training.

• Staff who were caring for young people aged between16-18 years were not trained to level three insafeguarding. Although we saw no evidence of a failureto safeguard children, we were not assured that all staffwho had contact with young people had received theappropriate level of safeguarding training. The providershould ensure that a process is in place to ensureclinical staff working with young people and/or theirparents/carers and who could potentially contribute toassessing, planning, intervening and evaluating the

needs of a young person and parenting capacity wherethere are safeguarding/child protection concerns hasreceived training to the appropriate level of competencyas outlined in the Intercollegiate guidance SafeguardingChildren.

• The hospital had three managers who acted as theleads for adult and children’s safeguarding and hadbeen trained to safeguarding level three for children.This included the theatre manager for the endoscopyservices; however, no other staff in theatres hadreceived this level of training.

• We raised the lack of children’s safeguarding level threetraining with the hospital and we received details oftheir action plan to address this. We also saw that thishad been discussed at the hospital’s annual clinicalgovernance meeting in 2015 and plans had been madeto increase the level of safeguarding training for all staff.

Mandatory training

• Mandatory training at the hospital was deliveredthrough self-directed online learning and face to facetraining. The hospital’s target for mandatory trainingcompletion was 95%.

• Training included modules relating to health and safety,infection prevention and control, informationgovernance, safeguarding for adults and children,medicines management and manual handling.

• From April 2015 to March 2016, compliance withmandatory training was 91% and we saw that this hadbeen discussed at departmental meetings to improvethe figure to meet organisational targets. Seniormanagers discussed different ways to deliver trainingincluding more access to online courses and anemphasis on encouraging staff to complete self-directedlearning.

• We saw that records of staff who had completed theirmandatory training were held by senior nursing staff incharge of departments.

Assessing and responding to patient risk

• The service conducted comprehensive risk assessmentsfor patients using the service and developed riskmanagement plans in line with national guidance.

• The hospital had a clear admissions policy which set outguidelines for safe admission of medical patients. Everypatient who attended the endoscopy facilities andchemotherapy unit was required to undertake apre-admission risk assessment. There were four

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different levels of risk assessment undertaken prior toadmission which began at the booking stage with amedical questionnaire. There was also a nurse ledtelephone and face to face assessment. The policy alsodefined which level of risk assessment wasautomatically required for specific patient groups; forexample, patients who had pacemakers (an internal orexternal electronic device used to regulate heart rates)fitted would automatically receive a face to faceassessment and if necessary a pre-admissionassessment was made by a consultant anaesthetist.

• Admissions were not accepted unless the patient wasunder the care of an appropriate consultant who hadpractising privileges at the hospital. The hospital did notaccept emergency or unplanned admissions until anappropriate consultant had liaised with the referrer andagreed to be present at the patient’s admission.

• Medical services within the Elstree Cancer Centre didnot provide 24-hour cover. Out of hours, provision wasthrough the inpatient ward area and the residentmedical officer. Patients undergoing chemotherapy whobecame acutely unwell were admitted to the maininpatient area for treatment.

• The hospital used the National Early Warning Score(NEWS) for all patients in line with the National Institutefor Health and Care Excellence (NICE) guidelines relatingto recognising and responding to the deterioratingpatient. This was a colour coded system staff used torecord routine physiological observations such as bloodpressure, temperature and heart rate, with clearprocedures for escalation if a patient’s conditiondeteriorated. Nursing staff that we spoke with were ableto describe the process and explained who they wouldcontact in an emergency, we saw evidence that thesechecks were made and recorded appropriately.

• The hospital had a clear critical transfer policy forpatients who deteriorated and needed a higher level ofcare than that provided by the hospital. There was aservice level agreement with a local acute NHS trust totransfer patients by ambulance if required. All staff wespoke with in the endoscopy service and chemotherapyunit were able to describe the process and their actions.Staff told us that this was rare and if this happened itwould be recorded as an incident. From April 2015 toMarch 2016, we saw that there had been no recordedincidents of patients being transferred as an emergencywhilst receiving medical care.

• Patients receiving chemotherapy treatments wereadvised of the risk of neutropenic sepsis (patientsreceiving anti-cancer treatments are susceptible toneutropenic sepsis due to a temporary reduced whiteblood cell count during treatment) and giveninformation to allow them to recognise any signs orsymptoms of sepsis after treatment. Staff had access toan algorithm based on NICE guidelines in regards totreatment of neutropenic sepsis, this includedtimeframes for antibiotic administration.

• The chemotherapy unit provided a 24 hour telephoneadvice service which was always staffed by the hospital’soncology nurses. We saw the telephone triage tool thatwas used which was based on UK Oncology NursingSociety (UKONS) recognised guidance designed topromote safer decision making. Patients were advisedto contact the 24 hour line for any queries and concerns.In addition, some staff at the main hospital site hadreceived training and guidance on how to use the triagetool. Staff told us that this meant that in an emergency ifa patient was unable to get through to the 24 hour linethey would still be able to receive an appropriateassessment. Staff could not provide us with any specificexamples of when a patient had not been able to getthrough to the 24 hour line.

• We saw that the hospital had a robust extravasationpolicy. Extravasation is a term used when medicinesthat are being administered intravenously (such aschemotherapy) unintentionally leak into thesurrounding tissue and cause damage. Staff were ableto describe the process for treatment and theimportance of recognising the early symptoms. Theservice had an agreement with a local acute NHS trustto transfer patients who needed treatment as a result ofextravasation.

• The service used a Spire Healthcare modified version ofthe World Health Organisation (WHO) five steps to safersurgery checklist. Staff conducting procedures wererequired to confirm the patient’s name, age, proceduresite and consent before starting treatment and recordthat this had been done on the checklist. We saw that inan audit conducted in March 2016 staff had recordeddetails on completion of the checklist in line with thehospital’s policy 95% of the time. We saw thatrecommendations from the audit were to ensure that allstaff recorded actions and this was discussed atdepartmental meetings and a reminder sent to all staff

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Nursing staffing

• During the inspection we observed in the endoscopyfacilities and chemotherapy unit that there was a goodskill mix and appropriate level of nursing staff to meetpatients’ needs.

• The hospital used an acuity tool to plan and reviewstaffing levels and skill mix which was based on nationalguidelines for staffing on wards in independenthospitals. Senior staff told us that they planned basedon the acuity levels of patients and the amount of ‘carehours’ each patient required. We saw that senior staffused historical data to calculate how many hours of carea patient needed and planned the rotas accordingly.Senior staff told us that on the wards this generallyequated to one registered nurse (RGN) and two healthcare assistants (HCA) for every five patients but thiscould be adjusted or increased to meet the acuity of thepatients. The clinical ward manager or matron and wardsisters were supernumerary and on each shift; theyacted in a supervisory position and provided a point ofescalation.

• There was no baseline acuity tool for nursing staffing inchemotherapy. The chemotherapy unit was staffed witha chemotherapy sister, four senior oncology nurses,eight oncology nurses and three HCAs. Senior staffplanned to have a minimum of four nurses and twoHCAs on duty per day and at least one senior member ofstaff to act in a supernumerary position; with sixchemotherapy rooms this meant that there was alwaysa member of staff to look after a patient. We saw thatthis number was adjusted downwards to meet thedemands of the service.

• Staffing for the endoscopy unit was made up of RGNs,HCAs and Operating Departmental Practitioners (ODP)who worked on the day case ward and in theatres. Therewere dedicated theatre staff with specific competencieswho assisted consultants with endoscopic procedures.

• There were no vacancies in the endoscopy service orchemotherapy unit at the time of our inspection.

• Clinical nurse specialists worked within the medicalservices; specifically breast care nurses and cancernurse specialists. The hospital employed one palliativecare nurse and two breast care specialist nurses.

• There was minimal use of bank and agency staff. Thehospital’s target was 3% use of bank and agency staff,from April 2015 to March 2016 the hospital average bank

and agency use was less than 1% and in theatres theyhad used no agency staff. We saw that bank or agencystaff would receive a comprehensive induction whichincluded a competency checklist.

• We observed effective handovers between nursing staffon the wards at the start of their shifts. The majority ofpatients that attended the endoscopy facilities andchemotherapy unit were admitted as day cases, weobserved appropriate handovers between theatre staffand nursing staff in the recovery area which included allvital information necessary for continuity of care.

Medical staffing

• The hospital’s medical advisory committee (MAC) wasresponsible for granting consultants practisingprivileges at the hospital. The MAC carried outappropriate checks for medical staff in regards to theirscope of practice and eligibility to practice.

• Consultants with practising privileges at Spire Busheywere required to be contactable at all times, when theyhad a medical patient at the hospital, and visit themdaily. They were also required to be able to arrive at theunit within a specified timeframe of 45 minutes if therewas an emergency. Nursing staff told us that they wereable to call and speak with the consultants at any timefor advice.

• The hospital had four resident medical officers (RMOs)who provided emergency consultant cover and medicaladvice 24 hours a day, seven days a week. The RMOsgenerally worked a week on duty and a week off dutyand stayed within the hospital at all times. Rotas werearranged so that there was one RMO available at alltimes in line with national guidance.

• Consultants with practising privileges were required tomake their own arrangements for appropriateequivalent cover for annual leave. This was with anotherconsultant with practising privileges at the hospital andcover arrangements were logged on an electronicregister.

• Nursing staff told us that they received effectivehandovers from medical staff when patients wereadmitted to the hospital and after consultants hadvisited their in-patients. The RMOs conductedhandovers at the change of their shifts with the newRMO on duty detailing any areas of concern andhighlighting any patients that may have higher acuityneeds and require extra monitoring.

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Major incident awareness and training

• The hospital had a business continuity plan whichdescribed what staff should do in the event of loss offacilities due to events such as severe weather or loss ofpower. Each department was provided with action cardsthat described the process in the event of an evacuationdue to a major incident affecting service. Staff were ableto tell us where the plan was located on the intranet andwhere paper copies and action cards were located andthey were familiar with the evacuation procedures.

• The Elstree Cancer Care Centre had a separate businesscontinuity plan due to the nature of the treatment beingdelivered. Staff were able to direct us to the plan and wesaw that they had attended specific training sessionsand conducted evacuation exercises.

• We saw evidence of regular fire alarm testing at bothsites.

Are medical care services effective?

Good –––

We rated the service as good for effectiveness because:

• Care and treatment was delivered in line with evidencebased guidance.

• There was a programme of local and national auditsconducted to improve care.

• The endoscopy service had started working towardsnational Joint Advisory Group in Gastroenterology (JAG)accreditation.

• Staff were proactively encouraged to develop new skills.• All nursing staff had received an up to date appraisal

and identified individual training needs.• The service had robust systems in place to ensure that

medical staff with practising privileges had receivedregular appraisals and had completed revalidation inline with General Medical Council (GMC) requirements.

• The service worked well with internal and externalteams to plan and deliver care and treatment.

However, we also found:

• Mental capacity assessments which were completed forpatients with Do Not Attempt Cardio PulmonaryResuscitation (DNACPR) orders were not alwaysrecorded in patients’ records in line with hospital policy.

Evidence-based care and treatment

• We saw evidence that patients’ needs were assessedand treatment delivered in line with legislation,standards and evidence-based guidance. For example,the endoscopy service followed National Institute andHealth Care Excellence (NICE) professional guidance forendoscopic procedures for patients aged 16 and over.

• The hospital had a comprehensive clinical auditprogramme which included local and national audits.For example, the chemotherapy unit were participatingin a national organisational neutropenic sepsis auditwhich looked at compliance to NICE guidelines for riskassessing, recognising and treating neutropenic sepsis;this was ongoing at the time of our inspection so resultswere not available. We did see that policies andprocesses relating to cancer care were based on NICEand UK Oncology Nursing Society (UKONS) guidelines.

• Local audits were undertaken to monitor and reviewcompliance to protocols and national guidance. Forexample, monthly audits were conducted for patientsassessed as being at risk of venous thromboembolism(VTE) being offered VTE prophylaxis in line with NICEguidelines.

• The hospital used a modified version of the WorldHealth Organisations (WHO) five steps to safer surgerychecklist which included a team brief and a teamdebrief in the checklist.

Pain relief

• Patients we spoke with told us that their pain had beenwell managed.

• The service met the core standards for painmanagement services (Faculty of Pain Medicine, 2015).We saw in medical records that patients with acute painhad an individualised analgesic plan appropriate totheir condition. Pain was assessed during observationsand recorded on NEWS charts; we saw that this wasaudited regularly to ensure that this standard was beingmet. From April 2015 to March 2016 we saw that auditsshowed that all patients had their pain scoresdocumented in their medical records in line with thehospital’s policy.

• Syringe drivers were used in the chemotherapy unitwhich delivered a slow steady flow of pain relief. We sawthat all staff had received specific training in the use ofthese.

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• The palliative care nurse specialist was able to speakwith patients about symptom control and arrange forassistance in the community for patients who neededhelp with pain control on discharge.

Nutrition and hydration

• Patients nutritional and hydration needs were assessedby a nurse upon admission. Nursing staff were requiredto confirm that patients had completed the ‘fasting’required for certain procedures.

• Patients who were having endoscopic procedures weregiven information prior to admission that detailed thetypes of food they could have and when to stop eatingsolid foods. They were also given information regardingfluid intake to ensure that they did not becomedehydrated.

• The catering and housekeeping department providedfood and drink for patients after procedures wherepatients were encouraged to eat before leaving the unit,for example, after undergoing a colonoscopy (aninternal endoscopic investigation of the bowel).

• Patients who attended the chemotherapy unit wereable to request food and drink which was delivered tothe chemotherapy unit for patients’ appointment times.Staff also had access to a kitchen area where they couldprepare hot and cold drinks for patients.

Patient outcomes

• Information about the outcomes of patients’ care andtreatment was collected and monitored to identify areasfor improvement and share best practice.

• The endoscopy service was working towards JointAdvisory Group Gastroenterology Society (JAG)accreditation and had an action plan to meet thestandards. The action plan was based on the results ofaudits which were based on JAG quality and safety inendoscopy global rating scale (GRS) (British Society ofGastroenterology Quality and safety indicators forendoscopy, 2009). The GRS audit was divided into fourareas which were clinical quality, patient experience,workforce and training. A comprehensive GRS audit ofthe endoscopy service had been conducted inSeptember 2015 and it showed that the service had anoverall compliance of 92%. Areas for improvement werehighlighted in the action plan and includedstrengthening the processes in place to deliver bespokeendoscopy training and formalised feedback toindividual staff members.

• There had been an annual external review of thedecontamination services in 2015 and accreditation hadbeen received from an organisation which measuredquality management systems.

• Each hospital within the organisation used a clinicalscorecard which displayed quarterly results frommonthly local audits in a number of areas includinginfection control, accurate record keeping, medicinesstorage and completion of risk assessments. The clinicalscorecards were available on the organisation’s intranetwhich meant that services were able to compare theirperformance to similar services within the Spire group.

• The chemotherapy unit conducted regular auditsrelating to peripheral and centrally inserted central lines(a long thin catheter inserted into the veins) used todeliver chemotherapy treatment. For example, in March2016 the unit scored 93% for compliance to aseptictechniques and insertion techniques. The unit haddeveloped an action plan which included remindingstaff of the correct alcohol solution to disinfect theinsertion site.

Competent staff

• All staff had the right qualifications, skills, knowledgeand experience to do their jobs. At the start of theiremployment with the hospital, staff were given acomprehensive induction and received on-goingtraining, opportunities for development andcompetency checks.

• Oncology nurses attended annual training sessions byan external provider to maintain and check theircompetencies and knowledge. We saw records thatshowed that these were up to date.

• Training for staff in endoscopy was based on BritishSociety of Gastroenterology (BSG) guidelines and wesaw that this was audited and reviewed on an annualbasis to ensure that staff received on-going appropriatetraining.

• All nursing staff were required to undertake basic lifesupport (BLS) as part of mandatory training. Saferstaffing guidelines recommend that at least onemember of staff on duty should have advanced lifesupport (ALS) training. There were 15 staff at thehospital trained in ALS, four of whom worked at thechemotherapy unit. We saw that rotas were planned toensure that at least one staff member per shift had ALStraining.

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• In theatres, one member of staff had undergone theEuropean Paediatric Life Support (EPLS) training. If ayoung person, aged 16-17 was having an endoscopicprocedures the theatre manager ensured that the EPLStrained member of staff was on duty. The residentmedical officer also had EPLS and was on duty 24 hoursa day.

• Revalidation is the process that all nurses and midwivesin the UK need to follow to maintain their registrationwith the Nursing and Midwifery Council (NMC) and allowthem to continue practising. We saw that the medicalservices had been holding workshops to assist staff withunderstanding revalidation requirements and trainingsessions in specific areas which could be used forrevalidation purposes; for example, an oncology studyday for all staff which included training about managingand screening for neutropenic sepsis.

• All registered nurses that worked in the wards andtheatres had valid nursing and midwifery registration orwere registered with the Health and Care ProfessionsCouncil. This confirmed that nurses and otherpractitioners, such as operating departmentpractitioners were trained and eligible to practise withinthe UK. There was an effective process in place toensure these were updated.

• The hospital director was responsible for ensuring thatall medical staff with practising privileges had thecorrect skills, competencies, experience andqualifications to carry out the care and treatmentprovided. The MAC assisted with this process byproviding professional advice. This includedcomprehensive background checks including Disclosureand Barring Service (DBS) checks and ensuring thatmedical staff were registered to practice in the area ofpractice. All medical staff were given a ‘consultants’handbook’ which clearly laid out the requirements ofmaintaining their practising privileges at Spire Bushey.Practising privileges were reviewed every two years bythe MAC and hospital director to ensure that consultantswere practising within their scope and meeting thehospitals and statutory requirements.

• From January 2015 to January 2016 all nursing staffincluding health care assistants and operatingdepartmental practitioners and 96% of support staffreceived an annual appraisal. Staff told us that this wasan opportunity for them to highlight their individualtraining needs and identify areas for improvement.

• Medical staff with practising privileges were required toprovide evidence of appropriate appraisals in line withthe General Medical Council (GMC) guidelines; this waschecked by the MAC and the hospital had acomprehensive policy which described the consultants’responsibilities. Consultants who did not provideappropriate evidence had their practising privilegestemporarily suspended until the evidence wasproduced.

• The pharmacy manager and two other pharmacists hadcompleted specific training to dispense medicationsrelated to oncology and at the time of our inspectionanother member of the pharmacy team was undergoingthe training.

Multidisciplinary working ( in relation to this coreservice)

• We saw that staff, teams and services worked effectivelytogether to deliver effective patient care.

• Weekly multi-disciplinary team (MDT) meetings wereheld for breast cancer care and were attended byoncology nurses, breast care specialists, consultantsand GPs; we saw evidence of this in patients’ medicalrecords; these MDT meetings were well established. Thehospital also held MDT meetings for patients withurology and bowel cancer, staff told us that they weredeveloping agreements with local NHS trusts to improveMDT meetings for patients in these groups. This washighlighted as an area for improvement on thehospital’s risk register and we saw that MDT meetings forurology had developed since April 2016.

• There were good working relationships between all theteams and we saw that staff in medical services liaisedwith outpatients and surgery to assess and plan careand treatment for patients.

• We saw that the palliative nurse specialist workedclosely with staff in the cancer care centre and on thewards to provide support and advice in planning end oflife care; this included providing important links tocommunity services and support networks.

• The breast care specialist nurse liaised with externalorganisations to provide support and advice forpatients.

• Nursing staff told us that they had developed goodworking relationships with consultants and that they feltconfident to contact them whenever it was necessary.

Medicalcare

Medical care

Good –––


• We saw that the service had good working relationshipswith local NHS acute trusts for transferring patients inline with agreed pathways.

• We saw that discharge plans included information sentto the patient’s GP and referral to other communityservices such as local hospices for ongoing care.

• The Elstree Cancer Care Centre was a partnershipbetween Spire Bushey hospital and another healthcareprovider. Spire Bushey provided oncology consultationand chemotherapy treatments and the provider theyworked with was responsible for delivering radiotherapytreatments. We observed effective working relationshipsat the centre and seamless interaction between theservices.

Seven-day services

• The chemotherapy unit and endoscopy facility providedservices Monday to Friday 8am to 8pm. Staff told us thatthey sometimes adjusted the times to meet demands,for example, staff in the chemotherapy unit told us thaton occasion they would deliver treatment on theweekends during bank holiday periods to ensurepatients received their treatment in a timely manner.

• The hospital had a resident medical officer (RMO) whowas contactable 24 hours a day, seven days a week.

Consultants responsible for patients were required to becontactable at all times when their patients were at thehospital.

• The chemotherapy unit provided a 24 hour telephoneservice to provide patients with advice and guidance atall times.

• Patients could phone the ward staff for advice at anytimes, and they could contact the consultant if required.

• There was an on call emergency theatre team that couldcarry out an emergency endoscopic procedure ifrequired.

Access to information

• There were systems and processes in place to ensurethat information needed to deliver effective care andtreatment was available in a timely manner.

• All staff had access to the hospital’s intranet where allpolicies and processes relating to care and treatmentwere located. Staff told us that this was easy to navigateand access to information formed a part of theircorporate induction.

• Consultants with practising privileges were required toensure that records that they held for their patients wereavailable to staff. If consultant’s held the patient’srecords they were required to provide a copy orsummary that was contained within the hospital’spatient records; we saw evidence of this in the recordsthat we looked at during our inspection.

• When patients moved between services or teamsrelevant information was shared appropriately and inline with the hospital’s policies. For example, we sawthat patients who had been transferred from NHSfacilities had a copy or summary of the care receivedbefore they were transferred and a letter detailing whythey had been transferred.

• The service had arrangements in place to ensure thattest results for patients were available in a timelymanner; this included co-ordination and planning ofappointments and care. Staff in endoscopy told us thatthe average time for endoscopy results was one to twodays and that results were available when patientsreturned for consultation one week to ten days aftertheir procedure.

Consent, Mental Capacity Act and Deprivation ofLiberty Safeguards

• Staff understood the relevant consent and decisionmaking requirements of legislation and guidance,including the Mental Capacity Act 2005 (MCA) andDeprivation of Liberty Safeguards (DoLS).

• MCA 2005 and DoLS training formed a part of mandatorytraining for staff.

• Staff were aware of the process of assessing mentalcapacity to consent to treatment but some were unableto tell us or show us where they would find theassessment tool to record their decisions.

• The hospital had a comprehensive consent policy whichwas up to date and regularly reviewed to ensurecompliance with legislations.

• We looked at the medical records of six patients whohad Do Not Attempt Cardio Pulmonary Resuscitation(DNACPR) orders; we found that most of these werecompleted correctly and in line with legislation. In twoinstances where the patient was assessed as lackingcapacity to consent to DNACPR, we found that thedecision had been correctly discussed with the patientsrelative or next of kin and consent sought from them.However, we found no evidence that an assessment ofcapacity had taken place. We highlighted this to senior

Medicalcare

Medical care

Good –––


managers who told us that consultants were required torecord details of the capacity assessments in themedical records in line with the hospital’s policy and thiswould be addressed in a briefing to all staff.

Are medical care services caring?

Good –––

We rated the service as good for caring because:

• Patients told us that they were treated with kindness,respect and compassion.

• We saw staff taking the time to interact with patientsand those accompanying them.

• The service conducted their own surveys to receivefeedback from those using the service.

• The hospital wide friends and family survey, whichincluded both NHS and private, scored consistently highwith the number of patients that would recommend thehospital.

• Patients spoke positively about the care they hadreceived.

• Patients were offered support to manage theirtreatment and conditions.

Compassionate care

• Patients and those close to them were treated withcompassion, kindness, dignity and respect includingwhen receiving personal care.

• We observed staff taking the time to interact withpatients in a respectful and considerate manner.

• Patients were given the opportunity to be accompaniedby a friend or relative for consultations and there werechaperones available in all areas.

• Nursing staff showed a holistic understanding of thepersonal, cultural, social, religious and physical needs ofpatients and those close to them.

• The hospital wide friends and family survey, whichincluded both NHS and private patients scored above97% for the number of patients who would recommendthe hospital from April 2015 to March 2016. Theresponse rates were on average 34% for the same timeperiod, which is in line with the England nationalaverage.

• Patients spoke positively about the caring andrespectful manner of all staff.

Understanding and involvement of patients and thoseclose to

• We saw staff in the chemotherapy unit greeting patientsby their first name and patients calling nursing staff bytheir first names upon arrival.

• In testimonials from patients about their treatment atthe cancer centre and the main hospital site we saw thatmany referred to the breast care specialist nurse and thesupport from nursing staff at the chemotherapy unit in apositive manner.

• We saw staff taking the time to explain information topatients in an appropriate manner and making surepatients new how to contact the units if they neededmore information.

• Nursing staff told us that conversations about the costsof treatment were handled in a sensitive manner andwas discussed as a part of the pre-admissionassessment and also again on admission.

• The palliative care nurse spent time with all patientswho had decided to stop having anti-cancer treatmentsand gave them information about the services andsupport that was available to them in the communitysuch as hospices and end of life care planning.

• We saw that patients and their loved ones had beeninvolved in the decision-making process and this wasreflected in patients’ medical records.

• Young people undergoing endoscopic procedures couldhave their parents accompany them to outside of thetheatre and then wait for them until they returned fromthe recovery area.

Emotional support

• Nursing staff showed an awareness of the impact that apatient’s care, treatment or condition could have ontheir well-being and those close to them.

• Staff in the chemotherapy unit had undergone specifictraining in regards to compassionate care and providingsupport for patients with life changing conditions.

• Patients were given information about relevantcounselling services and peer support groups.

• Clinical nurse specialists with specific knowledge inbreast, palliative and cancer care spent time withpatients and their loved ones to help them manage theirconditions and provide care and treatment.

Medicalcare

Medical care

Good –––


• The ‘Pink Petals’ peer support group was for patientswith breast cancer and those that had previously hadcancer. The group provided patients with a number ofopportunities to access links within communities andsupport and information for individuals.

• Staff told us that if they had to deliver distressing newsto a patient or their loved ones this would happen in asingle use room on a ward or in a consulting room toallow privacy.

• The chemotherapy unit had received the MacmillanQuality Environment Mark (MQEM) which was anassessment of services provided for cancer support. Apart of the assessment related to having a caring andsupportive environment where people could talk inconfidence and privacy.

Are medical care services responsive?

Good –––

We rated the medical services as good because:

• Services were planned to meet the needs of the localpopulation.

• At times of high demand the medical services modifiedhours of service delivery to meet the needs of patients.

• Staff had an awareness of the needs of patients withcomplex needs and had received dementia awarenesstraining.

• Staff showed good understanding of equality anddiversity.

• The hospital had a robust admissions and dischargepolicy which allowed flexibility for patients to choosetimes that suited them.

• Patients received detailed information about their careand treatment.

• The hospital was learning from complaints and hadreviewed their complaints procedure.

Service planning and delivery to meet the needs oflocal people

• Planning for service delivery was made in conjunctionwith a number of other external providers,commissioners and local authorities to meet the needsof local people. For example we saw that GPs and

community care providers were involved in planningcare for patients receiving chemotherapy and thehospital liaised with local NHS trusts to establishappropriate pathways of care.

• We saw that the needs of the population were discussedat organisational level and shared through annualquality accounts defining the role of the organisation indelivering healthcare in all communities.

• Staff were proud of the fact that they strived to delivercare in a manner that met the patients’ medical andsocial needs; this included arrangements to haverelatives or carers stay with patients at the hospital ornearby suitable accommodation.

• At times of high demand the medical services modifiedhours of service delivery to meet the needs of patients.Staff told us that this was managed in a manner whichmeant that they were not working more than theircontracted hours.

• Part of the strategy for Spire Bushey involvedredesigning and expanding the capacity for medicalservices to meet increasing healthcare demands. Wesaw that the service had plans to redesign theendoscopy facilities to provide greater space in thedecontamination area and to relocate the oncologypharmacy to a new site in 2017. The plans wereon-going at the time of our inspection, funding hadbeen secured and risk assessments were still beingconducted to ensure that the plans for redesign weresafe for staff and patients.

Access and flow

• The hospital had a robust admissions and dischargepolicy. It set out the time frame for admissions fromreferrers and the process for requests for emergencyadmissions. All admissions had to be agreed andaccepted by a consultant and a booking form had to bereceived.

• Consultants with practising privileges were required togive a minimum of seven days’ notice for plannedpatients’ admissions and this was highlighted in theirconsultant’s handbook. For emergency admissions,consultants were required to complete the bookingform and be present at the hospital to accept thepatient when they arrived.

• The scope of practice policy at the hospital set out theguidelines for procedures and treatments that could be

Medicalcare

Medical care

Good –––


carried out within medical services. Consultants whowere referring patients were required to ensure that theprocedure or treatment booked for their patients waswithin the scope of practice.

• Patients were able to access care and treatment at atime to suit them in line with the hospitals terms andconditions of admission. All patients were offeredflexibility of appointments and the hospital reportedreferral to treatment times (RTT) for NHS-fundedpatients in line with national guidance. From June 2015to March 2016 the hospital met the 92% target for allnon-admitted and admitted patients to receive an initialconsultation or treatment within 18 weeks of referral.

• There was no waiting list for endoscopic procedures andstaff told us that all endoscopic procedures were carriedout within two weeks of referral unless the patientrequested a time longer than two weeks.

• The hospital had a system in place to managecancellations of procedures or treatment for non-clinicalreasons, for example lack of staff. The hospital told usthat from July 2015 to June 2016 there had been 15cancellations of treatment across all services fornon-clinical reasons and all patients had been offeredalternative appointments within 28 days. Cancellationswere discussed at clinical governance meetings toidentify trends and areas for improvement.

• Patients who attended the chemotherapy unit hadalready received their initial consultation and staff toldus that appointments for treatment were planned anddiscussed with patients.

• There were arrangements and processes in place forpatients to receive emergency care and advice outsideof medical services’ normal working hours.

• GPs received written discharge summaries eitherelectronically through a centralised system or by post.

Meeting people’s individual needs

• Services were planned to meet the needs of differentpeople and those with complex needs. For example, wesaw that staff in medical services had attendeddementia awareness training and had access to thehospital’s dementia lead nurse for advice.

• Staff we spoke with were aware of the diversepopulation they served and were aware of the needs ofpeople with varying cultural, ethnic and religiousrequirements. Staff were able to describe the principlesof ‘protected characteristics’ as defined by theEqualities Act 2010.

• The hospital’s policy stated that discharge planningshould begin at the pre-admission assessment stagespecifically for home care packages and periods ofconvalescence. We saw evidence of this in patients’medical notes.

• Discharges for inpatients were planned to take placebetween 10am and 10pm. Patients who wished to bedischarged outside of hours received a risk assessmentin terms of care needs and were required to complete aform that stated that they were happy to leave at thetime.

• The palliative care nurse played an integral part indischarge planning for patients who had receivedcancer treatments. We saw that patients were providedwith comprehensive information packs of services andsupport groups; this included information relating tofinancial support.

• The breast care nurse specialist had formed a breastcancer support group called ‘Pink Petals’, this had beenformed in 2012. We saw that patients were able toaccess information regarding cosmetic and alternativetherapies through this group. For example, the breastcare nurse specialist arranged for a presentation ondifferent types of shampoos that were suitable forpatients receiving cancer treatments and would notcause irritation for patients who had received‘scalp-cooling’ therapy whilst receiving treatment.

• Weekly MDT meetings were conducted for patients withcomplex medical needs and we saw that this includedother healthcare providers such as GPs.

• Staff told us that if a patient attended medical serviceswho had learning disabilities they would be aware ofthis prior to admission and seek advice if the patient didnot have a carer attending with them; staff had notreceived specific training in caring for patients withlearning disabilities.

• The hospital had access to a telephone languagetranslation services for patients when required.

• There were hearing loops throughout the hospital toassist patients with auditory impairments.

• There was access for wheelchair users and lifts at bothsites for patients with mobility problems.

• Nursing staff told us that specific patientcommunication needs would be assessed prior toadmission and highlighted in the patient’s medicalrecords which complied with Accessible Informationstandards (NHS England 2015).

Medicalcare

Medical care

Good –––


• Visiting times on the wards were from 9am to 9pm,seven days a week, however, friends and family couldliaise with staff to arrange different visiting times ifrequired; this was highlighted in patient informationleaflets.

Learning from complaints and concerns

• Spire Healthcare Limited’s corporate complaints policydirected the management of complaints and timescales for responses. This was in line with industrystandards. All complaints were reviewed by the clinicalgovernance committees and medical advisorycommittee (MAC) and actions as a result of thecomplaint shared with individual departments via teammeetings.

• Patients were given written information on how to makecomplaints and leaflets were on display throughout thehospital. This information was also displayed on thehospital’s public website under ‘patient information’.

• From April 2015 to March 2016 the hospital received 126complaints. We saw that themes of complaints werediscussed at clinical governance meetings and areas forimprovement and learning were highlighted. Generally,themes of complaints related to billing information,miscommunications between providers and care andtreatment. We saw that patients were offered apologiesand compensation when billing errors occurred andstaff had been reminded of the importance ofinformation governance and maintaining patients’records when information between providers was noteffectively communicated.

• The hospital target was to respond to 75% of allcomplaints within 20 days of receipt, in line with theirorganisational policy. We saw that between April 2015and March 2016 they responded to 66% of complaintswithin 20 days. The organisation undertook an externalreview of their complaints process in September 2015and developed an action plan to improve theirperformance in this area. The hospital’s quality reportfor April 2016 to June 2016 showed that they hadexceeded their target and had closed 85% of complaintswithin 20 days. Staff told us that they planned to set upa patient’s forum and complaints committee to helpmanage and learn from complaints.

• Staff told us that they received a number ofcompliments and the complaints were also importantbecause it helped them to understand if they weremeeting patients’ needs.

Are medical care services well-led?

Good –––

We rated the medical services as good for being well-ledbecause:

• There was a clear vision and strategy for medicalservices which staff at all levels were aware of.

• There was a culture of openness and transparency andstaff felt confident to raise concerns.

• There was a robust governance system in place tosupport the delivery of the strategy and provideassurances to relevant stakeholders;

• Leaders were visible and approachable and encourageda culture of transparency and openness.

• Staff were encouraged to explore and develop new waysof working.

• There were good examples of public and staffengagement.

Leadership and culture of service

• The hospital was led by the hospital director andmatron; each department had a nominated head whowas a clear leader, such as a chemotherapy sister,theatre manager and ward manager.

• There was clear evidence of a strong leadership culturein medical services. The chemotherapy sister had beena part of the unit since it started and had played anintegral part in the implementation and furtherdevelopments. The theatre manager and clinical wardmanagers were responsible for leading and developingstaff and services for patients receiving endoscopicprocedures.

• Nursing staff at both sites told us that there leaders werevisible and approachable and felt that they were able toexpress any concerns to them and they would belistened to.

• Staff at Elstree Cancer Centre told us that since thehospitals director had been in post they had felt lessisolated as prior to that they did not see the hospitaldirector very often and they were now included in thesenior management team meetings.

Medicalcare

Medical care

Good –––


• We saw that leaders of the service encouragedsupportive relationships among staff throughdeveloping ‘buddy’ and mentoring systems for learningand peer support.

• There was a strong culture of openness andtransparency and staff at all levels spoke of identifyingareas for improvement to improve the patientexperience.

• Staff at all levels and in clinical and non-clinicalpositions told us that they felt valued as part of the teamand felt that their contribution mattered.

• All staff that we spoke to were proud and passionateabout the care they delivered and the support that theyoffered patients and each other.

Vision and strategy for this this core service

• Staff that we spoke to at all levels were aware of thehospital’s strategy to ‘Be outstanding in all things, be thenumber one choice for all patients, value and invest inour staff, promoting a culture of mutual respect andteamwork, provide a high quality and efficient patientexperience , work with GPs and consultants to deliverclinical excellence’.

• The strategic plan for medical services included theredesign and expansion of both the endoscopy facilitiesand chemotherapy unit.

• Staff that we spoke to were aware of the plans forgrowth and were positive about the changes improvingpatient care and felt that they were a part of it.

• Staff in medical services were aware of the organisationsvalues and felt that caring for patients through doing theright thing and ensuring patient safety was at the centreof all they did; we heard this from staff at all levels.

• Progress against the strategy was monitored andreviewed with updates disseminated via departmentalmeetings and team briefings.

Governance, risk management and qualitymeasurement for this core service

• There was an effective governance framework in placeto support the delivery of the strategy and good qualitycare. The hospital clinical governance committeereported to the Spire Healthcare Limited board.

• The clinical governance committee met quarterly. Thiscommittee had an overview of governance risk and

quality issues for all departments. Senior departmentleads attended. Information discussed included safetyalerts, learning from incidents, policy updates andaudits.

• Staff understood their roles and what they wereaccountable for, for example; the infection control leadsfor departments were responsible for attendinginfection and prevention control meetings and reportingon concerns and compliance to protocol.

• The Medical Advisory Committee (MAC) consisted of thehospital director, chairperson, matron and head ofclinical and non-clinical services, theatre manager,clinical governance and risk manager and consultantsfrom all specialities. The role and responsibilities of theMAC were clearly set out in the hospital’s policies; thisincluded their role in granting and reviewing practisingprivileges and quality assurance.

• Governance frameworks and management systemswere regularly reviewed by the clinical governancecommittee, MAC and senior management team.Improvements and changes to systems were madewhen required; we saw evidence of this in minutes frommeetings.

• All consultants applying for practising privileges wererequired to provide evidence of appropriate andadequate indemnity insurance. The consultants’handbook set out what the hospital’s minimumconsultant medical malpractice indemnity requirementswere.

• The hospital had processes in place to ensure thatmedical professionals granted practising privilegesmaintained an accurate personal record and appraisalrecord in line with General Medical Council (GMC)requirements of registration. This process was managedby the hospital director with input from the MAC whenrequired.

• The hospital had a central risk register which alldepartments fed into. Each department also had theirown separate risk assessment registers

• Leaders in endoscopy told us that the main risks werethe size of the endoscopy decontamination area,current capacity of theatres and the potential risk of notmeeting the standards required for JAG accreditationdue to the design of the building. We saw that therewere action plans to address each of these risks andthey were on the hospital wide risk register.

• The hospital used a safer surgery checklist which was amodified version of the World Health Organisation

Medicalcare

Medical care

Good –––


(WHO) five steps to safer surgery checklist designed forlocal use for invasive procedures. We saw evidence thatthis practice was regularly audited and educationdelivered when required in line with national standards.The organisation had arranged for two representativesfrom each Spire hospital to attend external training daysin regards to National Safety Standards for InvasiveProcedures (NatSSIPs, NHS England) in order for themto share learning with their colleagues. The theatremanager was involved in updating the organisation’spolicy related to performing invasive procedures basedon NatSSIPs and was extremely positive about theimpact these opportunities would have on ensuring safepatient care.

Public and staff engagement

• Patients and those close to them were given theopportunity to provide feedback through patient surveyquestionnaires given to them on admission. From July2015 to March 2016 97% of all patients said they wouldbe ‘extremely likely’ to recommend the hospital tofriends and family.

• The hospital’s public website invited patients to providefeedback through an online form and displayedtestimonials from other patients who had providedfeedback.

• The hospital conducted annual staff surveys in line withorganisational policies. The top five results from SpireBushey 2015 staff survey included 97% of staff reportingthat they believed that the work that they did made apositive difference to the hospital and 95% of staffreporting that their manager trusted them to make theright decisions at work. An action plan had beendeveloped to address the five lowest scoring resultswhich included 49% of staff reporting that otherdepartments did not understand the impact theiractions had on other teams and 32% of staff felt thatthere were not sufficient numbers of staff to meet thedemands of the service. We saw that the action planinvolved developing opportunities for all departmentsto attend regular meetings.

• The breast care nurse specialist had set up a supportand information group for patients called ‘Pink Petals’.

The group had been running since 2012 andmembership had steadily increased over the years.Members of the group attended events arranged andco-ordinated by the breast care specialist nurse at SpireBushey. These included closed social events such asfashion shows and events that offered opportunities forlearning and sharing information. Membership wasopen to all patients (past and present) who hadattended the breast care services and cancer carecentre. We saw that patients made very positivecomments about the support they had received throughmembership to the group. The group had presented thebreast care nurse specialist with a book filled withcomments and letters of thanks at a specialpresentation in 2015.

• We spoke with the breast care nurse specialist and theytold us that they had received encouragement andsupport in setting up ‘Pink Petals’ from their colleaguesand the senior managers and that there were plans toshare the concept within the Spire Healthcare group.

• All staff that we spoke to recognised the value of raisingconcerns and taking appropriate action if required.

• Managers in medical services had an ‘open door’ policyand we saw that staff were encouraged to discuss ideasfor innovation and improvement.

Innovation, improvement and sustainability

• Leaders and staff in medical services were continuouslylooking for opportunities to improve practice anddevelop ways of working to improve the quality of care.Staff at all levels attended national training sessions andevents to discover new treatments and developmentopportunities for staff. The endoscopy service wasworking towards achieving Joint Advisory Groupaccreditation.

• The ‘Pink Petals’ peer support group set up andmanaged by a member of staff was an integral part ofcare and treatment for a number of patients. We sawthat patients found this to be a valuable forum toexchange views, support each other and receiveimportant information about their care whichaddressed both physical and social needs.

Medicalcare

Medical care

Good –––


Safe Requires improvement –––

Effective Good –––




Information about the serviceSpire Bushey Hospital provides surgical services for variousspecialties to both private and NHS patients. The hospitalcares for adults and young people over 16 years of age.

There are two inpatient wards, Lea ward is on the groundfloor and has 34 single ensuite rooms, Gade ward is on thefirst floor and has 24 single ensuite rooms, and 12 day casepods with reclining chairs.

Pre-assessments are carried out within the day care unitwhere patients are seen in preparation for their admissionto hospital.

There are five theatres, three with laminar flow and alaparoscopic theatre with associated anaesthetic roomsand a recovery area. Sterile services are provided on siteand are CE accredited.

From April 2015 to March 2016, there were 11,398 surgicalepisodes, mainly for elective surgery. Of these 8% wereNHS funded and 92% were self-funded or patients withprivate medical insurance. There were 88 children agedbetween three and 18 years that attended for surgicalprocedures. The hospital had previously offered surgicalservices to children aged between three and 18 years, butchanged this in January 2016 to offer surgical services toyoung people aged 16 years and over.

The hospital offers a range of surgical procedures,including; orthopaedic, ear nose and throat, generalsurgery, cosmetic, gynaecology and urology procedures.

All patients are admitted and treated under the direct careof a consultant surgeon and medical care was supportedby resident medical officer (RMO).

We carried out an inspection of the hospital and visited theward, main theatre, recovery and pre-assessment clinic. Wespoke with 38 members of staff. We observed care andtreatment and reviewed six patient records. Prior to theinspection, we reviewed performance information aboutthe hospital. We talked to five patients and acknowledgedthe views expressed by patients on Care QualityCommission comment cards.

We carried out an announced inspection on 26 and 27 July2016 and an unannounced visit on 4 August 2016 and anannounced visit on 13 December 2016.

Surgery

Surgery

Good –––


Summary of findingsWe rated the surgical services as requires improvementfor safe and good for effective, caring, responsive andwell-led. This meant that surgery was good overall.

• Staff were encouraged to report incidents. They weredealt with appropriately and themes and outcomeswere communicated to staff.

• Action was taken to ensure patients were protectedfrom abuse. However, staff caring for yong people,were not trained to the right level in safeguarding.

• There was no access to a registered nurse (childbranch) when young people attended the hospital.

• The environment was visibly clean and staff followedthe hospital policy on infection control.

• There was appropriate equipment to provide safecare and treatment.

• Patients were assessed, treated and cared for in linewith professional guidance, such as the five steps tosafer surgery checklists.

• Treatment and care were provided in accordancewith evidence-based national guidelines. There wasgood practice, for example, assessments of patientneeds, monitoring of nutrition and pain.Multidisciplinary working was effective.

• Nursing, medical and other healthcare professionalswere caring and patients were positive about theircare.

• Patients told us they were treated with dignity andrespect.

• Patients were given appropriate written informationon what to expect from their care and treatment.

• There was appropriate discharge planning.• Information about the hospital complaints

procedure was available for patients and theirrelatives. Complaints were acknowledged,investigated and responded to in a timely manner.

• The hospital had a clear governance structure.• Information was cascaded to all staff.• There was strong leadership and staff felt supported

and valued.

Are surgery services safe?


We rated safe as requires improvement because:

• There was no access to a registered nurse (child branch)when young people attended the hospital.

• Staff caring for young people aged 16-18 years of agewere not always trained to level three in children’ssafeguarding.

• Some floor covering in patients’ bedrooms was notcompliant with infection control guidance. There was arefurbishment programme in place.

• The medication fridge on Gade ward was unlocked andstaff could not find the key.

However we found that:

• Staff told us they were encouraged to report anyincidents, and serious incidents were discussed at teammeetings and ward handovers. Staff were confident inreporting incidents and were aware of the importance ofthe duty of candour regulation.

• There was access to appropriate equipment to providesafe care and treatment.

• We observed the five steps to safer surgery checklistswere being completed appropriately.

• There were procedures in place for the reporting of allnew pressure ulcers, and slips, trips and falls. Action wasbeing taken to ensure harm free care.

• Nursing handovers were well structured within thesurgical wards.

• The environment was visibly clean. Equipment wasgenerally cleaned after use with an: ‘I’m Clean’ stickerplaced on to it.

• Staff had the appropriate training to be able recogniseand respond to deteriorating patients.

Incidents

• Staff understood their responsibilities to raise concerns,to record safety incidents, concerns and near missesand to report them internally and externally.

• The systems, processes and practices that wereessential to keep people safe were consistentlyidentified, put into practice and communicated to staff.

Surgery

Surgery

Good –––


• A system and process for reporting of incidents was inplace. Staff understood the mechanism of reportingincidents; this was confirmed verbally, both at juniorand senior level. The incident reporting form wasaccessible via an electronic system.

• From April 2015 to March 2016 there were 333 incidentsreported across the hospital for all services, 217 of theincidents were attributed to surgery and medicine. Eightof the incidents related to the chemotherapy unit andincluded incidents such as spilt anti-cancer treatment.

• From April 2015 to March 2016, 12 serious incidentsreported and nine deaths in the same time period. Asthe hospital offers palliative care, these deaths wereexpected.

• All these incidents had been investigated and there wasevidence of actions taken. For example, to preventpatient falls we saw a poster in each patient bedroomwith; ‘Call don’t Fall’ to encourage patient to call staffwhen mobilising.

• All serious incidents were analysed at clinicalgovernance meetings to ensure that lessons were learnt.This information was disseminated to staff via head ofdepartment meetings.

• In addition, a monthly bulletin was sent from Spire’shead office outlining incidents that had taken place inother hospitals. There was a system of red, amber, greenrating (RAG) with regards to rating of incidents. Learningwas shared both locally and throughout theorganisation, to enable procedures to be put into placeso that similar incidents did not reoccur.

• There had been no never events reported in the last 12months within surgery. Never events are serious patientsafety incidents that should not happen if healthcareproviders follow national guidance on how to preventthem. Each never event type has the potential to causeserious patient harm or death but neither need havehappened for an incident to be a never event (SeriousIncident Framework, NHS England March 2015).

• From November 2014, all providers were required tocomply with the Duty of Candour Regulation. The dutyof candour 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.

• Staff were fully aware of the duty of candour regulation(to be honest and open) ensuring patients always

received a timely apology when there had been adefined notifiable safety incident. We saw examples ofwhere duty of candour had been applied with regards toincidents and complaints.

Safety thermometer or equivalent (how does theservice monitor safety and use results)

• The safety thermometer is a tool for measuring,monitoring, and analysing patient harms and 'harmfree' care. Data is collected on a single day each monthto indicate performance in key safety areas, for example,new pressure ulcers, catheter urinary tract infectionsand falls.

• The hospital audited and monitored avoidable harmscaused to patients. From January 2016 to March 2016there were eight falls, no pressure ulcers and nocatheter infections reported. This information wasdisplayed on the wards.


• The hospital had policies and procedures in place tomanage infection prevention and control. Staff accessedpolicies via the hospital intranet and were able todemonstrate how these policies were easily available.

• The wards and theatres were visibly clean and tidy.• There was awareness amongst staff about infection

prevention and control and we observed staff washingtheir hands and using hand gel between treatingpatients. We observed all staff using alcohol hand gelwhen entering and exiting wards and theatres.

• We observed staff complying with ‘arms bare below theelbow’ policy. However, we observed a small number ofstaff were wearing nail polish and necklaces, which doesnot comply with infection control guidance. We raisedthis with the senior managers at the time of ourinspection who said they would address thisimmediately.

• There is a dedicated infection control lead who holds amaster’s degree in infection prevention and control. Thelead conducts one to one meetings with the infectionprevention and control links staff throughout thehospital to share learning. The lead also attends wardrounds to offer support and advice.

• We saw a robust audit programme ensures staffcompliance in delivering high standards of Infectionprevention and control.

Surgery

Surgery

Good –––


• Hand hygiene audits from April 2015 to December 2015across all surgical wards and theatres showed 95% -100% overall compliance.

• Personal protective equipment, such as gloves andaprons were used appropriately and were available insufficient quantities.

• We observed a lack of clinical handwashing facilities inward areas. Clinical hand basins were provided in utilityareas, but not in patient rooms. This meant that at thepoint of care, staff were washing their hands in patients’private bathrooms. Although the sinks in patientbathrooms had wrist operated taps, best practice wouldbe to have dedicated clinical sinks within ensuite rooms.Department of Health Guidelines 2013 HBN009 statethat: ‘Ensuite single bed rooms should have a generalwash-hand basin for personal hygiene in the ensuitefacility in addition to the clinical wash-basin in thepatient’s room’. This had not been taken intoconsideration when some of the bedrooms had beenrefurbished in 2016. This was raised with the seniormanagers at the time of our inspection who told us thiswas on the risk register and they had escalated this toSpire Healthcare.

• Not all the flooring in patient rooms were compliantwith Department of Health (DH) 2013 HBN0010 part A.Patient rooms had been refurbished prior to the 2013guidance, which meant that they were not compliantwith current Health and Building Note regulations 2013.Patient rooms were having carpets replaced with hardwood flooring as part of the hospital's refurbishmentprogramme. At the time of the inspection 85% of patientbedrooms had hard flooring in place.

• Some bedrooms had laminate flooring, but otherbedrooms and the day case pods had carpets. Carpetswere cleaned on a regular basis. This was raised with thesenior managers at the time of our inspection, and wesaw this was on the hospital risk register and they hadescalated this to Spire Healthcare.

• Equipment was cleaned after use with an; ‘I’m clean’sticker placed on it.

• The hospital’s Patient Led Assessments of the CareEnvironment (PLACE) for 2016 was 100% in cleanliness.

• There had been eight surgical site infections reportedfor April 2015 to March 2016. The patients involved hadmainly undergone orthopaedic procedures and breastand gynaecology surgery. These rates were lower than

other similar services. All infections were investigatedand no trends had been identified, for example withparticular surgeons, operations, theatres, or scrubteams.

• There had been no incidents of MRSA or Clostridiumdifficile from April 2015 to March 2016.


• There was sufficient equipment, such as anaestheticequipment, theatre instruments, blood pressure andtemperature monitors, commodes and bedpans.

• Resuscitation equipment, for use in an emergency in theoperating theatres and ward areas, were regularlychecked and documented as complete and ready foruse. The trolleys were secured with tags, which wereremoved monthly to check the entire contents to ensuretheir integrity and that they were within date. Howeveron the ward we found the resuscitation trolley hadsterile equipment, which had been opened. This meantit was no longer sterile. The paediatric resuscitationtrolley was in a locked room, which was not easilyaccessible. We raised this with the hospital managersand during our unannounced inspection on 4 August2016 we found all sterile equipment was in sealedpackaging and the paediatric resuscitation trolley was inthe main corridor and accessible.

• Staff within the recovery unit said they had all theemergency equipment they required at hand. Weobserved sufficient equipment available during our visit.

• There were systems to maintain and service equipmentas required. Equipment had been tested appropriatelyto ensure that it was safe to use.

• The hospital had a contract with an external providerthat completed most of the equipment maintenance.Faulty equipment was reported and recorded. Whenequipment was urgently needed, the maintenancecompany were contracted to replace it within 24hoursto enable normal service to continue.

• The Patient Led Assessment of the Care Environment(PLACE) audit 2016 for the hospital’s condition,appearance and environment was 98%.

Medicines

• There was an onsite pharmacy department whichopened between 8am and 5pm Monday to Friday and

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8am to 12 midday on Saturdays. There was a procedurein place for the senior nurse and the resident medicaloffice (RMO) to gain entrance to pharmacy if medicineswere needed urgently. Each had a separate key.

• The hospital pharmacist visited the clinical areas dailyto check agreed stock levels and to ensure there wasappropriate stock rotation. The pharmacist reviewedprescription charts to help guide ward staff in the safeprescribing and administration of medicines.

• Medicines were stored in a secure temperaturecontrolled room that had suitable storage andpreparation facilities for all types of medicines such ascontrolled drugs and antibiotics. We saw records of thedaily checks of ambient temperatures in the medicinesstorage room had been routinely completed.

• Medicines that required refrigeration were kept at thecorrect temperature. We saw records of the dailychecklists of ambient fridge temperatures. Thechecklists indicated what the acceptable temperaturerange should be to remind staff at what level a possibleproblem should be reported. Staff were aware of whataction to take if the fridge temperature was outside safeparameters.

• On Gade ward, the medication fridge was unlocked andstaff were unable to find the key. Therefore we were notreassured of the safety of medication at all times. Thiswas raised with the hospital senior management teamduring our inspection.

• Medicine cupboards were left unlocked in theatres,whilst theatres were in use to allow easy access. A riskassessment had been undertaken. The controlled drugcupboards were locked at all times.

• Controlled drugs were stored in a locked unit and thekeys held separately from the main drug keys. Wereviewed the controlled drug cupboards which were tidyand did not hold any other medicines in thesecupboards.

• In theatres we found some medication had beenprepared in advance and labelled, and left unattended.We raised this with the theatre manager who addressedthis immediately and discussed this practice withmedical staff to ensure this did not happen again. Onour unannounced inspection, we found that thispractice appeared to have stopped.

• We did not observe the administration of medicationduring our inspection. However, we checked sixmedicine charts which were all completedappropriately.

• Nursing staff were aware and were able to seekguidance from the hospital’s medicines policy andBritish National Formulary (BNF), which was the latestedition. The BNF is a pharmaceutical reference bookand contains advice on prescribing and pharmacology.

Records

• The hospital used a paper based records system forrecording patients’ care and treatment.

• Patients’ records were stored in a trolley behind thenurse’s station but this was unlocked, therefore we werenot reassured about the safety and confidentiality ofpatient records at all times.

• We reviewed six sets of patient records. Information waseasy to access and the records contained informationon the patient’s journey through the hospital includingpre assessment, investigations, results and treatmentprovided. However we found that three out of the sixsets of notes had no evidence that nursing staff hadreviewed the pre-operative assessment form as this hadnot been signed. We raised this with the hospitalmanagers at the time of our inspection who said theywould review the notes and investigate.

• We reviewed four sets of children and young peoplenotes and found that two did not have risk assessmentcompleted. This was raised with the matron during theinspection. However we found consent forms had beencompleted adequately and there was clear dischargeinformation.

• During the unannounced inspection we reviewed afurther 10 sets of notes of notes for children and youngpeople and found that all risk assessments had beencompleted.

• Daily care records such as fluid balance records andcare plans were stored in folders at the patient bedside.We looked at samples of records which were fullycompleted, legible with entries timed, dated and signed.

• Theatre records were completed and included the fivesteps to safer surgery checklist. We saw good staffengagement with the process and the forms werecompleted fully and appropriately.

• The final order of the theatre list was decided on the dayof surgery; this was communicated to theatre staff andtelephoned to the ward. However the lists were notreprinted which could have allowed for mistakes to bemade and is not in line with best practice. This wasraised at the time of our inspection and on the

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unannounced inspection we found that updatedtheatre lists were been printed on cream paper toindicate a change of the list and distributed to allclinical areas.

Safeguarding

• The hospital had safeguarding policies and proceduresavailable to staff on the intranet, including out of hourscontact details for hospital staff.

• Staff received training and had a good understanding oftheir responsibilities in relation to safeguarding ofvulnerable adults and children.

• Nursing staff on the ward had a compliance rate of 84%for adult safeguarding level two, and 69% for childrensafeguarding level two. Clinical staff and consultantshad training planned for the future for children’ssafeguarding level three. The aim was to ensure that allclinical staff would complete children’s safeguardinglevel three training. The matron had completedchildren’s safeguarding level three and could offeradvice to staff as required.

• The matron and OPD Manager, who was also thehospital safeguarding lead, were planning to completechildren’s safeguarding level four

• The nursing and medical staff were able to explainsafeguarding arrangements, and when they wererequired to report issues to protect the safety ofvulnerable patients.

• There was no access to a registered nurse (child branch)when young people attended the hospital. This did notmeet the Royal College of Paediatrics and Child Health(RCPCH) guidelines or those contained in theIntercollegiate Document (March 2014).

• Not all staff who were caring for young people aged16-18 years were trained to level three in children’ssafeguarding. This did not meet the Royal College ofPaediatrics and Child Health (RCPCH) guidelines orthose contained in the Intercollegiate Document (March2104) which states that clinicians who are potentiallyresponsible for assessing, planning, intervening andevaluating children’s care, should be trained to levelthree safeguarding. The hospital was working towardsensuring all staff had appropriate training. Although wesaw no evidence of a failure to safeguard children, wewere not assured that all staff who had contact withchildren or young people had received the appropriatelevel of safeguarding training. The provider shouldensure that a process is in place to ensure clinical staff

working with children, young people and/or theirparents/carers and who could potentially contribute toassessing, planning, intervening and evaluating theneeds of a child or young person and parenting capacitywhere there are safeguarding/child protection concernshas received training to the appropriate level ofcompetency as outlined in the Intercollegiate guidanceSafeguarding Children.

• The young people were under the direct care of aconsultant, who had completed safeguarding level threetraining, the consultant was not present for the durationof the young person’s stay.

• The hospital had a policy relating to safeguardingaround female genital mutilation (FGM) and posterswere displayed advising staff what to do if FGM wassuspected.

Mandatory training

• Staff received mandatory training to enable them toprovide safe care. Mandatory training included forexample infection control, fire, moving and handlingand health and safety. Some training was delivered viaface to face sessions and others were available via thee-learning on line.

• There was an induction programme for all new staff andstaff that had attended felt that the programme mettheir needs.

• Mandatory training was a rolling programme and wesaw that 95% of theatre and ward staff had completedthe training.


• Risks to patients who were undergoing surgicalprocedures had been assessed and their safetymonitored and maintained. For example patientsundergoing elective surgery attend a preoperativeassessment clinic and the hospital used the five steps tosafer surgery checklist, in line with national guidelines.

• The hospital used a Spire Healthcare modified versionof the World Health Organisations (WHO) five steps tosafer surgery checklist which included a team brief anda team debrief in the checklist.

• We observed the five steps to safer surgery checklist wasbeing used. We observed checks as they were beingcarried out, both in the ward and operating theatre. Thepractice appeared embedded throughout the hospital.

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• Patients for elective surgery attended a preoperativeassessment clinic where all required tests wereundertaken. For example, MRSA screening and anyblood tests. If required, patients were reviewed by ananaesthetist and had a dedicated appointment.

• Risk assessments were undertaken in areas such asvenous thromboembolism, falls, malnutrition andpressure ulcers. These were documented in the patient’srecords and included actions to mitigate the risksidentified.

• The national early warning score (NEWS) was used toidentify deteriorating patients in accordance with NICEclinical guidance CG50. Staff recorded routinephysiological observations, such as blood pressure,temperature, and heart rate, all of which were scoredaccording to pre-determined parameters. There wereclear directions for actions to take when a patient’sscore increased. There were appropriate triggers inplace to escalate care, which members of staff wereaware of. We reviewed six sets of patient notes andfound that scores were added up correctly andescalation was carried out appropriately. This meantthat patients who were deteriorating or at risk ofdeteriorating were recognised and treatedappropriately.

• There was a formal arrangement for patients to betransferred to the local NHS hospital if the patientrequired critical care level two or above. These arecritically ill patients, who require either organ support orcloser monitoring.

• There was access to a minimum of two units of ORhesus negative emergency blood. The hospital had a‘massive blood loss’ protocol and all staff we spoke towere aware of where the emergency blood was storedand how to obtain it. Further blood for transfusion wasobtained through the local NHS trust blood bank andthe staff could access these details.

• The practising privileges agreement required surgeonsto be contactable at all times when they had patients inthe hospital. They needed to be able to attend thehospital within 45 minutes. They had a responsibility toensure suitable arrangements were made with anotherapproved practitioner to provide cover in the event thatthey were not available, for example when they were onholiday. Staff told us that they were made aware whenconsultants were on holiday and who would be coveringfor them; this was written in the patients notes.

Nursing staffing

• The hospital used a staffing tool, dependency reviews,NICE guidelines and professional judgement to assessand plan staffing requirements to determineappropriate staffing levels. From this, the requirednumber of nurses and healthcare assistants werecalculated for each shift.

• During our inspection, we saw that planned numbers ofnursing staff had been met.

• The hospital used a team of bank staff to cover anyunfilled shifts in the ward and theatres to ensure theywere able to provide safe care.

• Data provided by the hospital demonstrated thatTheatres had not used any agency staff in the previous12 months, which is within our reporting period. Thetheatre manager told us that agency staff had not beenused for 15 years within theatres. There were lownumbers of agency staff that had been used on thewards.

• We saw that staff rotas were planned six weeks inadvance.

• During our inspection there was one nursing vacancywithin theatres and 3 nursing vacancies on the wards.

• Revalidation is the process that all nurses and midwivesin the UK need to follow to maintain their registrationwith the Nursing and Midwifery Council (NMC) and allowthem to continue practising. We saw processes in placeto assist nurses to maintain their registration, such asstudy days and NMC registration would be checkedmonthly to ensure staff kept these up to date.

• We observed that nursing handovers within the surgicalward were well structured and gave clear conciseinformation on each patient. The handovers occurred inthe clinical treatment room for all staff and patientprivacy, dignity and confidentiality were maintained.Appropriate information was shared such asmedication, pain management, discharge planning andtreatment plans.

Surgical staffing

• Patient care was consultant led. The hospital practisingprivileges agreement required the consultant to visitand review the patient daily and more frequently ifnecessary. Staff we spoke with confirmed thatconsultants did review patients when requested to doso.

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• There was a registered medical officer (RMO) inattendance in the hospital 24 hours a day, seven days aweek. The RMO provided medical support to wards andtheatres and was easily accessible via the hospital bleepsystem. The RMO generally worked one week on duty ata time and stayed within the hospital so they wereavailable 24 hours a day.

• There was not a dedicated anaesthetist on call system.Local policy was for staff to call the anaesthetist whowas present during the operation, and if they wereunavailable, an alternative anaesthetist would berecorded in the patients’ notes. Staff confirmed this wasthe process they would follow. We raised this with thesenior managers at the time of the inspection. Duringour unannounced inspection we found a standardoperating procedure was being implemented to ensureanaesthetist were on call and accessible. A riskassessment was in progress and all anaesthetist hadbeen sent a letter to confirm arrangements.


• There was a major incident policy in place relating to allservices within the hospital.

• Staff were aware of the hospital policy. A contact list forout of hours staff for emergencies was available. Thehospital had a contingency plan for responding toevents that could disrupt the service such as lack ofwater supply, breakdown of IT or telephone systems.There was a member of the senior management teamon call who would be contacted if necessary.

Are surgery services effective?

Good –––

We rated effective as good because:

• Policies were accessible, current and reflectedprofessional guidelines.

• Care was provided in line with best practice guidelines.• The hospital monitored adherence to policies by the use

of local audits.• Pain was managed well and pain management audited.• Patients’ nutritional status was assessed.• Patient outcomes were audited and showed results in

line with those nationally.

• The Medical Advisory Committee (MAC) ensuredconsultants were competent to practice and practisingprivileges were reviewed annually.

• There was evidence of good multidisciplinary working.

• Consultants were on call 24 hours a day and seven daysa week for their in and day patients and visited themdaily.

• There was a resident medical officer (RMO) providingmedical cover for patients and clinical support to staff.

• Staff were familiar with the consent policy.• Staff were aware of their role with regards to the Mental

Capacity Act and Deprivation of Liberty and hadreceived training.


• Assessments for patients were comprehensive, coveringall health and social care needs (clinical needs, mentalhealth, physical health, and nutrition and hydrationneeds). Patients’ care and treatment was planned anddelivered in line with evidence-based guidelines forexample nutritional and hydration needs, fallsassessment and consent.

• Policies were up to date and followed guidance from theNational Institute for Health and Care Excellence (NICE)and other professional associations for example,Association for Perioperative Practice (AfPP). Localpolicies, such as the infection control policies werewritten in line with national guidelines. Staff we spokewith were aware of these policies and knew how toaccess them on the hospitals intranet.

• The hospital raised awareness of policies by have a‘policy of the month’, which was audited the followingmonth to determine staffs understanding. Staff said theyfound this useful and encouraged them to read thepolicies.

• There was participation in relevant local and nationalaudits, including clinical audits such as surgical siteinfections and environmental audits.

• Venous thromboembolism (VTE) assessments wererecorded and were clear and evidence-based andcompliant with guidance from the National Institute ofHealth and Care Excellence (NICE 2010) for reducing therisk of venous thromboembolism in adults.

• We saw the hospital had systems in place to providecare in line with best practice guidelines (NICE CG50:Acutely ill patients: Recognition of and response to

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acute illness in adults in hospital). For example, an earlywarning score was used to alert staff should a patient’scondition deteriorate. The system used incorporatedescalation actions that should be taken.

• We saw audits of the five steps to safer surgery were98% compliance from January 2016 to June 2016.Observational audits had also been carried out fromFebruary 2016 to June 2016 with a compliance of 96%.Action plans included ensuring staff signed parts of theform and documenting patient pre-operativetemperatures.

• There was participation in the Private HealthcareInformation Network (PHIN) in accordance with thecompetition and markets authority. PHIN had recently(March 2016) assessed the hospital for readiness tocommence submitting data in September 2016 andraised no concerns. The data sets to be submittedincluded patient satisfaction, adverse events andPatient Reported Outcome Measures for hips, knees,cataract, groin and hernias surgery.

Pain relief

• Patients we spoke with said that their pain was wellmanaged during their treatment.

• Our observation of practice, review of records confirmedthat pain was assessed and managed effectively.

• Patients’ records showed that pain had been riskassessed using the scale found within the NEWS chartand medication was given as prescribed. We observedstaff asking patients if they were in pain and patientstold us they were provided with pain relief in a timelymanner. Pain management for individual patients wasdiscussed at handovers as required.

Nutrition and hydration

• Patients’ nutrition and hydration status was assessedand recorded using the Malnutrition Universal ScreeningTool (MUST).

• In all six records we reviewed, we observed that fluidbalance charts were completed appropriately and usedto monitor patients’ hydration status.

• Intravenous fluids were prescribed, administered andrecorded appropriately in the patient notes reviewed.

• Patients were given fasting instructions at pre-operativeassessment, which were aligned with therecommendations of the Royal College of Anaesthetists,(RCOA). Patients were offered drinks if there was delay intheatre times to maintain their hydration.

Patient outcomes

• The hospital participated in the elective surgery, PatientReported Outcome Measures (PROMS) national audit.The hospital data in May 2016 showed that for theOxford hip score, of the 19 patients reported 100%reported an improvement in health after theirprocedure. Data for Oxford knee score showed that ofthe 21 patients reported 90% reported an improvementin health after their procedure.

• From April 2015 to March 2016, there had been fiveunplanned readmissions, eight unplanned returns totheatre and 14 unplanned transfers of patients to thelocal NHS hospitals. Each case had been reported as anincident and investigated, but no trends had beenidentified. This is low numbers compared to similarproviders.

• The hospital had achieved 100% in the National JointRegistry submissions from April 2015 to March 2016.

Competent staff

• Staff had the skills, knowledge and experience to delivereffective care and treatment to patients.

• There was a specific induction programme for all staff.Staff that had attended the induction programme toldus this was useful. Staff would have a period of beingsupernumerary during their induction.

• Nursing staff felt well supported and adequately trainedin their local areas.

• Registered nurses had completed intermediate lifesupport training. Basic life support training wasprovided to support staff. This ensured that all staff wereable to respond to a collapsed patient.

• Resident medical officers (RMO) were trained inadvanced life support (ALS). The hospital had 15 stafftrained to ALS level in addition to the RMO. We saw thatrotas were planned to ensure that at least one staffmember per shift had ALS training.

• The RMO also had European Paediatric Life Support(EPLS) as well as one member of staff in theatre. If ayoung person, aged 16-18 was attending theatres thetheatre manager ensured that the EPLS trained memberof staff was on duty.

• All staff we spoke with told us that they had received anannual appraisal and found this a positive experience.Hospital data showed that 100% of theatre staff hadcompleted an appraisal and 76% of wards staff hadcompleted an appraisal.

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• We saw evidence that all registered nurses andprofessional staff that worked in the wards and theatreshad valid nursing and midwifery registration or wereregistered with the Health and Care Professions Council.This confirmed that nurses and other practitioners, suchas operating department practitioners andphysiotherapists, were trained and eligible to practisewithin the UK. There was an effective process in place toensure these were updated.

• The role of the Medical Advisory Committee (MAC)included ensuring that consultants were skilled,competent and experienced to perform the treatmentsundertaken. Practising privileges were granted forconsultants to carry out specified procedures using ascope of practice document. The hospital checkedregistration with the General Medical Council theconsultants’ registration on the relevant specialistregister, Disclosure and Barring Service (DBS) check andindemnity insurance.

• There were arrangements which required the consultantto apply to undertake a new technique or procedure notundertaken previously by the practitioner at thehospital. The introduction of the new technique orprocedure had to have the support of the MAC, whichmay have taken specialist advice such as that from theNational Institute for Health and Care Excellence or therelevant Royal College. The practitioner was alsorequired to produce documentary evidence that theywere properly trained and accredited in the undertakingof that procedure.

• Practising privileges for consultants were reviewedannually. The review included all aspects of aconsultant’s performance, including an assessment oftheir annual appraisal, volume and scope of activity,plus any related incidents and complaints. In addition,the MAC advised the hospital about continuation ofpractising privileges. The hospital used an electronicsystem to check when privileges were due to expire.

Multidisciplinary working

• Our observation of practice, review of records anddiscussion with staff confirmed effectivemultidisciplinary team (MDT) working practices were inplace.

• All relevant staff, teams and services were involved inassessing, planning and delivering people’s care andtreatment and worked collaboratively to understandand meet the range and complexity of people’s needs.

• Staff described the multidisciplinary team as beingsupportive of each other. Health professionals told usthey felt supported and that their contribution to overallpatient care was valued.

• We observed good working relationship between nurse,doctors and allied professionals.

• Discharge letters were sent to the patients’ GPsimmediately after discharge, with details of thetreatment provided, follow up care and medicationsprovided.

Seven-day services

• Consultants were on call seven days a week for patientsin their care.

• There was cover 24 hours a day by the RMO to provideclinical support to surgeons, staff and patients.

• There was not a dedicated anaesthetist on call system.Local policy was for staff to call the anaesthetist thatcarried out the operation, and if they were unavailablethis would be documented in the patients’ notes as towho to call and staff confirmed this was the process theywould follow.

• There was an on call system for theatre staff,radiographers, physiotherapists and pharmacists. Staffwe spoke with were aware how to access thisinformation if they needed to call someone out of hours.

• There was a senior manager on call 24 hours a day forstaff to access for support and advice.


• There were computers throughout the individual wardareas to access patient information including testresults, diagnostics and records systems. Staff were ableto demonstrate how they accessed information on thehospitals electronic system.

• Staff said they had good access to patient relatedinformation and records whenever required.

• We observed on-going care information was sharedappropriately at handovers.


• The hospital had a consent policy that staff werefamiliar with.

• The hospital had three nationally recognised consentforms in use; there was a consent form for patients whowere able to give valid consent, another for patients

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who were not able to give consent for their operation orprocedure, for example if they lacked mental capacity,and one for young people aged between 16 and 18years.

• Some staff were unaware that there were three differentconsent forms available; this was raised with the wardmanager during our inspection who said that theywould raise this at the staff meeting.

• Staff understood consent, decision-makingrequirements, and guidance.

• Consent to care and treatment was obtained in line withlegislation and guidance, including the Mental CapacityAct 2005 (MCA).

• Staff we spoke with had undergone training in MCA 2005to ensure that they were competent to meet patients’needs and protect their rights, should a patient lackcapacity. The training received included training ofDeprivation of Liberty (DoLS). Staff had anunderstanding of when DoLS may be required.

• Training was provided as part of the hospital’smandatory training package. Information provided bythe hospital indicated that 100% of ward nursing staffand 100% of theatre staff had completed all theirmandatory training modules in MCA 2005 and DoLS.

• The service ensured there was a two week cooling offperiod for cosmetic patients, between patients beingseen in outpatients and a procedure taking place. Thisallowed the patient time to decide whether to have acosmetic procedure and allow them time to ‘cool off’.This is in line with national guidance from the GeneralMedical Council and British Association of Aesthetic andPlastic Surgeons.

Are surgery services caring?

Good –––

We rated caring as good because:

• Staff were caring and compassionate to patients’ needs.Patients spoke highly of the care they had received.

• Patients and relatives told us they received a goodstandard of care and they felt well looked after bynursing, medical and allied professional staff.

• We saw examples of staff taking measures to ensurepatients’ privacy and dignity were respected.

• All patients we spoke with felt informed about their careand treatment.

• Consultants visited patients’ throughout the day andwere available to answer any questions they had.

• Information was shared with patients and their relativesand opportunities to ask questions.

• The friends and family score were consistently between97% and 99% of patients that would recommend thehospital.

• PLACE (Patient Led Assessment of the CareEnvironment) score for 2016 for dignity and respect was83%, which was in line with the national average of 84%.

Compassionate care

• Staff took measures to ensure patients’ privacy anddignity, for example, patient room doors were closedunless patients wanted them open. Patients told us thatthey were treated with compassion, dignity and respectduring their hospital stay. The PLACE score for ensuringpatients were treated with privacy and dignity was 83%,which was in line with the national average of 84%.

• Patients we spoke with told us that staff treated themwith respect.

• Staff responded compassionately to pain, discomfort,and emotional distress in a timely and appropriate way.

• Patients told us call bells were answered promptly, thatstaff were kind and caring and they would be happy fortheir family to come to the hospital for treatment.During our inspection call bells were being answeredpromptly.

• We saw that nursing staff introduced themselvesappropriately and knocked on the door of side roomsbefore entering.

• We received positive comments from the patients wespoke with about their care. Examples of theircomments included “staff are caring and thoughtful”,“Staff always tell you who is looking after you and arevery attentive” and “nurses made me feel at home, theytalk about home life and are interested in me”.

• Patient feedback from comment cards includedcomments such as: ‘staff were very welcoming, politeand helpful’ and ‘I felt supported and treated withdignity and respect at all times’.

• Patient satisfaction survey results for July 2016 showed83% of all patients rated the care and attention receivedfrom nursing staff as excellent, with 14% of all patientsrating it as very good.

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• The friends and family survey results from July 2015 toJune 2016 showed that between 97% and 99% ofpatients would recommend the hospital to family andfriends. The response rates were similar to the Englandaverage at 34%.

Understanding and involvement of patients and thoseclose to them

• Patients said they felt involved in their care. Patients andrelatives had been given the opportunity to speak withthe consultant looking after them.

• Patients said the doctors had explained their diagnosisand that they were fully aware of what was happening.None of the patients had any concerns regarding theway they had been spoken to. All were verycomplimentary about the way they had been treated.

• Consultants visited their patients throughout the dayand were available to answer any questions they had. Inaddition, they informed patients what to expect andtheir plan of treatment.

• We observed the care of one patient in theatre. Staffintroduced themselves to the patient and gaveinformation on what would be happening and what toexpect.

• The hospital had open visiting this meant that patientscould be supported by friends and family.

Emotional support

• Staff spent time with patients and families and wereable to provide emotional support.

• Patients and those close to them were able to receivesupport to help them cope emotionally with their careand treatment.

• One patient who had recently suffered bereavementtold us that staff were compassionate caring and spenttime with them during their in-patient stay.

• Staff showed an awareness of the emotional and mentalhealth needs of patients and were able to refer patientsfor specialist support if required.

• There was information available to staff on how tocontact members of the clergy to meet patients’different spiritual needs.

Are surgery services responsive?

Good –––

We rated responsive as good because:

• Service planning met the needs of the local people andthe community.

• The booking system for patients offered flexibility.• The admitted referral to treatment times (RTT) for NHS

patients were being met.• Access and discharge arrangements were effective.• All areas were accessible to patients with mobility

problems.• There was support for people with a learning disability,

and reasonable adjustments were made to the serviceprovided.

• Arrangements were in place to support patients livingwith dementia.

• The Medical Advisory Committee (MAC), the clinicalgovernance committee and the patient experience andcomplaints committee reviewed all complaints. Actionsand learning from complaints was shared with all staff.

• Written information on medical conditions, procedures,and finance was available.

• The service ensured there was a two week cooling offperiod between patients agreeing to undergo cosmeticsurgery and the surgery being performed.


• The service understood the different needs of thepeople it served and acted on these to plan, design anddeliver services, for example disabled toilets wereavailable, and there were wet rooms and showers thatwere easily accessible to accommodate wheelchairsand patients with walking aids.

• The booking system was flexible, allowing patientswhere possible to select times and dates for treatmentto suit their family and work commitments.

• The hospital had a good relationship with the local CareCommissioning Groups (CCG) for planned proceduresand a good relationship with the local trust whichenabled them to work together to manage waiting lists.

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• The hospital had an admissions policy which detailedthe criteria for NHS patients that could be safely treatedat the hospital. These criteria had been agreed with theCCG that commissioned NHS care at the hospital.

• Consultants had planned, dedicated theatre lists. Thisenabled patients to be booked onto these lists. Inaddition, staff with specific skills and competencies tomeet the needs of the patients could be allocated toparticular theatres, for example staff that could assistwith ophthalmic surgery.

• The environment and facilities were appropriate andrequired levels of equipment were available.

Access and flow

• The hospital’s pre admission policy and local contractsensured that all patients were seen at the pre-operativeassessment clinic. This meant that patients who hadco-existing conditions were identified, so that anypre-operative work, for example blood tests, could bedone. This minimised unnecessary cancellations.

• Staff began planning the patient’s discharge during thepreadmission process where they gained anunderstanding of the patient’s home circumstances anddaily care needs.

• The hospitals admitted referral to treatment timeswithin 18 weeks for NHS patients were being met. RTTmonitors the length of time from referral through toelective treatment; the national average was 90%. FromApril 2015 to March 2016 the hospital exceeded thenational average and on some occasions this was 100%.


• Services were planned to take into account theindividual needs of patients.

• All patients completed a medical questionnaire that wasreviewed by the pre assessment nurses. Some patientsrequired a face to face appointment; other patients hada telephone assessment dependant on their individualneeds.

• Patients discharge plans took account of their individualneeds, circumstances, and ongoing care arrangements.For example one patient we spoke with said they had allthe equipment ready at home to assist with recoverysuch as a toilet raise and walking aids.

• All areas were accessible to patients and relatives whohad problems with mobility.

• An interpretation service was available to patients whodid not speak English and staff were aware of how toaccess it.

• Staff we spoke with had attended dementia training andhad an awareness of the needs and challenges patientsliving with dementia faced.

• There was an opening visiting policy at the hospital. Thismeant that patients could be supported by their lovedones during consultations and loved ones could askquestions about their treatment and care.

• The service ensured there was a two week cooling offperiod between patients agreeing to undergo cosmeticsurgery and the surgery being performed. The cosmeticnurses would carry out a pre-assessment on all patientbooked for cosmetic surgery and ensure the two weekcooling off period was adhered to.

• Patients felt they were given appropriate writteninformation on what to expect from their care andtreatment.


• Spire Healthcare had a corporate complaints policy thatdirected the management of complaints and associatedtimescales. Complaints were handled effectively andconfidentially.

• Staff were aware of how to deal with complaints, theywould try to resolve the issue if they could. If they couldnot resolve the complaint, they told us that they wouldreport the patient’s concerns to a senior member ofstaff.

• There was a ‘Please talk to us’ leaflet that explained howa patient could make a complaint. Guidance was alsoavailable on the hospital website.

• There was a dedicated complaints lead that updatedeach complaint regarding its current status or outcome.This information was shared at weekly managementmeetings. The hospital director, the matron, MedicalAdvisory Committee (MAC) and clinical governancecommittees reviewed all complaints. We saw evidenceof actions taken as a result of complaints. These wereshared with individual departments via team meetings.For example complaints about lack of communicationwas discussed at staff meetings and the implementationof hourly intentional rounding, which ensured eachpatient was visited by a member of staff every hourwould assist with regular communication.

• The hospital had received 126 complaints from April2015 to March 2016 which was a slight decrease of three

Surgery

Surgery

Good –––


from 2014/15. We saw that between April 2015 andMarch 2016 they responded to 66% of complaints within20 days. The organisation undertook an external reviewof their complaints process in September 2015 anddeveloped an action plan to improve their performancein this area. The hospital’s quality report for April 2016 toJune 2016 showed that they had exceeded their targetand had closed 85% of complaints within 20 days. Therewas a patient forum and complaints committee in placeto help manage and learn from complaints.

• The Care Quality Commission had received fourcomplaints about the service during 2015/16. Therewere no trends identified and the hospital responded tothe complainants promptly.

• Staff were aware of outcomes from complaints, actionstaken or lessons learnt.

• Staff were able to identify changes made as a result ofconcerns reported. One example was complaints aboutthe charges made for procedures. Action taken includedprinting the information on the registration form and onposters in the outpatient department and booking staffto explain the charges. The consultant medicalsecretaries had also been made aware of the chargesystem.

Are surgery services well-led?

Good –––

We rated surgical services good for well-led because:

• The hospital had a clear vision in place to deliver goodquality services and care to patients.

• We saw strong leadership, commitment and supportfrom the ward and theatre managers.

• Hospital senior managers were visible, approachableand supportive.

• There were comprehensive risk registers for the wholehospital.

• Staff told us that if incidents took place, they wanted tobe open and transparent with patients about anyfailings.

• The culture of learning from incidents was promotedamongst staff, and they told us they were encouraged toreport incidents.

• Staff could raise concerns or share ideas and feel thatthey were listened to.

• Staff were enthusiastic about working at the hospitaland felt valued and respected.

• The hospital gained feedback from both patients andstaff.

However we found

• The senior hospital management had not takenreasonable practicable action to provide a safe servicefor children and young people. The hospital staff did nothave access to a registered nurse (child branch) andchildren’s services were not discussed at any meetings.

Leadership/culture of service related to this coreservice

• The hospital was led by a senior leadership team whichconsisted of the hospital director, the matron/head ofclinical and non-clinical services, finance andcommercial manager, theatre manager and businessdevelopment manager. The ward and pharmacydepartments had a designated clinical head ofdepartment.

• Leadership within the surgical services reflected thevisions and values of the hospital and promoted goodquality care.

• We saw strong leadership, commitment and supportfrom the hospital management team. The senior staffwere responsive, accessible and available to supportstaff.

• Staff told us that the hospital director and matron werehighly visible and very approachable, providingassistance when required, they felt able to escalate anyconcerns.

• Staff reported that their direct line managers weresupportive and kept them informed of day to dayrunning of the departments.

• The heads of department were positive about theservices offered and the level of care provided.

• The nursing team, theatre team, physiotherapy teamand administration team communicated well togetherand supported each other.

• Staff were enthusiastic about working at the hospitaland how they were treated by them as a whole. Theyalso felt respected and valued.


• There was a clear Spire Healthcare vision and a set ofvalues. Quality and safety were the top priority.

Surgery

Surgery

Good –––


• Staff were aware of the overall hospital vision, whichwas, ‘To be outstanding in all things, be the number onechoice for all patients, value and invest in staff, providehigh quality and efficient patient experience and workwith GPs and consultants to deliver clinical excellence’.

• The hospital had a clear vision to expand services bothon site and off site over the next five years, commencingwith expanding outpatients.


• A governance framework was in place to monitorperformance, which reported to the Spire Healthcareboard. All committees had terms of reference whichaccurately reflected their role in the hospital, theirstructure and purpose.

• Clinical effectiveness and audit meetings were attendedby departmental leads, matron/head of clinical andnon-clinical services and the clinical governance andrisk manager. These committees monitored anddiscussed a range of hospital issues such as safetyalerts, shared learning from incidents, policy updatesand reported to the clinical governance committee (CG).

• The CG committee met quarterly. The hospitalsubcommittees reported into the CG committee andtherefore this committee had an overview ofgovernance, risk and quality issues for all departments.Senior department leads attended these meetings andwere responsible for cascading information back to theirdepartment.

• Although a lead paediatric consultant was a member ofthe medical advisory committee (MAC), children andyoung peoples’ service was not a set agenda item.Children and young peoples’ services were discussed atthis committee when relevant. This was raised withsenior managers during our inspection. During ourunannounced inspection on 4 August, we were told thatboth the lead paediatric consultant and the leadanaesthetist would be the representative at MAC forchildren’s services and this would be included on theagenda.

• The senior hospital management had not takenreasonable practicable action to provide a safe servicefor children and young people. The hospital did nothave access to a registered nurse (child branch)available to advise or manage the care and treatment ofchildren and young people. The hospital had stoppedoffering surgical services to children aged under 16

years of age in January 2015. During our unannouncedinspection on 4 August we were told that registerednurses (child branch) had been recruited to the bankand would be on duty when children attendedoutpatient clinics, to assist with risk assessments andpre-operative assessments for young people aged 16-18years and would work on the ward if required.

• The role of the MAC included supporting the hospitalsenior managers to ensure that all consultants wereskilled, competent and experienced to perform thetreatments undertaken. Practising privileges weregranted for consultants to carry out specifiedprocedures using a scope of practice document, thesewere reviewed annually. Registration with the GeneralMedical Council (GMC), the consultants’ registration onthe relevant specialist register, DBS check andindemnity insurance were all checked by the hospitaland ratified by the MAC. An email was automaticallygenerated to remind a consultant if for example theirappraisal or indemnity was overdue or expired. Ifconsultants failed to respond to the reminder theirpractising privileges were suspended.

• There was a clear policy about the introduction of newtechniques. Applications were reviewed with the localMAC and corporately to ensure the supporting evidencewas sufficient to ensure the safety and effectiveness ofthe procedure.

• The hospital had completed local as well as nationalaudits. For example, a regular audit had beencompleted to ensure that compliance with the VTEassessments was monitored and acted upon in line withthe hospitals policy and national standards.

• Audit reports were reviewed locally at clinicalgovernance meetings and MAC and results shared withstaff through the heads of department. We saw evidenceof this in the meeting minutes.

• We reviewed the hospital risk register and noted therewere risks identified for each department. Each risk hadcontrol measures and an identified owner. Risksincluded for example inadequate control to ensure fullpatient records are always available, control measureincluded policy in place to ensure records are availableand audits, inadequate storage space on both the wardand theatres control measure included a review of stockand moving equipment to ensure space is available, andlack of bariatric equipment on the ward, control

Surgery

Surgery

Good –––


measure included bariatric patients to be closelymonitored by staff, risk assessments, audit of bariatricpolicy and develop a business plan for additionalequipment.


• There were a number of methods of communicatingwith staff, such as, the newsletter ‘Bushey Tales’, emailsand team meetings as well as information on computerscreen savers and the hospital social network page.

• The hospital sought feedback from patients, both thosewho were funded privately or by the NHS. Monthlyfriends and family test results were collected. Thefriends and family test is a survey designed for NHSpatients to gauge feedback from patients about thequality of service and whether patients wouldrecommend the service to their friends and family. Thehospital also conducted its own survey for privatepatients. Both sets of results were consolidated into amonthly report and were discussed at clinicalgovernance and effectiveness meetings.

• There were various methods to engage with staff suchas a communication folder in the staff restaurant,monthly tea with the senior manages and staff eventssuch as charity music quiz and hospital parties.

• All new overseas members of staff have a buddy whohelps them get settled in the local community.

• The hospital conducted annual staff surveys in line withorganisational policies. The top five results from SpireBushey 2015 staff survey included 97% of staff reportingthat they believed that the work that they did made apositive difference to the hospital and 95% of staffreporting that their manager trusted them to make theright decisions at work. An action plan had beendeveloped to address the five lowest scoring resultswhich included 49% of staff reporting that otherdepartments did not understand the impact theiractions had on other teams and 32% of staff felt thatthere were not sufficient numbers of staff to meet thedemands of the service. We saw that the action planinvolved developing opportunities for all departmentsto attend regular meetings.


• The hospital had plans to expand all services on site andoff site and had funding agreed, this includedout-patient services and in patient services.

Surgery

Surgery

Good –––


Safe Requires improvement –––

Effective Not sufficient evidence to rate –––




Information about the serviceSpire Bushey hospital provides a range of outpatient anddiagnostic imaging services for privately funded,self-paying and NHS patients including children aged twoto 18 years. The out patients and diagnostic imagingservice was arranged over three floors with access betweenthe levels via lift or stairs. There was no dedicatedpaediatric outpatient facility however; there were threededicated paediatric clinics weekly and the remainder ofthe time children under the age of 18 were seen in mixed,adult and children, clinics.

The outpatient services offered included: orthopaedics,neurospinal surgery, gynaecology, general surgery, urology,oncology, ear, nose and throat (ENT), ophthalmology,gastroenterology, interventional radiology, cardiology,respiratory medicine, nephrology, dermatology,endocrinology, audiology, clinical neurophysiology,dietetics, haematology, neurology, oral & maxillofacial, paincontrol, plastic surgery, podiatry, psychiatry, radiology,rheumatology. Specialist services included bariatric, sportstherapy, sports medicine and speech therapy.

The outpatient department (OPD) is across three floors.The main OPD reception area is on the lower ground floor.The physiotherapy department, CT scanning and MRIscanning departments are also on the lower ground floor,each with their own smaller waiting areas, changing roomsand booking in desks.

The main OPD area is on the ground floor, with 16consulting rooms, two treatment rooms, one minoroperations room, phlebotomy room and the main waitingarea along with a small booking in desk.

On the first floor, a further 3 consulting rooms are situatedin the cardiac department, which also has specialisedequipment to aid in the diagnosis and treatment of cardiacand respiratory disorders

The diagnostic imaging service offers computerisedtomography (CT) scanning, magnetic resonance image(MRI) scanning, non-obstetric ultrasound scanning, x-ray,digital mammography and orthopantomogram (OPG). Themain imaging department with X-ray, mammography andultrasound is on the first floor.

The physiotherapy department has eight treatment rooms,a hydrotherapy pool with two changing rooms and agymnasium.

The clinical neurophysiology department has separateequipment to aid in the diagnosis of complex neurologicalconditions.

Pathology services were provided offsite at Spire pathologyservices and also at a number of locations across theUnited Kingdom.

In total, there were 87,022 attendances at outpatients,including 7,177 under 18 year olds, from April 2015 to March2016. Of the total number of attendances, 4% were NHSpatients and 96% were privately funded patients.

During the inspection, we spoke with 16 members of staffincluding a doctor, nurse, radiologists, housekeeper,engineer, administrators and physiotherapists. We spokewith seven patients and we reviewed six patient medicalrecords.

We visited the outpatient department reception; treatmentareas and waiting rooms, the diagnostic imaging


Outpatients and diagnosticimaging

Good –––


department; treatment areas and waiting rooms, thephysiotherapy department and the hydrotherapy pool; thetreatment rooms and the waiting areas. We visited thecardiac centre, waiting area and the treatment rooms.

Summary of findingsCaring, responsive and well-led we rated as good. Safewe rated as requires improvement. This led to an overallrating of good.

We inspected outpatients and diagnostic imaging foreffectiveness but it was not rated.

We found:

• Staff identified and addressed safety concerns. Staffwere clear with regards to the process to reportincidents and were fully aware of the Duty ofCandour regulation.

• There was good evidence of learning from incidents.• There were good infection control procedures in

place and the areas we visited were visibly clean.• Staffing levels were appropriate for the service

provision with minimal vacancies.• Staff were suitably qualified and skilled to carry out

their roles effectively and in line with best practice.• Staff delivered patients’ care and treatment following

local and national guidance for best practice.• Staff obtained patient consent before care and

treatment was given.• Safeguarding systems were in place and staff knew

how to respond to safeguarding concerns.• The hospital management team planned and

delivered services in a way that met the needs of thelocal population. The importance of flexibility, choiceand continuity of patient care was reflected in theservices. Patients could access the right care at theright time.

• The imaging department planned and delivered careand treatment in line with current evidence-basedguidance, standards and best practice. Staff had theright qualifications, skills, knowledge and experienceto do their job.

• Staff were supported to participate in training anddevelopment.

• Multi-disciplinary teams worked well together toprovide effective care.

• Referral to treatment times were in line with thenational average and patients could makeappointments easily and quickly when required.

• Patients were positive about the way staff treatedthem in all outpatient and diagnostic areas.



Good –––


• There were toys and books in the waiting areasspecifically for children when they attendedoutpatients, physiotherapy or diagnosticsappointments.

• Information on how to raise a concern or complaintwas available for patients. The hospital complaintslead took complaints and concerns seriously andresponded to them in a timely manner.

• A patient forum was implemented in response topatient feedback. The forum consisted ofself-funding patients that had previously used thehospital services with a representative from seniormanagement. The forum met to discuss possibleimprovements and the patients’ perspective on howservices were provided.

• Staff had knowledge regarding the vision for thehospital. There was good staff satisfaction. Staff feltsupported and valued. There was a strong culture ofteam working across the areas we visited.

However we also found,

• Staff who were responsible for potentially assessing,planning, intervening and evaluating children’s carein outpatients, did not all have the correct level ofsafeguarding children training.

• The hospital did not employ or have access to aregistered nurse (child branch), that was availablewhen children attended the hospital.

• Carpets in treatment rooms and some hand washbasins were non-compliant with health buildingnotice (HBN) regulations.

• Medical notes were not always available for staff whowere treating patients in the department

Are outpatients and diagnostic imagingservices safe?


We rated the outpatient and diagnostic imaging service asrequires improvement safe because:

• The hospital did not employ or have access to aregistered nurse (child branch) when children attendedthe hospital. This did not comply with nationalguidance.

• Staff caring for children young people aged between2-18 years of age were not always trained to level 3 insafeguarding.

• One consultant brought in his own mobile ultrasoundmachine to use in clinics which did not comply withhospital policy. The manager was unable to evidencehow this was cleaned and maintained.

• Carpets in treatment rooms and some hand washbasins were non-compliant with infection controlguidance and Health Building Notifications (HBN).

• Some medical notes were not always available for staffwho were treating patients in the outpatientsdepartment.

However we found,

• Staff knew how to report incidents and there was goodlearning from incidents.

• All the staff we saw were abiding by the arms bare belowthe elbows policy.

• Equipment was up to date and clean, processes were inplace to ensure it was well maintained.

• Medicines and records were stored securely.• There were safeguarding policies and procedures in

place and staff were familiar with them.• There was good evidence of learning and feedback from

incidents.• Staff maintained high levels of mandatory training. All

areas had local induction programmes in place tosupport new staff.

• Staffing levels ensured the needs of patients were metwith little use of agency staff.

Incidents



Good –––


• All the staff we spoke with knew how to report incidentson the electronic incident reporting system and couldexplain what incidents they would report.

• A clinical governance and risk manager was in place tooversee all incidents within the hospital, alongside thehead of clinical and non-clinical services. Incidents werediscussed at senior management meetings, clinicalgovernance meetings and there were monthly adverseincident meetings. If necessary, an incident would alsobe discussed at speciality meetings including medicinesmanagement committees. Following these meetingsfeedback would then be disseminated to staff inoutpatients and radiology.

• There were 74 clinical incidents in outpatients anddiagnostic imaging between April 2015 and March 2016.This was comparable with similar independent acutehospitals.

• There were 38 non-clinical incidents reported during theperiod April 2015 to March 2016, this was higher thanother comparable independent acute hospitals.

• There were no never events reported for outpatientsduring the period April 2015 to March 2016. Never eventsare “serious patient safety incidents that should nothappen if healthcare providers follow national guidanceon how to prevent them. Each never event type has thepotential to cause serious patient harm or death butneither need have happened for an incident to be anever event.”

• We saw evidence of learning from incidents. Staffexplained how the changing area, lighting and grab railsin the hydrotherapy pool had been improved as a resultof an incident investigation after a patient had fallenand new checks had been introduced to the labelling ofblood samples leading to a reduced number of rejectedsamples.

• We saw minutes of team meetings detailing incidentsand their outcomes. This assured us there was goodfeedback and learning from incidents.

• From 1 April 2015 all independent healthcare providerswere required to comply with the Duty of CandourRegulation 20 of the Care Quality Commission(Registration) Regulations 2014. The Duty of Candour isa regulatory duty that relates to openness andtransparency and requires providers of health and socialcare services to notify patients (or other relevantpersons) of certain notifiable safety incidents andprovide reasonable support to that person.

• All the staff we spoke with understood the Duty ofCandour but told us they had never had to apply it to acomplaint or incident.

• The diagnostic imaging manager was aware of theirresponsibility regarding Ionising radiation (medicalexposure) regulations IR(ME)R and there were policiesand guidelines for the diagnostic imaging departmentdeveloped in line with IR(ME)R

• The imaging department had an agreement with aradiation protection advisor (RPA) from anotherhealthcare provider who carried out equipment checksyearly or when required to do so.


• All the areas we visited were visibly clean and free fromdust.

• All the staff we saw were abiding by the arms bare belowthe elbows policy and we saw a doctor remove hiswatch, tuck in his tie and wash his hands before hetouched the patient.

• There was sanitiser hand gel in dispensers throughoutthe OPD and posters were displayed encouragingvisitors to the department to sanitise their hands.

• Personal protective equipment in the form of gloves andaprons was available and we saw staff using thesecorrectly.

• Cleaning throughout the outpatient and diagnosticimaging department was by a team of housekeepers ona daily basis but staff wiped down equipment betweenpatients using disinfectant wipes.

• Staff informed us that they cleaned any couches andphysiotherapy equipment using antibacterial wipesafter each patient.

• Staff explained the procedure for dealing with patientswith communicable diseases. Patients were given thelast appointment of the day to reduce contact withother patients. Staff gave the areas the patient hadvisited a deep clean once the patient had left thedepartment.

• Hand hygiene audits were completed routinely everytwo months and we saw there was good compliance,and the usage of hand gel dispensers were auditedevery two months. April 2015 to December 2015 therewas an overall compliance of 95% - 100%.

• The house keeping department carried out routinecleaning audits along with spot checks and domesticsupplies cupboard audits.



Good –––


• Mattresses were audited annually for their state of repairand any which were stained or torn were replacedimmediately. The house keeping manager told us thatall taps were turned on daily to flush the water as apreventative measure of legionella build up.

• Fabric curtains in the consulting rooms were steamcleaned annually and housekeeping replaceddisposable ones every three months. The dates we sawon a curtain confirmed this.

• We saw some of the consulting rooms in thedepartment were carpeted, which does not comply withhealth building notice (HBN) regulations. Managementhad identified this as an infection prevention control riskand we saw the action plan for replacement of thecarpets with vinyl flooring. The refurbishment wasscheduled to be completed by September 2016.

• The carpets were visibly clean but we did not review anycarpet cleaning schedules.

• Clinical hand basins were not provided in consultationrooms when the hospital was built. This did not complywith current Health and Building Notice (HBN) 009(2013). been identified and were due for replacement aspart of a rolling plan of refurbishment expected to becompleted by September 2016.

• The flooring in the OPD disabled toilet was not HBNcompliant as it did not have a continuous returnbetween the floor and the wall meaning effectivecleaning could be difficult. This was not identified onthe refurbishment plan or on the risk register.


• One consultant brought in his own mobile ultrasoundmachine to use during his clinics. At our initialinspection the OPD manager was unable to evidencehow this was cleaned and maintained. When werevisited in December 2016 the hospital had developeda process for checking the equipment for servicing andmaintenance but we were not assured about the safetyof the equipment and how this was stored in-betweenclinics.

• The outpatient reception was tidy and uncluttered.When patients arrived staff directed them to the relevantwaiting area where they entered a second receptionarea.

• We found signage throughout the department to beclear and easy to follow.

• There were clear warning signs in areas where ionisingradiation and magnetism was used.

• The physiotherapists tested the water in thehydrotherapy pool three times a day to measure theacidity or alkalinity, chlorine levels and cleanliness ofthe water. We saw the completed daily checklists. Thephysiotherapists flushed the pool filter on a weeklybasis; we saw evidence of this in completed records. Anoffsite company tested the water microbiology once aweek. On site engineers were called if any parameterswere found to be out of range. We did not see any out ofrange parameters.

• Staff told us that there were no difficulties in purchasingnew equipment if it was required. The outpatientsdepartment had just acquired a new pulse oximeter. Apulse oximeter is a mobile piece of equipment whichmeasures the amount of oxygen in a patient’s blood bybeing attached to a patient’s finger.

• The hospital had recently acquired a new magneticresonance imaging (MRI) scanner able to producedetailed images of every part of the body in less than 60minutes.

• A second, mobile MRI scanner was available onSaturdays to help keep waiting times down.

• The hospital CT scanner enabled high quality images tobe obtained using lower than normal doses of radiation.

• We saw equipment throughout the department hadbeen cleaned and “I am clean” stickers had beenapplied. We also saw that the equipment was clean.

• We saw that diagnostic equipment maintenance wascarried out under contract with an external engineeringcompany and the equipment manufacturer in the caseof the MRI scanner. Safety testing had been carried outfor all electrical equipment.

• Risk assessments of radiation equipment wereperformed by the radiation protection supervisor (RPS)with support from the radiation protection advisor(RPA).

• Radiographers told us about the protective gownsprovided to parents or carers who were required tosupport patients during CT or MRI.

• Physiotherapy staff told us they closed the blinds in thehydrotherapy pool area when the pool was in use toprevent patients being visible from the car park andprotect their privacy and dignity. However, from the carpark, we could see directly into the hydrotherapy pooland saw a patient entering the pool with the support ofa physiotherapist. We raised this during our inspectionand this was rectified immediately. During theunannounced inspection on 4 August we saw the blinds



Good –––


were fully drawn and we could not see directly into thehydrotherapy pool from the car park. Staff recognisedthis was a privacy and dignity issue and discussed plansto use mirrored glass or tinted windows to address this.

• We looked at the resuscitation trolley stored in the mainOPD reception. We found it to be well stocked withequipment for adults and children. We saw the dailycheck list was completed thoroughly. However, some ofthe items in the trolley were not being stored in sterilepackaging and one of the carbon dioxide (CO2)detectors was out of date. We raised these issues withthe physiotherapy department manager who replacedthe items immediately.

• We saw staff used a treatment room to store equipmentdue to lack of suitable storage space. Staff told us theymoved the equipment into a room which was not beingused, when the room was to be used. We saw a lack ofspace had been identified on the risk register.

• We saw waste was segregated with domestic waste inblack bags, infectious waste in orange bags and sharpsinto yellow sharps bins as per hospital policy. We sawused sharps bins were being stored in an unlockedroom prior to collection and disposal, this is not only ahealth and safety issue, but also contravenes theEuropean Waste Directive which states that all binswaiting collection must be stored in a locked room or ina waste truck in a designated locked compound. Weraised this with the outpatient manager during ourinspection. We visited this room on our unannouncedinspection on 4 August and found the door was lockedwith a key code pad and only unused sharps containerswere being stored.

Medicines

• The hospital had a pharmacy on site that provided dailycover between 8am and 5pm. Nursing staff reportedthat the pharmacy team were available to offer supportand advice to both staff and patients and dispensedoutpatient prescriptions.

• The diagnostic and imaging clinical lead showed us howcontrast media used in diagnostic imaging was kept inlocked fridges with the keys to the fridge stored in a keysafe which was accessed by a code.

• Contrast media was prescribed by radiologists.Radiographers, who had received training and had theircompetency assessed, were able to administer contrastmedia. Blood tests to ensure good kidney function werecarried out before the contrast was administered.

• In outpatients, medicines were stored in a lockedcupboard in the treatment room and the keys were keptwith the nurse in charge. There were no controlled drugsstored in the outpatient department. We checked themedications and found them to be in date with a goodsystem of stock rotation in operation.

• We saw daily checklists of fridge and warmertemperatures were completed.

• The hospital did not use FP10 prescription forms. OnlySpire Bushey prescription sheets (private prescriptions)were used, these were recorded in a prescriptions bookand all medications were dispensed by the onsitepharmacy.

• The diagnostic and imaging clinical lead told us thatsedation was not offered to patients undergoingdiagnostic imaging.

Records

• The hospital did not have a robust system to ensurepatient notes were always available. The informationprovided by the hospital prior to our inspection statedthat: “Not all the patients that come to the nursesdressing clinic have their notes available but patients donormally bring a copy of their discharge letter so thenurses know what to do”. Following an appointment at anurse-led clinic, nursing staff recorded specific details ofthe patient’s procedure on an outpatients appointmentrecord note taking template; these sheets of paper werelater inserted in to the patient’s medical records.

• We reviewed six sets of patient medical records andfound that in four of them it was recorded on theoutpatient appointment record template: “Did not haveconsultant notes available (for reference at the time ofattending an outpatient appointment)”, one had “notesavailable” and one did not mention if notes wereavailable or not. We asked the administration managerabout the availability of notes for patients attending theOPD but were unable to get a satisfactory answer. Weraised this with the senior hospital managers who toldus that a review of patient notes was underway toensure a complete set of notes would be available whenpatients attended the OPD, this was also on the hospitalrisk register.

• Nurses could access information regarding date andtype of surgery from the computer system and liaisewith the ward if necessary to assess patients’ needs anddressing changes required.



Good –––


• Consultants seeing patients in the department had theirown notes. If patients were seen as an emergency, theconsultant’s secretary would fax over a copy of the lastclinic notes or GP letter so that the consultant had notesavailable.

• Consultants were in the process of implementing anelectronic records storage system for all patients’ notesto improve access to patient notes.

• Consultants had access to the picture archivecommunication system (PACS), and this was availableon computers in all consulting rooms so previous x-rayand scan images could be viewed quickly and easily.

• All pathology results were available online althoughmany consultants used the hard copy of reports sent bythe laboratory.

• The diagnostic and imaging lead described to us howpatients could have their images stored on anencrypted compact disc for them to take away, if theyrequired to share this with another hospital.

• The physiotherapy department used electronic recordsfor patient notes and were one of the only Spirehospitals nationally to do so. This meant patient recordswere always available and up to date.

• The hospital kept records of breast implants used foreach patient to ensure traceability should there be aproduct recall or issues identified with specific implants.The Breast and Cosmetic Implant registry was not yetavailable nationally at the time of inspection.

Safeguarding

• The hospital had safeguarding policies available on theintranet, including how to manage suspected abuse andout of hours contact details for hospital staff.

• Staff received training on safeguarding throughelectronic learning and had a good understanding oftheir responsibilities in relation to vulnerable adults andchildren. Data received from the hospital stated that100% of all staff working in outpatients had receivedsafeguarding training to level two for both adults andchildren.

• Staff were able to explain how to raise a safeguardingconcern. Posters were displayed in the departmentadvising staff how to respond to a safeguarding issue,including contact details of the safeguarding leads.

• Staff who were caring for children young people agedbetween 2-18 years were not always trained to levelthree in safeguarding. Although we saw no evidence of a

failure to safeguard children, we were not assured thatall staff who had contact with children or young peoplehad received the appropriate level of safeguardingtraining. The provider should ensure that a process is inplace to ensure clinical staff working with children,young people and/or their parents/carers and whocould potentially contribute to assessing, planning,intervening and evaluating the needs of a child or youngperson and parenting capacity where there aresafeguarding/child protection concerns has receivedtraining to the appropriate level of competency asoutlined in the Intercollegiate guidance SafeguardingChildren.

• All the staff we spoke with had undertaken safeguardingtraining of vulnerable adults and children at level two.Although there was some confusion among the staffwith regarding the level of safeguarding training theyhad undergone and whether it was adult or children. Sixmembers of staff in the OPD were working towardschildren safeguarding level three. Clinical staff andconsultants had training planned for the future forchildren’s safeguarding level three. The aim was toensure that all clinical staff would complete children’ssafeguarding level three training. The matron hadcompleted children’s safeguarding level three and couldoffer advice to staff as required. The matron and OPDManager, who was also the hospital Safeguarding Lead,was planning to complete children’s safeguarding levelfour

• The outpatient manager was the lead for both adult andchildren safeguarding and had undertaken childrensafeguarding level three training. The physiotherapymanager and the diagnostic imaging manager also hadchildren safeguarding level three training along with fiveother physiotherapists.

• Three members of staff in diagnostic imaging had levelthree children safeguarding training. One radiologisthad children’s safeguarding level three training.

• On our follow up inspection we found twophlebotomists were undergoing level three childrensafeguarding and there was additional training plannedfor all staff that were caring for children and youngpeople.

• The hospital had a policy relating to safeguardingaround female genital mutilation (FGM) and posterswere displayed advising staff what to do if FGM wassuspected.



Good –––


Mandatory training

• The staff we spoke with had received mandatorytraining by e-learning and face to face on a variety oftopics including but not limited to incident reporting,safeguarding, manual handling, information governanceand health and safety. All areas had local inductionprogrammes in place to support new staff.

• Staff told us that managers were supportive of themtaking time to complete their training.

• We observed the training records for OPD staff and sawthey were all up to date and 100% compliance.

• In the physiotherapy department we saw 100%compliance with mandatory training.

• In MRI department we saw electronic training records for32 staff, there was 100% compliance with mandatorytraining.


• The hospital had a policies and guidelines for thediagnostic imaging department which included detailson “local rules”, radiation protection supervisors (RPS)and radiation protection advisors (RPA) in line withionising radiation (medical exposure) regulations(IR(ME)R)

• The diagnostic imagining department manager was theradiation protection supervisor for the diagnosticimaging department

• The hospital had a policy on the requesting ofdiagnostic imaging by physiotherapists called:‘procedure and guidelines for physiotherapistsrequesting diagnostic MRI and plain film x-rays.’

• The imaging manager informed us that staff alwaysasked patients if they had undergone an x- ray recently.If the previous x- ray was relevant diagnostic imagingstaff could obtain it electronically to avoid the patientbeing over exposed to radiation.

• Women of childbearing age were asked if there was anychance of them being pregnant and procedures weredelayed until there was a definitive “no” if they wereunsure. We saw a radiographer confirming with a femalepatient that she was not pregnant before they began theprocedure.

• The radiology department had clear processes in placeto ensure that the right patient received the correctradiological scan. Staff used a PAUSED guidance thatencouraged staff to pause and follow a checklist prior toproceeding. The PAUSED checklist includes, checking

with the patient details verbally, confirming the correctsite to be x-rayed/scanned, confirming the examinationis on the right date and the right time, selecting thecorrect imaging protocol, recording the dose ofexposure, ensuring images are stored correctly andinforming the patient on how they can get the results.

• Staff asked patients who had had contrast administeredto wait in the department for half an hour so the staffcould monitor them for any potential side effects.

• Administration staff in the cardiac department told us ofa number of occasions where cardiac physiologists hadarranged for patients to be transferred to the local NHShospital after assessments had shown they were unwell.

• We saw the hospital critical care transfer policy whichstated that in the event of an emergency in outpatientsfor adults or children, 999 would be called.

Nursing staffing

• There is no national baseline acuity tool for nursingstaffing in outpatients. The outpatient manager told usthat four staff, two registered general nurses (RGN) andtwo health care assistants (HCA) was safe staffing foroutpatients on a daily basis and this was based on theirexperience and professional judgement.

• During our inspection there were two RGNs, two HCAsand three supernumerary HCAs on shift. Staffing levelswere adequate to meet the needs of patients and therewas an appropriate skill mix including HCAs, registerednurses and administration staff.

• There were no unfilled shifts for the period January 2016to March 2016.

• We reviewed the staff rota for outpatients and saw allshifts were full. The rota for staffing on day one ofinspection stated two RGN and three HCA, and this waswhat we saw.

• The service used a mix of nurses, allied healthprofessionals and health care assistants, all who werecompetent to carry out their specific roles.

• At the time of our inspection, the hospital did notemploy a registered nurse (child branch) but this hadbeen identified as a risk and the OPD manager wasmaking plans to address this by the use of bankchildren’s nurses to work at the time of paediatric clinicsand be available to support the hospital.

• There was minimal use of bank and agency staff in OPD.The hospital used an induction process to ensure thatbank and agency staff had specific competencies andunderstanding of local policies.



Good –––


• The OPD used the same agency practitioner for twohours every week to work in cardiology clinics; therewere no other agency nurses used. We spoke to amember of bank staff who confirmed they had attendeda local induction.

• The department employed two cosmetic nurses whocovered eight clinics per week. Both nurses had specificcompetencies to work in cosmetic services.

• There were no vacancies in OPD at the time ofinspection.

• The department had recently employed three new HCAsand these would be supernumerary for a minimum offour weeks. This could be longer if they requiredadditional training and support.

• Interviews were scheduled to recruit a registered nurse(child branch) who would be on duty for paediatricclinics and available to support staff when childrenattended the hospital.

Medical staffing

• Consultants and radiologists attended the outpatientdepartment and diagnostic imaging department on setdays at set times. This meant that the departmentmanagers knew in advance which consultants wereattending and were able to arrange staffingappropriately.

• The four consultant cosmetic surgeons who hadpracticing privileges with the hospital were all registeredon the general medical council (GMC) specialist register.

• Medical staff were contacted by telephone, email or viatheir secretaries to offer advice to staff if they were notpresent at the hospital.

• There was a resident medical officer (RMO) at thehospital 24 hours a day. Staff could easily contact theRMO for advice or to review a patient.


• We saw the Spire Healthcare Business Continuity planwhich had been adapted for Spire Bushey. The plan wasin date and detailed action to take in OPD and imagingin event of a major incident such as a bomb explosion,widespread fire or flood, prolonged loss of power,heating, communications or water. Staff were aware ofthe policy although they had not received any specifictraining or carried out scenarios.

• We saw a departmental action card detailing theprocedure to follow in case of flooding. It was in dateand detailed which staff needed to be contacted.

• Staff told us about fire alarm testing which happened onFriday mornings.

Are outpatients and diagnostic imagingservices effective?


We inspected, but did not rate the outpatient anddiagnostic imaging service for effectiveness. We found that:

• Policies and guidelines were up to date and based onbest practice and national institute for clinicalexcellence (NICE) guidelines.

• The outpatients and diagnostic imaging departmentprovided a seven day service.

• Effective multi-disciplinary team (MDT) meetings tookplace with input from national colleagues

• New staff had a significant period of supervision.• Consent to care and treatment was obtained in line with

legislation and guidance, including the Mental CapacityAct 2005 (MCA) by the consultants.


• Policies were up to date and followed guidance from theNational Institute for Health and Care Excellence (NICE).

• The imaging department used diagnostic referencelevels (DRLs) as an aid to optimisation in medicalexposure. DRLs were cross-referenced to national auditlevels and if they were found to be high, a report to theradiation protection advisor would be made.

• The diagnostic imaging department was accredited formulti-modality prostate imaging using guidelinesdeveloped by NICE. Multimodality prostate imagingenables an accurate diagnosis of prostate cancerrecurrence post initial treatment.

• The hospital complied with the NICE quality standardfor breast care recommendation that a clinical nursespecialist was present during appointments.

• Patients undergoing cosmetic surgery were given amandatory two week cooling-off period between theinitial consultation and committing to the procedure, toallow them time to reflect on the information prior tomaking a final decision. This was in line with bestpractice.

Nutrition and Hydration



Good –––


• Staff told us that on occasion the staff restaurant hadprovided out patients with a meal if required.

• We saw staff offering patients hot drinks after they hadundergone procedures.

Pain relief

• There was no oral pain relief or controlled drugs kept inoutpatients.

• Staff told us: “If a patient saw a consultant and it was feltthat pain relief was required, the consultant wouldcomplete a private prescription and the patient wouldpurchase pain relief from the hospital pharmacy. If apatient attended OPD and was in a lot of pain, we wouldconsider admitting them, or we could consult the RMOfor review of pain managment”.

• Local anaesthetic was stored in a locked cupboard inthe x-ray department.

Patient outcomes

• The physiotherapy team were trialling patient specificfunctional scale (PSFS). Data from every discharge wasadded to a master spreadsheet on a monthly basis byall physiotherapists. The purpose of the study was todetermine quality of life improvements, averageimprovement per physiotherapy session and number ofsessions per point change.

• The physiotherapy department recently carried out anaudit on the small number of patients having bespokeknees fitted. The audit showed increased patientsatisfaction.

• We did not see any evidence of patient outcome specificrelated audits being performed in outpatients anddiagnostics

Competent staff

• All staff working in outpatients, diagnostic imaging andphysiotherapy services had an up to date appraisal, with100% compliance.

• The Human Resources lead reviewed the health andcare professions council (HCPC) registration status forallied health professionals electronically on an annualbasis.

• The hospital supported in house training anddevelopment. We spoke with three staff who had startedtheir careers at the hospital and progressed to moresenior positions.

• The hospital supported and supervised physiotherapystudents to work at the weekends to gain experience.The hospital then had the option to recruit the studentsand support them through further formal training.

• We spoke with one physiotherapist who was beingfunded through a master’s degree (MSc). There werefour physiotherapists undertaking MSc courses in total.

• Two radiographers we spoke with, who used the MRIscanner, had received specialist MRI training in Londonand had undertaken intensive scanner software trainingprovided by the company who supplied the scanner.

• Radiographers could undergo training to enable themto rotate through all areas of diagnostic imaging if theychose to do so. This enabled staff to support other areaswithin diagnostic imaging during periods of staff leaveor sickness.

• We asked two new members of staff if they had receivedan induction. Both staff members told us that they hadand that it had been very informative.

• The department had recently employed three new HCAsand it was planned that they would be supernumeraryfor a minimum of four weeks, with an option to extendthis period if additional training and support wasrequired.

• All doctors who had practising privileges were atconsultant level and were registered with the GeneralMedical Council (GMC). This meant patients could beassured that registered practitioners treated them.

• Patients who attended outpatient clinics and thediagnostic imaging department told us that theythought the staff had the right skills to treat, care andsupport them.

Multidisciplinary working (related to this core service)

• Our observation of practice, review of records anddiscussion with staff confirmed effectivemultidisciplinary team (MDT) working practices were inplace.

• The hospital held a national multidisciplinary team(MDT) meeting every Monday night purely for breastcare. Breast care nurse specialists, breast careconsultants, oncologists, histopathologists andradiologists regularly attended and consultants fromSpire hospitals nationally joined in to discuss individualpatient cases via Skype.



Good –––


• The hospital offered a consultant led “one stop” breastcare clinic Monday to Friday. Patients could undergoconsultation and diagnostic tests all in one visit. Breastcare nurse specialist were always in attendance at theclinics to offer support to the patients.

• A specialist physiotherapist told us they attended MDTmeetings on an ad-hoc basis but there was continuousliaison with consultants and specialist respiratorynurses.

• Weekly urology MDT meetings had just been set up butwere not yet fully embedded.

• There were specialist nurses at the hospital for breastcare, cosmetic nurses and chemotherapy nurse. Staffand patients could access them for support andinformation.

Seven-day services

• Outpatient and diagnostic imaging services wereavailable seven days a week.

• Outpatient and x-ray appointments were available from8am until 9pm Monday to Friday, 8am to 2pm Saturdaysand 9am to 1pm Sundays.

• MRI scanning was available from 8am to 8pm Monday toFriday and Saturdays from 9am to 1pm. Thursdaymornings were reserved for NHS patient prostatescanning.

• CT scanning was available Tuesday, Wednesday andFriday 9am to 5pm, Mondays 9am to 6pm and Thursday9am to 8pm. The longer days were to accommodate therequirement for the presence of cardiologists. Saturdays8am to 1pm were reserved for contract with a local NHStrust.

• 24 hour cover for x-ray and CT scanning was provided byradiographers on an on call basis.

• Physiotherapy was available in the gymnasium and thehydrotherapy pool 7.30am to 8.30pm Monday toThursday, 7.30am to 6pm Fridays and 8am to 1pmSaturdays. At the weekend, the hydrotherapy pool wasreserved for in patient use.

• The cardiac centre did not see any medical emergenciesand was available to outpatients from 8am to 9pmMonday and Tuesday, 9am to 8pm Wednesday, 8am to6pm Thursdays, 9am to 5pm Fridays and 9am to 1pmSaturdays.

• A nurse led dressing clinic was available for wound careevery day.

• When the outpatient department was closed, patientscould phone the ward staff for advice.


• The hospital had a policy for the storage andmanagement of patient medical records which detailedstorage and retention, who could access them and whatto do with them when the patient was discharged.

• Information leaflets were displayed in the waiting arearegarding availability of chaperones, potentialadditional charges, and availability of translationservices, providing feedback regarding patientexperience, information on insurance policies and whatto do if you had been waiting more than 15 minutes foryour appointment.

• Spire Healthcare policies were accessible, current andreflected professional guidelines, for example, NationalInstitute for Health and Care Excellence (NICE). Theywere stored on the intranet, the policies we viewed werein date and staff showed us how they accessed them.

• Each clinic room had a computer where staff couldaccess examination results and view x-ray images.

• Diagnostic imaging departments used the picturearchive communication system (PACS) to store andshare images, radiation dose information and patientreports. Staff were trained to use these systems andwere able to access patient information quickly andeasily.

• All diagnostic images were reported on within 48 hoursand sometimes sooner. We saw one image had beenwaiting two days, when we raised this with theradiographer she explained the specialist radiologistwould be in the clinic on that day (day three) and so itwould be reviewed. Staff explained that allradiographers checked images as they were beinggenerated and alerted the relevant radiologist if theysaw anything abnormal.

• Some radiologists viewed and reported on images fromhome via a secure network.


• We reviewed the hospital policy; ‘Consent toInvestigation or Treatment’ and found it wascomprehensive, in date and compliant with nationalguidance such as NICE.

• The MRI lead radiographer showed us that the MentalCapacity Act 2005 (MCA) and Deprivation of LibertySafeguard (DoLs) training was covered as part ofmandatory training



Good –––


• The diagnostic imaging manager told us that writtenconsent for children under 16 years to undergoprocedures was obtained from someone with parentalresponsibility.

• The outpatient manager told us that for many patientsconsent to procedures was implied but as a minimumconsent was obtained from the patient verbally.

• We saw a doctor explaining the risks and benefits of theprocedure and obtaining written consent from a patientwho was about to undergo CT scanning.

• Patients undergoing cosmetic surgery were given amandatory two week cooling-off period between theinitial consultation and consenting to the procedure, toallow them time to reflect on the information prior tomaking a final decision. This was in line with bestpractice.

Are outpatients and diagnostic imagingservices caring?

Good –––

We rated the outpatient and diagnostic imaging service asgood for caring because:

• We saw patients were treated with dignity and respect.• Feedback from patients was consistently positive about

the way staff cared for them and the treatment they hadreceived.

• Patients told us they were well informed.• All the patients we spoke with told us they would

recommend the hospital to friends and family.• The hospital wide friends and family survey, between

April 2015 to March 2016, which included both NHS andprivate patients scored above 97% for the number ofpatients who would recommend the hospital.

Compassionate care

• We observed staff being polite and friendly towardspatients.

• All the patients we spoke with were complimentary ofthe staff and the hospital.

• We saw staff taking the time to interact with patients in arespectful and considerate manner.

• Patients told us staff were kind, respectful and alwaysintroduced themselves.

• Staff respected patient dignity and privacy at all times.We observed all consultations took place in closedrooms and staff knocked on clinic room doors beforeentering.

• Patients we spoke with in diagnostic imaging andoutpatients praised the staff for the compassionate carethey provided.

• We saw staff covered patients with blankets to protecttheir dignity during procedures.

• There were posters offering patients the use of achaperone during appointments. A HCA told us thatacting as a chaperone was part of her role. We saw HCAsperforming this role.

• Patients told us that staff always asked their permissionbefore starting interventions. We saw patientsundergoing procedures and staff regularly asking themif they were feeling alright.

• The hospital wide friends and family survey, whichincluded both NHS and private patients scored above97% for the number of patients who would recommendthe hospital between April 2015 to March 2016. Theresponse rates were on average 34% for the same timeperiod, which is in line with the England nationalaverage. All the patients we spoke with in the outpatientand diagnostic imaging department said they wouldrecommend the hospital to their families and friends.

• Once patients had undergone a CT or MRI scan we sawthey were offered a hot drink and advised when theirscan results would be available.

• Staff ensured those patients who had been givensedation had transport home or organised for a taxi forthem.


• One patient told us that if they had any questions theywould telephone the department, staff would answerthe call quickly and be able to help.

• We saw a doctor in CT explaining a procedure to apatient. The doctor was calm and clear and allowed thepatient time for questions and repeated information ifthe patient asked for it and asked the patient; “Is thatok?” often.

• The consultants’ secretaries provided patients with awritten quotation of the cost of their cosmetic surgeryprior to admission.

Emotional support



Good –––


• We saw a nurse offering support and kindness to therelative of a patient who was undergoing a procedure.The patient was concerned their relative was worriedand upset and the nurse reassured the patient that shewould look after the relative giving updates to each ofthem.

• Specialist nurses were available at the hospital. Therewas a specialist breast care nurse, cosmetic nurse andchemotherapy nurse that patients could book anappointment with for advice, support or if they felt theyneeded to discuss their care.

Are outpatients and diagnostic imagingservices responsive?

Good –––

We rated the outpatient and diagnostic imaging service asgood for responsive because:

• Services were planned and delivered in a way that metthe needs of the local population. The importance offlexibility, choice and continuity of care was reflected inthe services.

• Care and treatment was coordinated with otherservices.

• One-stop clinics were available for some specialitiessuch as breast care to minimise the amount ofattendances for patients.

• Outpatient and diagnostic imaging was a seven dayservice with evening and weekend appointmentsavailable

• The department had specific clinics for paediatrics• There was a telephone interpretation service available

for those patients who did not speak English.• There was good evidence of learning from complaints.


• Clinics were held at weekends and evenings to provideflexibility for patients and keep waiting lists down.

• There were three dedicated paediatric clinics held eachweek.

• Some consultation rooms were used for specificspecialties, with dedicated equipment, for example; ear,

nose and throat (ENT); and ophthalmology. This meantconsultants would be able to work in an appropriateroom according to their specialty and staff could bearranged to support and deliver the service.

• Some outpatients clinics had been designed as‘one-stop’ so patients could undergo tests and aconsultation within the same appointment; theseincluded specialities, such as breast care.

• There was free car parking available and there weredisabled spaces close to the entrance to thedepartment.

• If patients needed to be seen urgently the departmentoffered a clinic room to consultants and there were twohours a day reserved in the MRI scanner to see urgentpatients.

Access and flow

• The Department of Health target of 92% for referral totreatment time (RTT) was met and exceeded for April2015 to March 2016. The hospital routinely achieved96% to 100%. The RTT is the time period between whena referral for treatment is made and the date of theinitial consultation. The Department of Health stated forNHS patients, 95% of non-admitted patients shouldstart consultant-led treatment within 18 weeks ofreferral; however, this was withdrawn in June 2015.

• The department offers evening and weekend clinics toprovide patients with flexible access to appointments.

• Some NHS patients were able to book theirappointment via an NHS referral system, which allowedthem to choose a time that was more convenient forthem. Alternatively, patients could contact theoutpatients booking teams directly. Staff in the bookingteams also contacted patients if a referral was receivedfrom a GP or other referrer that was urgent.

• A second, mobile MRI scanner was also available onSaturdays to help manage waiting times.

• Three patients told us they had been referred by theirGP, seen within 72 hours at the hospital and had no waitfor their appointment on arrival at the outpatientdepartment.

• One physiotherapist told us they were able to referpatients for x-ray and other scans to aid in diagnosis.

• Five patients told us they had not experienced anydelays when they had attended for their appointment.Two patients said there had been an occasion wherethey had been kept waiting but that the receptionist hadexplained the reason for the delay to them.



Good –––


• The OPD manager told us there was no national SpireHealthcare policy for dealing with patients who did notattend appointments (DNA). Since 1 June 2016 therehad been 168 DNAs out of approximately 7000appointments. Administrators contacted patients if theydid not attend for their appointment. If the patient nolonger needed an appointment, this was recorded. Wesaw an administrator telephone a patient who had notarrived for their scan. The administrator spoke politelyto the patient and explained how to rebook.

• Since 1 June 2016 records were being kept of laterunning clinics. We saw the records and there wereapproximately 34 late running clinics recorded. Oneclinic was over 90 minutes late starting. The OPDmanager told us that all the patients concerned wereinformed of the delay and that the information hadbeen presented at the clinical governance meeting andan action plan had been drawn up for dealing with theconsultants concerned.

The OPD manager told us of two occasions when clinicshad been cancelled, one was due to a burst water mainpreventing access to the areas around the hospital and theother was when a consultant did not arrive for their clinic.We saw that management had responded appropriately oneach occasion.


• The hospital had a dementia lead who could be calledupon for advice and support when seeing patients withdementia.

• There was a small area dedicated to children in thewaiting room. There were age appropriate toys andbooks in a closed toy box and crayons and colouringbooks were available from the receptionist on request.

• There was a chair available in the waiting room forlarger patients.

• Staff were able to move the chairs in the waiting roomsto accommodate a wheelchair although the corridorsaround the treatment rooms were narrow and not easilynavigated in a wheelchair.

• There were disabled toilets to the side of the mainwaiting area.

• Lifts were available so patients did not have to use thestairs.

• Hot drinks and water were available free of chargethroughout the department.

• The hospital offered access to translation services via atelephone language line for patients where English wasnot the first language. We saw posters in the waitingarea describing how to arrange for an interpreter, theposters were in multiple languages. However, a patientrecently attended the department who did not speakEnglish and was deaf; the patient brought their owninterpreter.

• The MRI scanner was able to scan disabled patients inthe MRI safe wheel chair or using the MRI safe walkingframe. The scanner table was able to hold patientsweighing up to 250kg meaning larger patients could bescanned safely.

• The outpatient department did not have a specificprocedure in place for patients with learning difficultiesbut told us that they would seek advice and supportfrom the patient’s parent or carer.

• One patient we spoke with had been anxious that theywere too wide to be scanned; the consultant hadadvised the patient to contact the MRI department. Thepatient told us the staff in the MRI department invitedthem to come and “have a go” on the table to reassurethemselves they would fit in the scanner.

• Patients who needed to get undressed for proceduressuch as CT, MRI and x-ray were shown to individualchanging rooms where there were lockers for theirpossessions and a chair. Patients were given gowns andslippers to put on and offered robes to cover up further.

• Once patients were changed ready for their procedurethey could wait in the waiting area or stay in thechanging room and wait to be collected by staff if theypreferred.

• Patients undergoing MRI scanning could listen to musicor audio stories either via CD or the internet if theywanted to. We saw a radiographer offering a patient thischoice however, the patient wanted to be left to sleep.

• One patient who attended for an MRI scan told us thatthe radiology staff had arranged for him to have hisprocedure in two sessions with a comfort break in themiddle because the procedure would be toouncomfortable for him in one session.

• Staff told us of occasions when they had liaised withother departments to arrange for appointments to beon the same day for a patient who needed to attendmultiple clinics.

• Patients told us they had received information prior totheir appointments either by telephone call or emailand sometimes both.



Good –––


• Patients that we spoke with after their appointment saidthat they had received information about when theywould receive their test results and if they requiredfurther diagnostics or treatment what that wouldconsist of.

• We did not see any information leaflets which weresuitable for children and young people.


• Spire Healthcare Limited’s corporate complaints policydirected the management of complaints and timescales for responses. This was in line with industrystandards. All complaints were reviewed by the clinicalgovernance committees and medical advisorycommittee (MAC) and actions as a result of thecomplaint shared with individual departments via teammeetings.

• The hospital complaints procedures werecommunicated to patients in a leaflet called ‘Please TalkTo Us’.

• Senior managers told us about a complaint receivedfrom a patient regarding additional charges incurredduring an outpatient consultation for diagnostic testswhich were performed. We saw posters displayedthroughout the department explaining that diagnostictesting would incur additional charges. This evidencedlearning from complaints.

• From February 2015 to March 2016 there were 12complaints.Five complaints were upheld, twocomplaints related to communication of test results,one related to dressings leaking, one related to chargesand one related to dignity and privacy in the MRI.Complaints were handled within 20 days in line withhospital policy. Lessons learnt from complaints wereshared with all staff, such as improving communicationwith patients.

• All the patients we spoke with told us they had nocomplaints but knew how to complain if they everneeded to. One patient said they had made a complaintin the past and had been pleased with the way it hadbeen handled and the feedback they had received.

• We saw; “You said we did,” posters in the departmentexplaining what had been improved as a result ofpatient feedback, including setting up a patient forumand creating notice boards throughout the hospital.

• A patient forum was implemented in response topatient feedback. The forum consisted of self-funding

patients that had previously used the hospital serviceswith a representative from senior management. Theforum met to discuss possible improvements and thepatients’ perspective on how services were provided.

• The hospital was proud of the large number ofcompliments they regularly received.

Are outpatients and diagnostic imagingservices well-led?

Good –––

We rated the outpatient and diagnostic imaging service asgood for well led because:

• Staff we spoke with were aware of the hospital visionand values and the individual department strategy.

• The hospital had a clear governance structure.• Information was cascaded from the clinical governance

committee to all hospital staff via team meetings.• The hospital had an effective risk register and staff were

aware of the risks specific to outpatients and diagnosticimaging.

• Hospital senior management members were visible,approachable and supportive.

• Staff were proud to work for the hospital and feltsupported and valued.

• Staff felt well informed and involved in the developmentof the new outpatients facility.

• There were innovative ways of communicating with staffsuch as newsletters and social media.

Leadership / culture of service

• The service was led by the diagnostic imaging manager,outpatients manager and physiotherapy manager whowere accountable to the matron who in turn reported tothe hospital director.

• Each department had a manager who was responsiblefor the day-to-day management and staffing levels.

• Staff told us they felt confident to raise issues and thatthe hospital manager and matron were very regularlyseen in the department and always enquired after staffpersonally.



Good –––


• Staff told us that the senior and local managers werevery supportive and actively promoted training andcareer development through in-house training andmore formal education such as a master’s degreetraining.

• All the staff we spoke with told us they felt valued andwere proud of the teams they worked in and of theservice they provided.

• We saw that communication within the hospital wasgood between all staff groups at all levels.


• All the staff we spoke with were aware of the corporatevision for Spire Healthcare, which was, ‘To be recognisedas a world class healthcare provider,’ and: ‘To bringtogether the best people who are dedicated todeveloping excellent clinical environments anddelivering the highest quality patient care’. Seniormanagers told us that the hospital aspired to becomeworld class providers within the sector.

• Spire Bushey values were; caring is our passion,succeeding together, driving excellence, doing the rightthing, delivering on our promises and keeping it simple.

• The hospital values were displayed on pop up bannersthroughout OPD and staff told us they felt that everyonelived by the values.

• A clear strategy was in place for the department andstaff told us how they had all been involved indeveloping it through input at team meetings.

• There had recently been approval to develop outpatientand diagnostic services offsite and staff told us theywere kept well informed about developments and hadbeen actively involved in making decisions regardinglayout and fixtures and fittings for the new facility.


• Governance structures were robust and clear. Thehospital clinical governance committee reported to theSpire Healthcare Limited board.

• The clinical governance committee met quarterly. Thiscommittee had an overview of governance risk andquality issues for all departments. Senior departmentleads attended. Information discussed included safetyalerts, learning from incidents, policy updates andaudits.

• Departmental team meetings took place weekly andoutcomes and information was shared at departmental

meetings which took place monthly. Outcomes ofdepartmental meetings were then shared at hospitalmanagement meetings. Minutes of meetings werecirculated to all staff by email and we saw evidence ofthese.

• Risk management was led by the dedicated riskmanagement committee set up in 2015. The committeemet quarterly to review the hospital wide risk registerwhere they identified and tracked risks. We saw thehospital wide risk register, which was up to date andeach risk had been rated according to its severity.

• Every department had their own risk assessmentregister which covered risk assessments completed ineach department. The head of the departmentmanaged the departmental risk assessment register.

• Risks were identified through variety of sourcesincluding but not limited to: risk assessment results,annual planning, KPI’s, policy, complaints, staff &patient surveys, external accreditation/assessments,incidents, audit and national recommendations.

• We reviewed the hospital risk register and saw thatoutpatient and diagnostic imaging department hadrisks and control measures identified and reviewed.

• The OPD took part in routine monthly audits includinghand hygiene and patient notes audits.

• The OPD had recently carried out a three month audit ofconsent compliance for minor surgery andimplemented a World Health Organisation (WHO) safersurgery checklist as a direct result of their findings.

• Diagnostic imaging had very recently introducedmonthly image audits for the MRI scanning; there wasno feedback to date. Radiographers carried outintervention audits every six months.

• Staff who were exposed to radiation wore radiationmonitoring badges which were checked for doseexposure monthly.


• There were a number of methods of communicatingwith staff, such as, the newsletter; ‘Bushey Tales’, emailsand team meetings as well as information on computerscreen savers and the hospital social network page.

• We saw the Bushey Tales which the staff receivedmonthly. There were updates on incidents andcomplaints and compliments as well as information on



Good –––


award winners, staff social activities and new starters.Staff spoke enthusiastically about the newsletter andfelt it kept them informed of developments within thehospital.

• The hospital wide staff forum which met quarterly. Stafftold us this helped keep them motivated and wellinformed of changes and news across the hospital.

• The hospital operated a, “policy of the month” schemewhere one policy every month was highlighted to raiseawareness and compliance with staff across thehospital. We saw the policy displayed on the noticeboards in MRI and CT and staff told us how theyaccessed it and evidenced they had read it. An audit hadtaken been carried out to ask staff if they had read thepolicy and understood the content. We saw evidence ofthe audits and action plans were staff were required tore-read the policy to become familiar with the contents.

• We were told by senior management that outpatientstaff had taken part in the staff satisfaction survey butdue to an error made at data input stage it was notpossible to identify any trends specific to OPD staff.

• Staff told us they were proud to work for Spire BusheyHospital; they said they felt engaged and motivated.

• The hospital held an awards ceremony and staffreceived rewards in the form of vouchers and certificatesfor outstanding contribution to the service. Staff couldbe nominated by colleagues and patients. Staff told usthat they felt this was a good way to reward staff.

• We spoke to a bank nurse who told us she feltconsidered and treated as equal with the permanentstaff.

• A patient forum was implemented in response topatient feedback. The forum consisted of self fundingpatients that had previously used the hospital serviceswith a representative from senior management. Theforum met to discuss possible improvements and thepatients’ perspective on how services were provided.

• A patient experience and complaints committee met aspart of the existing governance structure to ensurepatients’ experiences and complaints were used toimprove quality and customer service.

• Staff and members of the public were keen to speakwith us during the inspection and told us they were gladto have the opportunity to show off their “excellentdepartment”. One member of staff told us “this is alovely place to work”.


• The hospital had recently secured £23 million servicedevelopment investment. Plans were in place toimprove the outpatient department. Work wasunderway on an offsite facility where the outpatientdepartment would relocate. This would allow both theoutpatient and the inpatient facilities at the mainhospital site to expand.

• The medical services had plans to expand capacity andwere constantly striving for new ways to improve. Thisincluded applying for Joint Advisory Group inGastroenterology (JAG) accreditation and redesigningthe endoscopy unit.



Good –––


Safe Not sufficient evidence to rate –––

Effective Not sufficient evidence to rate –––

Caring Not sufficient evidence to rate –––

Responsive Not sufficient evidence to rate –––

Well-led Not sufficient evidence to rate –––

Information about the serviceTermination of pregnancy (TOP) refers to the treatmentprovided to terminate a pregnancy, by surgical or medicalmethods.

Spire Bushey Hospital provides medical and surgicaltermination services to patients from Hertfordshire, NorthLondon and surrounding areas. Services are available onTuesdays, Thursdays and Saturdays between 9am and5pm.

The service is mainly provided to self-funded patients, andthey are offered a range of termination of pregnancy (TOP)services including pregnancy testing, early medicalabortion, early surgical abortion, abortion aftercare,contraceptive advice and contraception supply.

The service holds a licence from the Department of Health(DH) to undertake termination of pregnancy procedureswithin Spire Bushey Hospital. The licence is publicallydisplayed within the outpatients department.

Medical terminations of pregnancy are carried out onpatients between six and eight weeks gestation. Earlysurgical terminations of pregnancy are carried out onpatients up to 16 weeks gestation. Terminations ofpregnancies of a later gestation period are referred toanother provider.

At Spire Bushey Hospital, 13 medical terminations ofpregnancy and 12 surgical terminations of pregnancy werecarried out between April 2015 and March 2016. Patientsaged 16 and above were treated by the service; anyonebelow 16 years of age was referred to another provider.

There were two consultants who carried out thetermination of pregnancy service, with support from the

outpatient manager for medical terminations, and generalsurgery staff for surgical terminations. Medical secretariesand the head of clinical and non-clinical services alsosupported the governance of termination of pregnancyservices. We spoke with five staff about the service.

The inspection was conducted using the Care QualityCommission’s methodology of inspecting this type ofservice. We looked at the medical records of 27 patients,including some young people under the age of 18. We wereunable to observe interactions with patients or proceduresduring our inspection due to no patients being seen on thedays of our visits.

This service was not rated because there was insufficientevidence.


Termination of pregnancy



Summary of findingsWe found that:

• Staff who were responsible for potentially assessing,planning, intervening and evaluating young people’scare, did not all have the correct level of children’ssafeguarding training.

• Termination of pregnancy services governance issueswere not always effective. There was no evidencethat the service was discussed or reviewed at anycommittee meeting.

• Not all HSA1 forms had a reason for terminationdocumented in line with legislation.

• Not all patient records had evidence that a HSA4form had been completed and sent to the chiefmedical officer.

• Records did not always contain consistentinformation to demonstrate all aspects of patientscare or medicines received.

• Screening for sexually transmitted diseases did nothappen within the service. There were no processesin place for patient referral to obtain screening. Thisdoes not comply with national guidance.

• Some records contained errors that had beencrossed out but no initials to state who had rectifiedthis error or crossed the previous content out.

• Audits did not always accurately reflect the evidencein patient records, which meant non-compliancewith Department of Health Required StandardOperating Procedures (RSOP), was not alwaysidentified or addressed.

• Action plans were in place following audits; howeverthey were not always effective or robust enough toaddress compliance findings.

However we found:

• Patients were protected from abuse and avoidableharm, as staff knew how to recognise untowardincidents and report them appropriately. There werearrangements in place to share and action anyidentified learning points following incidents.

• All staff we spoke with understood duty of candourand how this applied to their practice.

• Robust procedures were in place for managingmedicines used in terminations. All staff within theservice and pharmacy team were aware of legislationsurrounding medicines that induced termination ofpregnancy.

• Clear processes and practices were in place inrelation to safeguarding, with staff having completedthe necessary training in adult safeguarding.

• Patients underwent thorough assessments prior toany treatment being delivered, with any potentialrisks documented and explained to patients.

• National guidance was followed during treatmentwithin the service, and all staff had a goodknowledge of guidance and best practice.

• Procedures were in place to ensure effectiveness ofboth medical and surgical terminations; the servicehad a 0% failure rate.

• Staff understood the need to show care andcompassion towards patients deciding to undergo atermination, and were aware of the emotionalimpact this may have on patients.

• Services were easily and readily accessible topatients, with clinics available at various timesthroughout the week, including one weekend day.

• Clinical audit plans were in place within the servicethat observed compliance with required operatingprocedures (RSOP).

• The corporate risk registered identified theappropriate risks relating to the service.

• There was an inclusive and team-working culturethroughout the service, with a drive for effectivepatient care.





Are termination of pregnancy servicessafe?


We found that:

• Not all HSA1 forms had a reason for terminationdocumented in line with legislation.

• Not all patients had evidence that a HSA4 form hadbeen completed and sent to the chief medical officer.

• We found that records audits did not accurately reflectthe patient records reviewed.

• We did not see evidence of conversations regardingcontraception being conducted with patients, orwhether long acting reversible methods were discussedor offered.

• Screening for sexually transmitted diseases did nothappen within the service. There were no processes inplace for patient referral to obtain screening.

• Staff who were responsible for potentially assessing,planning, intervening and evaluating young peoplecare, did not all have the correct level of children’ssafeguarding training.

• Records did not always contain consistent informationto advice on patients care or medicines received.

• Some records contained errors that had been crossedout but no initials to state who had rectified this error orcrossed the previous content out.

• Consultants did not document that a patient hadcapacity to consent to the termination procedure, therewas no prompt for this within the pre-assessmentpaperwork.

However we found:

• Patients were protected from abuse and avoidableharm, as staff knew how to recognise untowardincidents and report them appropriately. There werearrangements in place to share and action anyidentified learning points following incidents.

• All staff we spoke with understood duty of candour andhow this applied to their practice.

• Infection control procedures and policies were in placeto protect people, and all areas inspected were visiblyclean and suitable for use.

• Processes were in place to ensure medicines wereavailable, and were dispensed in a safe way. All staffwere aware of legislation surrounding medicines thatinduced termination of pregnancy.

• Clear processes and practices were in place to ensurepatients were kept safe from avoidable harm and abuse.Safeguarding policies were available and accessible forstaff. Staff we spoke with had knowledge of thesepolicies and were able to describe the process ofreporting a safeguarding concern.

• Patients underwent thorough assessments prior to anytreatment being delivered, to ensure any clinical riskswere addressed and mitigated, including thedevelopment of a blood clot.

Incidents

• Patients were protected from abuse and avoidableharm, as staff knew how to recognise untowardincidents and report them appropriately. There werearrangements in place to implement any identifiedlearning points following incidents.

• There was an electronic reporting system in place toallow staff to report incidents and receive feedbackelectronically.

• Staff were encouraged to report incidents and all staffwe spoke with were familiar with how to do so.

• A clinical governance and risk manager was in place tooversee all incidents within the hospital, alongside thehead of clinical and non-clinical services. Incidents werediscussed at senior management meetings, clinicalgovernance meetings and there were monthly adverseincident meetings. If necessary, an incident would alsobe discussed at speciality meetings including medicinesmanagement committees. Following these meetingsfeedback would then be disseminated to staff within theservice.

• There had been one reported incident within thetermination of pregnancy service since April 2015 whichon investigation was categorised as a serious incident.

• The SI related to the dispensing of terminationmedication to another provider that was not registeredto carry out termination of pregnancy procedures. Wesaw a robust root cause analysis had been completedonce this had been brought to the attention of thesenior management team. Although an investigationhad not been commenced until five months after theinitial incident had occurred due to a delay in thehospital being made aware of the error. We observe that





actions documented on the root cause analysis,including a communication book, a new procedure putin place for management of termination medicines andadvice to staff, were in place to prevent the incidentoccurring again in the future. All pharmacy staff wespoke with were aware of the incident and lessonslearnt from this had been discussed at their specialtymedicines management meeting.

• There had been no reported never events relating totermination of pregnancy services 12 months prior tothe inspection. Never events are serious incidents thatare wholly preventable as guidance or safetyrecommendations that provide strong systemicprotective barriers are available at a national level andshould have been implemented by all healthcareproviders. Each never event type has the potential tocause serious patient harm or death. However, seriousharm or death is not required to have happened as aresult of a specific incident occurrence for that incidentto be categorised as a never event.

• From 1 April 2015 all independent healthcare providerswere required to comply with the Duty of CandourRegulation 20 of the Care Quality Commission(Registration) Regulations 2014. The Duty of Candour isa regulatory duty that relates to openness andtransparency and requires providers of health and socialcare services to notify patients (or other relevantpersons) of certain notifiable safety incidents andprovide reasonable support to that person.

• Clinical staff within the termination of pregnancy servicewe spoke with were fully aware of the Duty of Candourregulation and what this meant in their practice. Stafftold us they had received training on Duty of Candour.


• All areas where termination services were carried out,including clinical and waiting areas, were visibly cleanand tidy.

• The consultation rooms and waiting areas were cleaneddaily by housekeeping staff.

• Staff complied with the hospitals infection preventionand control policies. All clinical staff were arms barebelow the elbow to enable effective hand washing andreduce the risk of infection. There were hand washingfacilities, supplies of alcohol gel and personal protectiveequipment (PPE) in consulting rooms and throughoutthe service. Alcohol gel dispensers were availableregularly from the hospital entrance to all clinical areas,

to enable patients and visitors to sanitise hands andprevent spread of infection. We saw staff carrying outappropriate hand hygiene practice when enteringclinical areas.

• A number of infection control audits are completed inall areas of the hospital regularly including withinoutpatients and surgical areas. Hand hygiene auditsfrom April 2015 to December 2015 across all surgicalwards and theatres showed 95% - 100% overallcompliance.

• Single use equipment was used and disposed of in linewith manufacturer’s guidance. There were suitablearrangements for the handling, storage and disposal ofclinical waste, including sharps in a clinicalenvironment.

• Fabric curtains in the consulting rooms were steamcleaned annually and housekeeping replaceddisposable ones every three months. The dates we sawon a curtain confirmed this.

• We saw some of the consulting rooms in thedepartment were carpeted, which was not compliantwith health building notice (HBN) regulations. Thesenior management team had identified this as aninfection prevention control risk and we saw the actionplan for replacement of the carpets with vinyl flooring,however there were no specific dates for completion ofthis.

• Not all of the hand basins were compliant with HBNregulation 00-09, but these had been identified andwere due for replacement as part of a rolling plan ofrefurbishment, there were not specific dates set forcompletion of this.

• We saw that equipment used for numerous patients,including the ultrasound machine, had a visible green; ‘Iam clean’ sticker on it to indicate it was clean and readyfor use. Staff told us they were responsible for cleaningsuch equipment after each use and told us how this wascarried out in line with guidance. We saw oneultrasound machine within the consulting room usedand this was visibly clean and had a sticker present toshow it had been cleaned the morning of ourinspection.


• Resuscitation equipment was available in theoutpatient department and within surgical areas shouldit be required by those carrying out termination ofpregnancy services. These were checked and





maintained by the relevant teams from each area. Weobserved that laryngoscopes and suction catheterswere not stored in their sterile packaging across allresuscitation trolleys; this was addressed immediatelywhen raised with staff.

• All areas where consultations and treatments werecarried out were private and did not allow patients to beseen or overheard whilst receiving termination ofpregnancy services.

• Oxygen cylinders were available in the treatment roomand on the resuscitation trolley. The oxygen cylinderswere all in-date.

• Emergency call bells were located in treatment rooms,recovery areas and patient toilet facilities. These werechecked on a weekly basis by each area.

• All equipment had been serviced and safety checked inline with the provider’s policy, all disposable equipmentwas stored within sterile packaging in-line withmanufacturers’ guidance.

• The staff understood their responsibilities in relation tomanaging clinical waste and the disposal of pregnancyremains.

Medicines

• The hospital had a pharmacy on site that provided dailycover from 8am to 5pm Monday to Friday, and from 8amto 1pm on Saturdays. Nursing staff reported that thepharmacy team were available to offer support andadvice to both staff and patients and dispensedprescriptions.

• All medicines required for termination of pregnancyservices were dispensed by the hospital pharmacy, thiswas located next to the outpatient department (OPD)where the consultations and early medical terminationsof pregnancy were carried out.

• A doctor prescribed all medicines for patientsundergoing early medical termination of pregnancy,including prophylactic antibiotics to reduce the risk ofpost-procedure infection.

• Medicines that induced termination of pregnancy wereprescribed only for patients undergoing medicaltermination following a face-to-face consultation with adoctor. Doctors and the pharmacy team told us the firstdose must be taken on the hospital site, but the seconddose of medicine could be taken home by the patientfor self-administration.

• A copy of the British National Formulary (BNF) 2016 wasavailable in both treatment rooms and pharmacy fordoctors or pharmacy staff to refer to. The BNF is thenational authority on the selection and use ofmedicines.

• There was an established system for the managementof medicines to ensure they were safe to use. Medicinesthat had temperature storage requirements were keptrefrigerated. The minimum and maximum temperaturesof fridges were monitored daily to ensure thatmedication was stored correctly; we reviewed records oftemperature recordings and found them to be up todate. There were systems in place to check for expiredmedicines and to rotate medicines with a shorter expirydate. Stickers were placed onto medicine boxes thatwere due to expire within the next six months.

• We observed appropriate security procedures in placeto ensure only approved staff could access medicinesand out of hours provisions were clear.

• Medication administration records were containedwithin all patient records we reviewed, they were clearand complete. However medicine charts thatdocumented what a patient had been administeredduring surgery were not always present in all the patientrecords we reviewed.

• We saw that the allergy status of each patient wasclearly documented on their medication administrationchart and this correlated with any documented allergiesin their patient record.

• Pharmacy teams carried out numerous audits inrelation to administration and safety of medicines,including admissions medication chart completion,medicines reconciliation and oxygen prescribing. Weobserved that learning points relating to any auditoutcomes or incidents were shared throughout thepharmacy team and with staff carrying out terminationof pregnancy services. An example of this is through anoxygen prescribing audit, it was noted that not allmedical staff were correctly completing a medicinechart when oxygen had been administered. To improvecompliance with this pharmacy staff send a memo to allareas to advise on the correct process for oxygenprescribing and also discussed this during a medicinesmanagement committee.

Records

• We reviewed 27 medical records of patients that hadundergone termination of pregnancy, one of these





related to a patient under the age of 18 years. Recordswere generally well maintained and clearly documentedthe consulting doctor and date the patient was seen.However, not all records were completed thoroughly.We found some had errors crossed out that had notbeen initialled by the clinician completing the record.We also found the information contained in patientrecords to be inconsistent. Some records contained alist of medicines administered during surgery; othershad this page missing so we could not see ifprophylactic antibiotics had been administered.

• Some records had been amended by senior managersfollowing an audit, with treatment dates added after thetermination had been carried out. The senior managerhad not been involved in the clinical care of the patient.

• There were comprehensive pre-operative healthscreening questionnaires and assessment pathways.However, the format these were presented on did notmake it clear what actions had been completed. Eachbox had a list of actions, and one large area at the sidefor staff to sign when complete, there were no lines orboxes to be able to link each signature to an action. Weobserved that staff drew a line through all questions tosuggest all actions then signed the bottom of the page;this did not make it clear whether actions had all beencompleted, or none had been completed. It was alsonot clear which staff grade was completing this area ofthe patient’s record.

• The assessment process for termination of pregnancylegally requires that two doctors agree with the reasonfor termination and sign a HSA1 form to indicate theiragreement. In the 27 medical records we checked, allHSA1 forms contained two consultant signatures. ThreeHSA1 forms did not document a reason for thetermination. We raised this with the senior managersduring the inspection who reviewed the records andprovided us with the HSA4 form that had a reasondocumented for all patients. A copy of the HSA1 formwas filed in the patient’s medical record, which isconsidered best practice by the Department of Health‘Procedures for the Approval of Independent SectorPlaces for the Termination of Pregnancy’ (Abortion)required standard operating procedures (RSOP).

• Documentation audits of HSA1 forms were carried outevery three months. The hospital reported a 100%compliance rate for the period January 2016 to June2016. However, the records identified as not having areason stated for termination had been marked in the

audit as having a reason documented. This meant theaudits were not being completed accurately andtherefore learning was not identified in relation to thecompletion of records and no actions had been taken toaddress non-compliance with the completion of HSA1forms.

• The Department of Health requires every providerundertaking termination of pregnancy to submit detailsof the pregnancy and demographical data using anHSA4 form, recording demographic and other data forevery termination of pregnancy performed within 14days. We found that three sets of patient notes did notcontain evidence that a HSA4 form had been completedand sent to the Department of Health. This informationwas audited by the hospital and we saw evidence that78% of HSA4 forms had been completed and sent to theDepartment of Health between January 2016 and June2016. This is not compliant with the Abortion Act whichstates that the Chief Medical Officer must be sent theHSA4 within 14 days of the termination of pregnancytaking place. We raised this with the seniormanagement team during our inspection. During ourunannounced inspection we observed that service hadimplemented an online process where HSA4 formscould be tracked.”

• All patients had a venous thromboembolism (VTE)assessment to determine their risk of developing ablood clot. This is recommended by the Royal College ofObstetricians and Gynaecologists (RCOG) to reduceavoidable harm and death from VTE. We saw completedVTE assessments in all the patients’ medical notes wereviewed.

Safeguarding

• Spire Bushey had clear processes and practices in placeto ensure patients were kept safe from avoidable harmand abuse.

• Safeguarding policies were available and accessible forstaff. Staff we spoke with had knowledge of thesepolicies and were able to describe the process ofreporting a safeguarding concern.

• Not all staff caring for young people aged between 16-18years had the required children safeguarding training atlevel three. The Royal College of Paediatrics and ChildHealth (RCPCH) or those contained in the IntercollegiateDocument (March 2014) guidance state that cliniciansresponsible for assessing, planning, intervening andevaluating children, should be trained to level three.





• Some staff we spoke with had received adult andchildren safeguarding training within the previous sixmonths, this training was at level three in line withintercollegiate guidance.

• Both consultants who carried out the terminations hadchildren’s safeguarding training to level three.

• Termination of pregnancy services were not provided toany patients under the age of 16. Staff told us thatpatients would be advised on the most appropriateprovider when they called to book an appointment. Wesaw that no patients under the age of 16 had been seenwithin the service in the previous 12 months. Onepatient, who was 17 years old, had undergone athorough safeguarding assessment, which wasdocumented, including details about their capacity toconsent and involvement of their parent in theirtreatment.

• Staff were aware of female genital mutilation (FGM),which involves genital cutting and female circumcisionand removal of some or all of the external femalegenitalia.

• Staff were also aware of child sexual exploitation, withregards to their role in safeguarding young or vulnerableadult patients. Initial assessments included questionsaround consent and coercion to sexual activity andlifestyle to identify coercion, suspicion of sexualexploitation or grooming, sexual abuse and powerimbalances. When there was any suspicion of abusesafeguarding referrals were made to the safeguardingteam. There had been no safeguarding referrals forpatients being seen for termination services.

• Patients were not routinely seen alone during the initialconsultation, therefore there was no reassurance thatthe patient had not been pressured or coerced into thedecision to have a TOP. We raised this with the seniormanagers during our inspection who told us they wouldreview the consultation process.

Mandatory training

• Mandatory training covered a range of topics includinghealth and safety, manual handling, infection control,information governance and basic life support.

• The organisational target for completing mandatorytraining was 100%. Data provided showed that 100% ofstaff within the terminations of pregnancy services wereup to date with mandatory training.


• All patients were asked about their medical history toassess their suitability for treatment; this includedassessment of potential risk factors. If a patient wasunsuitable for treatment, for example due to existinghealth conditions, at Spire Bushey they would bereferred to another provider. We did not see evidence ofany patients being referred elsewhere because theywere unsuitable, and staff told us they could not recallthis happening.

• Prior to termination procedures, patients should have ablood test to identify their rhesus status. It is importantthat any patient who has a rhesus negative blood groupreceives treatment with an injection of anti-D. Thistreatment protects against complications, should thepatient have future pregnancies, and is in line with theDepartment of Health regulated standard operatingprocedures. The records that we revieweddemonstrated that all patients underwent a blood testprior to the termination procedure and those who had arhesus negative blood group did receive an anti-Dinjection. A record of all patients who had receivedanti-D was kept.

• All patients had an ultrasound scan to confirmgestation. If the practitioner was uncertain of theirfindings they would discuss this with a colleague, and ifnecessary refer to an alternative provider.

• Spire Bushey had adopted the national, ‘five steps tosafer surgery’ checklist, which was designed to preventavoidable mistakes. All surgical termination records wereviewed contained completed checklists with the riskoutcome documented.

• All patients had undergone a venous thromboembolism(VTE) assessment to determine their risk of developing ablood clot in their legs or their lungs. This isrecommended by the Royal College of Obstetricians andGynaecologists (RCOG) to reduce avoidable harm anddeath from VTE. We saw completed VTE assessments inall the patients’ medical notes we reviewed.

• All patients were risk assessed at the point of admissionand recovery staff used a national early warning score(NEWS) to record routine observations, such as bloodpressure, temperature and heart rate.

• The hospital had clear policies in place in regards toresponding to a deteriorating patient. Consultants toldus that while there was no official on call system due tothe small size of the termination of pregnancy serviceand no requirement for it, they would attend the





hospital out of hours if a problem occurred with theirpatient. There had been no transfers to NHS acute trustsfollowing a termination procedure in the previoustwelve months.

• If a patient lived a long distance from the hospital, andtheir drive home would be more than a couple of hoursthen they would be advised to stay overnight following asurgical termination. We were told this rarely happened,and if it did then the resident medical officer would beprovided with the consultant details who had performedthe termination, to call if there were problemsovernight.

Nursing staffing

• There were no dedicated nursing staff that solelycovered termination of pregnancy services, howeverduring clinic days the OPD manager provided nursingsupport to patients and doctors for early medicalterminations.

• For surgical terminations ward and theatre staffsupported the consultant carrying out the termination.

• The service used a mix of nurses, allied healthprofessionals and health care assistants, all who werecompetent to carry out their specific roles.

• There was minimal use of bank and agency staff inoutpatients on the ward and theatres. The hospital usedan induction process to ensure that bank and agencystaff had specific competencies and understanding oflocal policies.

Medical staffing

• Patients care was consultant led. There were twoconsultants who carried out assessments, early medicalterminations and surgical terminations at Spire Bushey.

• The consultants attended the hospital on set days at settimes. This meant that the department managers knewin advance which consultants were attending and wereable to arrange staffing appropriately.

• There was a resident medical officer (RMO) at thehospital 24 hours a day. They could be easily contactedby staff for advice or to review a patient for example, forpain management.


• We saw the Spire Healthcare Business Continuity planwhich had been adapted for Spire Bushey. The plan wasin date and detailed action to take in event of a majorincident such as a bomb explosion, widespread fire or

flood, prolonged loss of power, heating,communications or water. Staff were aware of the policyalthough they had not received any specific training orcarried out scenarios.

• We saw a departmental action card in outpatients thatdetailing the procedure to follow in case of flooding. Itwas in date and detailed which staff needed to becontacted.

• Staff told us about fire alarm testing occurred everyFriday morning.

Are termination of pregnancy serviceseffective?


We found that:

• We found that audits in line with guidance did notaccurately reflect the patient records reviewed.

• We did not see evidence of conversations regardingcontraception being conducted with patients, orwhether long acting reversible methods were discussed/offered.

• Screening for sexually transmitted diseases was notundertaken for women undergoing TOP. There were noprocesses in place for patient referral to obtainscreening. This does not comply with national guidance.

• A post-abortion advice line was not available to patients24 hours a day.

• Consultants did not document that a patient hadcapacity to consent to the termination procedure, therewas no prompt for this within the pre-assessmentpaperwork.

• Patients were not routinely asked about sharinginformation with their GPs.

• Patients were not routinely provided with dischargesummaries following their treatment, there was noevidence of this being offered to all patients.

However we found:

• Some policies and procedures that were in line withnational guidance were in place within the service,these had been reviewed within the necessary timeframe.





• Procedures were in place to ensure effectiveness of bothmedical and surgical terminations; the service had a 0%failure rate.

• Both consultants who provided the termination servicewere suitably qualified and competent to carry out theprocedures.

• Staff had access to relevant guidelines, policies andprocedures in relation to termination of pregnancyservices.

• All care records we reviewed contained signed consentforms from patients. Possible side effects andcomplications for each type of termination weredocumented and the records showed that these hadbeen fully explained.


• Policies and procedures were in place, and had beenreviewed within the necessary time frame. All staff wespoke with knew which policies were relevant totermination of pregnancy services and how to accessthem. Not all policies were developed in line withDepartment of Health RSOP and professional guidance.

• We did not see evidence that contraceptive optionswere discussed with patients during their initialassessment. Staff told us that most patients weredischarged with a week’s supply of a contraceptive pill,but that long acting reversible contraceptive (LARC)methods were not fully discussed. Staff told us thatoccasionally they would fit an intrauterine devicefollowing a surgical termination but that this did nothappen often. This was not in line with RSOP whichstate services should be able to provide all methods ofcontraception, including long acting reversiblemethods, immediately after termination of pregnancy.Patients were not given information to take awayregarding contraception. We raised this with seniormanagers and during the unannounced inspection on 4August we saw an action plan to address this.

• Screening for sexually transmitted diseases was notundertaken. Some patients received prophylacticantibiotics that would treat chlamydia; (One type ofsexually transmitted disease) however; there were notrecords of this in all patient notes. Guidance states thatpatients should be screened for chlamydia duringassessment and also a risk assessment completed toestablish whether other sexually transmitted diseasesare likely. There were no processes in place to referpatients to an alternative provider if they were at high

risk of other sexually transmitted diseases. We raisedthis with senior management and during theunannounced inspection on 4 August we saw an actionplan to address this.

• Whilst the service audited some aspects of patient careand outcomes they did not audit all aspects of RSOP 16,which states, subject providers should audit include:▪ Waiting times▪ The outcome of consultations; the number of

women who do not proceed to a termination▪ The use and availability of pathways to specialist

services for women with significant medicalconditions and to antenatal care for women decidingto continue their pregnancy

▪ The availability of a female doctor for women whowish to consult a woman - especially those fromcertain cultural backgrounds and ethnic minorities,with arrangements for non-English speaking women.

▪ The number of staff competent to provide allmethods of reversible contraception

▪ Patient choice across the range of service provisionto include follow-ups, contraception and abortionmethods

▪ Patient experience for those who have returnedhome after taking the second medicine for atermination of pregnancy

▪ Rates of complications▪ The prevention of infective complications▪ Failure rates▪ The number of women who have had repeat

abortions and whether they left the service withsuitable contraception including uptake of LARC

▪ Patient experience▪ Complaints/critical incidents▪ Number of patients who return for follow-up

appointments.• Areas not audited included outcomes relating to patient

experience of those who take the second dose ofmedicine home, the number of patients who do notproceed to termination following consultation andnumber of patients who have repeat abortions andwhether LARC were provided to those patients.

Pain relief

• Pre and post-procedure pain relief was prescribed forpatients undergoing a surgical termination. If a local





anaesthetic was administered this was documentedwithin patient records. Patients were routinely providedwith non-steroidal anti-inflammatory medicines, alongwith paracetamol and codeine where required.

• Patients choosing medical abortion were givenanalgesia at the time of the termination and a smallsupply was given to the patients for them to take home.

• Doctors we spoke with demonstrated a thoroughunderstanding of pain relief requirements for patientsand what advice they would give to patients followingtreatment. Patients were provided with a leaflet on“managing your pain” following their termination toprovide them with advice at home.

Patient outcomes

• Spire Bushey carried out some of the auditsrecommended by RCOG, such as consent for treatment,options of abortion, confirmation of gestation andcontraception discussion. We found that in some areasthe audit findings did not accurately reflect ourobservations of patients’ records during the inspection.For example the service kept a register of anti-Dinjections that had been administered. However, auditscarried out had identified that no patients since Januaryhad received anti-D; this was contradictory to recordswe reviewed which showed two patients had receive it.We also saw contraception had been supplied to threepatients but the audit stated no patient had beenoffered contraceptives in line with guidance. This meantthat the service could not accurately show they weremeeting RSOP and guidance.

• Patients who had had early medical termination wereseen within the hospital 10-14 days after their initialtreatment; this was to perform an ultrasound to checkthe effectiveness of the procedure.

• Patients who had undergone a surgical terminationwere advised if the procedure had been effective afterthe surgery, we saw this was also documented on theirrecord.

• Information provided by the service showed that in thelast 12 months there had been no failed terminations,either by early medical and surgical methods.

• Patients were offered two options relating to earlymedical terminations up to eight weeks gestation. Firstlythey could take the initial dose of medicine in thehospital, and then return two days later for asubsequent medicine to be administered (a vaginal

pessary or oral tablet), or they could take the secondmedicine away with them to take in their own home.Patients left the hospital to pass products of conceptionin a place of their choice.

• Documentation audits of HSA1 forms were carried outevery three months. The hospital reported a 100%compliance rate for the period January 2016 to June2016. However both patient records we identified as nothaving a reason stated for termination had been markedin the audit as having a reason documented. This meantthe audits were not being completed accurately andtherefore learning was not identified in relation to thecompletion of records and no actions had been taken toaddress non-compliance with the completion of HSA1forms.

• The Department of Health requires every providerundertaking termination of pregnancy to submit detailsof the pregnancy and demographical data using a HSA4form, recording demographic and other data for everytermination of pregnancy performed within 14 days.This information was audited by the hospital and wesaw 78% compliance of evidence of a HSA4 form beingcompleted and sent between January 2016 and June2016. This is not compliant with the Abortion Act whichstates that the Chief Medical Officer must be sent theHSA4 within 14 days of the abortion taking place.

Competent staff

• Both consultants who performed surgical terminationsat the hospital were consultant surgeons and membersof the RCOG. Both consultants had been revalidated byan NHS trust in the previous 12 months and hadreceived appraisals.

• One consultant had very recently left the NHS; there wasnot a system in place to ensure their competence tocarry out terminations once revalidation was againrequired. We raised this with senior managers at thetime of inspection, who told us they would review theprocess.

• All assessments, ultrasounds and treatments in relationto terminations were carried out directly by the twoconsultants.

• Staff told us they had regular annual performanceappraisals. Information provided showed that 100% ofstaff had completed an appraisal in the 12 months priorto our inspection.

Multidisciplinary working (related to this core service)





• We observed medical, nursing and non-clinical staffworking well together, and all staff we spoke with told usthat they could approach each other to discuss anyconcerns they had about a patient or the treatment theywere being provided with.

• There were no links with external agencies in relation totermination services, including for contraception andsexual health services.

• The hospital had a service level agreement in place withthe local NHS trust, which allowed them to transfer apatient to the hospital in case of medical or surgicalemergency.

Seven-day services

• Spire Bushey offered termination of pregnancy serviceson Tuesday, Thursday and Saturday.

• The RSOP set by the Department of Health recommendsthat patients should have access to a 24 hour adviceline, which specialises in post-abortion support andcare. Spire Bushey had a general hospital helpline thatcould be accessed 24 hours a day, however out of hoursthere were no staff that could provide specificpost-abortion advice to patients. Staff were unsure whothey would refer patients to if they had questions ornon-emergency problems post-abortion out of hours.We raised this with senior management during theinspection and at the unannounced inspection we sawactions were in process to introduce a dedicated postabortion 24 hour advice line via a service levelagreement with another provider.

• Out of hours, patients could phone the ward staff forgeneral advice and the consultant could be contacted ifrequired.


• Staff had access to relevant guidelines, policies andprocedures in relation to termination of pregnancyservices.

• Each patient was sent a medical questionnaire tocomplete prior to attending the hospital; patients werealso able to complete this during their time in thehospital. The medical questionnaire provided staff withinformation on any medical conditions to ensure theycould safely be treated at Spire Bushey. Patients whowere not suitable for treatment would be referred to themost appropriate facility to their needs.

• Patient records were paper based, with surgicaltermination records kept by the hospital and earlymedical termination records kept by the consultant whocarried out the treatment.

• Paper versions of HSA1 forms were shared between thetwo consultants in the hospital to provide the tworequired signatures for the treatment to be compliantwith legislation. Signed copies of HSA1 forms were keptin all patient records.

• All patients received the leaflets which provided writteninformation about their post treatment care. The guidehad a section dedicated to recovery, which detailedwhat would normally be expected following treatment.Abnormal symptoms were also listed, with informationon what patients should do if they experienced any ofthese.

• The Department of Health RSOP states that whereverpossible the patient’s GP should be informed abouttheir termination of pregnancy. Within patient records itwas not documented whether the patient had beenasked about correspondence with their GP. If a patienthad expressly declined any correspondence this waswritten as a note on the front sheet of their record butno documentation of a discussion with patients aboutsharing of information. Because discussions aroundinformation sharing with GP were not documented wecould not see any evidence of GPs being informed if apatient consented.

• Patients were not routinely given discharge summariesof their care documenting what had been carried out.Staff told us that many patients did not want to takeinformation home with them due to the private natureof the procedure. We saw no evidence that patientswere asked if they would like their dischargeinformation.


• We reviewed the hospital policy ‘consent toinvestigation or treatment and found it wascomprehensive, in date and compliant with nationalguidance such as NICE.

• All care records we reviewed contained signed consentfrom patients. Possible side effects and complicationsfor each type of termination were documented and therecords showed that these had been fully explained.

• When patients expressed any doubts about treatment,staff carefully discussed their concerns. Patients were





offered a second consultation if they were not entirelysure about their decision to terminate the pregnancy,this meant there was no pressure on patients to decideto have an abortion.

• Staff we spoke with were aware of the Mental CapacityAct and could describe the process of assessingpatient’s capacity, but medical records did notdocument whether a patient had capacity to consent.

• Both consultants had received training in relation to theMental Capacity Act.

Are termination of pregnancy servicescaring?


We found that:

• Staff showed an understanding of the compassionateand emotional support that patients required duringand after a termination.

• Patients were well supported to make decisions abouttheir care.

• Pre and post abortion counselling was accessible to allpatients.

• All consultation were held in private rooms.• The hospital wide friends and family survey, which

included both NHS and private patients scored above97% for the number of patients who would recommendthe hospital between April 2015 to March 2016.

Compassionate care

• Whilst we did not observe any interactions with patientsrequiring termination during our inspection, staffcontinually spoke of the need to be kind andcompassionate towards patients and respect theirdecisions at all times.

• Staff told us that patients’ preferences for sharinginformation with their partner or family members wereestablished, respected and reviewed throughout theircare.

• Staff told us they had received ‘thank you’ cards frompatients expressing their thanks for the dignified andrespectful way their treatment was carried out.

• Feedback forms were provided by the hospital topatients undergoing terminations, however this wascollated as hospital wide feedback and results could notbe segregated to show feedback specifically frompatients who had undergone a termination.

• The hospital wide friends and family survey, whichincluded both NHS and private patients scored above97% for the number of patients who would recommendthe hospital between April 2015 to March 2016. Theresponse rates were on average 34% for the same timeperiod, which is in line with the England nationalaverage.


• Patients could request a chaperone to be presentduring consultations and examinations and there weresigns displayed to inform patients that this support wasavailable.

• Staff told us that, during the initial assessment with apatient, they explained all the available methods fortermination of pregnancy that were appropriate andsafe. The staff considered gestational age and otherclinical needs when suggesting these options topatients.

• Staff supported patients who needed time to considertheir decision. We saw in the patients notes that asecond consultation was offered, with a date and timethat was convenient for the patient.

• The Department of Health requires every providerundertaking termination of pregnancy to submit detailsof the pregnancy and demographical data using a HSA4form, following every termination of pregnancyperformed. The Department of Health RSOPrecommends that every patient is told that the contentof the HSA4 is used for statistical purposes by theDepartment of Health and data published isanonymised. Staff told us that patients were informed ofthis process during their consultation and reassuredthat their personal information would be kept safe andconfidential.

Emotional support

• Staff told us that all patients requesting an abortionwould be offered the opportunity to discuss theiroptions and choices with, and receive psychologicalsupport from a trained counsellor.





• Patients who were upset, anxious or unsure about theirdecision were given extra time and support.

• All patients were offered counselling services pre andpost treatment. Contact numbers were also providedand patients could make an appointment forpost-abortion counselling if needed.

• Staff told us they discussed potential emotionspost-abortion with all patients, this included regret,depression and sadness. Staff told us they reassuredpatients that these were common feelings for patientsfollowing an abortion and advised them on how to dealwith these emotions and when to seek further support.

Are termination of pregnancy servicesresponsive?


We found that:

• Services were easily and readily accessible to patients.• Clinics were available at various times throughout the

week, including one weekend day.• All pre and post abortion care was carried out at the

hospital.• There had been no complaints about the service within

the last 12 months.• Translation services were available if required.


• Services were planned and delivered in a way that metthe needs of the local population. The importance offlexibility, choice and continuity of care was reflected inthe services provided to patients.

• Spire Bushey is easily accessible by public transport orcar, and is in close proximity to Watford and itssurrounding area. There was parking directly outside thehospital. The premises were suitable to carry outtreatment and aftercare for patients seeking terminationof pregnancy.

• At Spire Bushey, termination of pregnancy clinics werecarried out on Tuesday, Thursday and Saturday. Ifpatients needed to access services outside of theiropening hours or at weekends, they could besignposted to alternative provider.

• Patients were either referred by their GP or self-referred.Staff told us that all patients in the previous 12 monthshad self-referred and were self-funded.

Access and flow

• Patients booked their appointments throughtelephoning the hospital directly, appointments wouldthen be booked by consultants’ medical secretaries.

• Staff told us that patients could be offered a provisionalsame day service, where they were booked on the sameday for an appointment, assessment, ultrasound scanand treatment, for early medical terminations. Thisallowed patients to access the hospital and terminationservices quickly if required. Patients were assessed fortheir suitability for this.

• The hospital offered all aspects of pre-assessment care,including discussions about pregnancy options,ultrasound scans to confirm pregnancy and gestation,and medical assessments.

• All patients completed a pre-consultation questionnaireeither over the phone, by email or in person prior totheir appointment. Consultations were face-to-face witha consultant who undertook all aspects ofpre-assessment care, including counselling, medicalhistory, ultrasound scanning to confirm pregnancy anddetermine gestational age and screening tests.

• If patients were assessed as having a gestation of over16 weeks, they were referred to another provider asappropriate. If there was suspicion of an ectopicpregnancy, they were referred to a local NHS acutehospital for immediate further assessment andtreatment.

• The Department of Health RSOP recommend thatpatients should be offered an appointment within fiveworking days of referral and they should be offered theabortion procedure within five working days of thedecision to proceed. The service monitored itsperformance against the waiting time guidelines set bythe Department of Health. Data provided by the serviceshowed that in the last 12 months, 96% of patients wereprovided with treatment within five days of initialassessment.

• The percentage of patients treated at less than 10 weeksgestation is a widely accepted measure of howaccessible abortion services are. Information providedby the service showed that 65% of patients were seen atless than 10 weeks gestation. This is worse than thenational average of 80%.





• Patients could contact Spire Bushey in order to make anappointment for post-abortion counselling.Post-abortion face to face counselling was available toall patients following their treatment.


• The service was accessible to patients living withdisabilities and the area where consultations and earlymedication terminations were carried out was situatedon the ground floor and disabled toilet facilities wereavailable.

• Lifts were available throughout the hospital to accessareas where surgical terminations were carried out.

• Translation services were available for patients who didnot speak English, via a telephone translation service.Staff knew how to access this if required, but told usthey had never needed to.

• Patients were given leaflets during their initialassessment which had information regarding differentmethods of termination and options available forabortion. Information leaflets were only displayed inEnglish but were available in any other language onrequests. However, staff we spoke with did not knowhow to access written information in other languages.

• All patients were asked how they would preferpregnancy remains to be dealt with, they could eitherallow the hospital to dispose of them, or make their ownarrangements for burials. We saw forms present in eachrecord we reviewed that showed women had beenasked their preference and this had been adhered to.This was in line with RSOP national guidelines.

• Following surgical termination the pregnancy remainswere stored separately from other clinical waste andwere collected from the hospital and sent forincineration.


• Spire Healthcare Limited’s corporate complaints policydirected the management of complaints and timescales for responses. This was in line with industrystandards. All complaints were reviewed by the clinicalgovernance committees and medical advisorycommittee (MAC) and actions as a result of thecomplaint shared with individual departments via teammeetings

• There were effective systems in place for managingcomplaints within the hospital.

• There had been no complaints about the termination ofpregnancy service between May 2015 and May 2016.However, staff told us they were aware of the complaintsprocess, and how to refer patients if they wished tomake a complaint.

Are termination of pregnancy serviceswell-led?


We found that:

• Termination of pregnancy governance processes werenot always effective. There was no evidence that thequality or management of the service was discussed orreviewed at any committee meetings.

• Action plans were in place following audits; howeverthey were not always effective or robust enough toaddress compliance findings.

• Audits did not always identify non-compliance withguidance.

• There was non-compliance with some aspects of thenational guidance.

However we found:

• There were appropriate supporting policies andprocedures in place for termination services, these werereviewed annually.

• Clinical audit plans were in place.• The corporate risk register identified the appropriate

risks relating to the service.• There was an inclusive and team-working culture

throughout the service, with a drive for effective patientcare.

Leadership / culture of service

• The service was overseen daily by the outpatientdepartment manager and lead by the head of clinicaland non-clinical services who reported directly to thehospital director.

• Staff told us that there was generally a good culturewithin the hospital and staff were all supportive of eachother within their daily roles. Staff told us they felt it wasimportant to provide safe and effective care to patientsat all times.





• Some staff felt that high turnover of nurses throughoutthe whole hospital sometimes impacted on culture asthey felt it took longer for staff to understand practicesand the ‘family’ nature of the hospital. The hospital hadexperienced a period of high staff turnover in theprevious 12 months due to changes within shiftpatterns.

• The hospital maintained a register of patientsundergoing a termination of pregnancy, which is arequirement of regulation 20 of the Care QualityCommission (Registration) Regulations 2009. This wascompleted for each patient at the time the terminationwas undertaken and was retained for a minimum ofthree years, in accordance with legislation.


• Spire Bushey had a clear vision and strategy in place.The hospitals values were; caring is our passion,succeeding together, driving excellence, doing the rightthing, delivering on our promises and keeping it simple.

• Staff were aware of the organisation’s values andstrategy and were committed to providing a qualityservice.

• There was no specific strategy in place for termination ofpregnancy services.


• The clinical governance committee met quarterly. Thiscommittee had an overview of governance risk andquality issues for all departments. Senior departmentleads attended. Information discussed included safetyalerts, learning from incidents, policy updates andaudits. However, governance procedures were notalways effective within the termination of pregnancyservice, because audits were inaccurate and there was alack of action plans in place for addressingnon-compliance with guidance and regulations.

• A clinical audit plan was in place. Staff told us that auditoutcomes were shared with members of the service andalso discussed at governance meetings. However, wedid not see any items relating to termination ofpregnancy services having been discussed at theprevious three quarters clinical governance meetings.Audits carried out included medical and surgicaltreatments and completion of HSA1 and HSA4 forms.However, we found these audits did not accuratelyrepresent patient records and the care provided to

them. This included completion of HSA1 and HSA4forms, and also administration of anti-D. We did not seeevidence that the termination of pregnancy service wasdiscussed at any meetings.

• Two records we reviewed did not have a reason for thetermination documented on the HAS1 form. We raisedthis with the head of clinical services for furtherinvestigation as this had not been identified within thenecessary audit. This was non-compliant with theAbortion Act 1967.

• There were action plans in place following recordsaudits, which documented the action, who wasresponsible for overseeing its completion and acompletion date. Audits for both Q1 and Q2 2016 notedthe same actions: ensuring the TOP register wascompleted, copy of HSA4 form to be placed in recordsand for consultants to complete clinical recordsappropriately. There were no actions in relation to HSA4forms being completed and sent in the necessarytimeframe, contraceptive advice or sexual healthscreening, all of which were noted as non-compliant inaudits. HSA1 completion was not an action as it had notbeen identified as non-compliant during audits.

• The Department of Health requires every providerundertaking termination of pregnancy to submit detailsof the pregnancy and demographical data using a HSA4form, following every termination of pregnancyperformed. We saw from audits that this was not alwaysdocumented within patient’s record. If a HSA4 form isnot completed for each patient, this is non-compliantwith the Abortion Act 1967. Action plans were in placefollowing audits; however non-compliance with HSA4form completion was not noted within them. Thereforewe were not reassured of the validity of the auditprocess and that actions were being discussed atrelevant committees to review or improve the service.

• The service held a licence from the Department ofHealth (DH) to undertake termination of pregnancyprocedures within Spire Bushey Hospital. The licence ispublically displayed within the outpatients department.

• Legislation requires that for an abortion to be legal, twodoctors must each independently reach an opinion ingood faith as to whether one or more of the legalgrounds for a termination is met.They must be inagreement that at least one and the same ground is metfor the termination to be lawful. We saw all completedHSA1 forms had two signatures.





• The organisation had a corporate risk register whichincluded various areas of risk identified, such as healthand safety, clinical incidents and infection control. Therewas one risk that related to medicine management ofabortifacient medication, due to the serious incidentrelating to dispensing these medicines to anunregistered location to provide the service.


• There were a number of methods of communicatingwith staff, such as, the newsletter ‘Bushey Tales’, emailsand team meetings as well as information on computerscreen savers and the hospital social network page.

• There was a hospital wide staff forum which metquarterly. Staff told us this helped keep them motivatedand well informed of changes and news across thehospital.

• The hospital operated a “Policy of the month” schemewhere one policy every month was highlighted to raiseawareness and compliance with staff across thehospital. An audit would take place to ask staff if theyhad read the policy and understood the content. Wesaw evidence of the audits and action plans were staffwere required to re-read the policy to become familiarwith the contents.

• A patient experience and complaints committee met aspart of the existing governance structure to ensurepatients’ experiences and complaints were used toimprove quality and customer service.


• There had been no innovations in relation totermination of pregnancy services, however staff told usthat if they felt processes or patient care could beimproved then this would be supported by the hospital.





Outstanding practice

• The formulation of the ‘Pink Petals’ support group wasinspired by the needs of the local community andprovided an accessible platform for all patients to gaininformation and support to help them manage theirconditions.

Areas for improvement

Action the provider MUST take to improve

• The hospital must ensure that HSA1 and HSA4 formsare completed in line with the Abortion Act 1967 for allpatients.

• The hospital must ensure there is a process to ensurethat all equipment used within the hospital is clean,safe, well maintained and stored safely at all times.

• Take reasonable practicable action to provide a safeservice for children and young people.

• Meet the requirements for staffing levels for children’sservices in accordance with the Royal College ofNursing standards for clinical professionals and servicemanagers, ‘Defining Staffing Levels for Children andYoung People’s Services’, (2013) .

• Ensure there is access to a registered nurse (childbranch) available to advise on the management andcare and treatment of children and young people.

• Ensure staff that have responsibility for assessing,planning, intervening and evaluating children’s care,must be trained to level three in safeguarding children.

Action the provider SHOULD take to improve

• Ensure effective governance processes are in placeand that termination of pregnancy services auditsreports to a committee to review results and actionplans.

• The hospital should ensure that all audits relating tothe termination of pregnancy service accurately reflectfindings in patient records.

• The hospital should ensure that it is documentedwithin patient notes following a termination ofpregnancy whether consent to share information withtheir GP has been given or declined.

• The hospital should consider installing clinical handbasins in patient bedrooms when refurbishing thedepartment in line with latest infection controlguidelines.

• Consider replacing carpets in consulting rooms andsome hand wash basins in patient bedrooms tocomply with health building notice (HBN) regulations.The floor coving in patient bedrooms and bathroomswas not compliant with infection control guidelines.

• Ensure that MCA capacity assessments are alwaysrecorded in line with organisational policy andguidance.

• Ensure medical notes are always available for staffwho are treating patients in the outpatientsdepartment.

• Ensure consultants do not bring mobile equipment touse without being able to evidence how it is cleanedand maintained.

Outstandingpracticeandareasforimprovement

Outstanding practice and areasfor improvement


Action we have told the provider to takeThe table below shows the legal requirements that were not being met. The provider must send CQC a report that sayswhat action they are going to take to meet these requirements.

Regulated activity

Diagnostic and screening procedures

Surgical procedures

Treatment of disease, disorder or injury

Regulation 17 HSCA (RA) Regulations 2014 Goodgovernance

(1) Systems or processes must be established andoperated effectively to ensure

compliance with the requirements in this Part.

(2) Without limiting paragraph (1), such systems orprocesses must enable the registered person, inparticular, to

(a) assess, monitor and improve the quality and safety ofthe services provided in the carrying on of the regulatedactivity (including the quality of the experience of serviceusers in receiving those services)

(c) maintain securely an accurate, complete andcontemporaneous record in respect of each

service user, including a record of the care and treatmentprovided to the service user and

of decisions taken in relation to the care and treatmentprovided.

How the regulations were not being met:

Not all HSA1 forms had the reason for the termination ofpregnancy highlighted on the form.

There was no audit trail or process in place to ensureHSA4 forms were sent to the Department of Healthwithin 14 days in accordance with the Abortion Act 1967.

The TOP audits were inaccurate and there was lack ofdetailed action plans for addressing non-compliancewith guidance and regulations.

TOP services were not discussed at any committeemeetings to review or improve the service.

Regulation

This section is primarily information for the provider

Requirement noticesRequirementnotices


One consultant brought his own ultrasound machine, wewere not reassure this was clean, safe, well maintainedand stored safely at all times.

Regulated activity


Surgical procedures


Regulation 18 HSCA (RA) Regulations 2014 Staffing

1) Sufficient numbers of suitably qualified, competent,skilled and experienced persons

must be deployed in order to meet the requirements ofthis part.

(2) Persons employed by the service provider in theprovision of a regulated activity must—

(a) receive such appropriate support, training,professional development, supervision and

appraisal as is necessary to enable them to carry out theduties they are employed to perform.

How the regulation was not being met:

There was a lack of registered nurses (child branch) tocare for young people on the ward.

Not all staff were trained to the right level insafeguarding. This did not meet the Royal College ofPaediatrics and Child Health (RCPCH) guidelines or thosecontained in the Intercollegiate Document (March 2014)which states that clinicians who are potentiallyresponsible for assessing, planning, intervening andevaluating children and young people’s care, should betrained to level three safeguarding.

Regulated activity


Surgical procedures


Regulation 20 (Registration) Regulations 2009Requirements relating to termination of pregnancy

CQC (Registration)

Regulation

Regulation




(2) The registered person must ensure that, unless twocertificates of opinion have been received in respect ofthe service user

(a) no termination of pregnancy is carried out; and

(b) no fee is demanded or accepted from a service user.

How the regulations were not being met:

Not all HSA1 forms had the reason for the termination ofpregnancy highlighted on the form.




Action we have told the provider to takeThe table below shows the legal requirements that were not being met. The provider must send CQC a report that sayswhat action they are going to take to meet these requirements.


Enforcement actionsEnforcementactions


Documents

Spire Bushey Hospital NewApproachComprehensive Report … · 2020. 2. 2. · LetterfromtheChiefInspectorofHospitals Wecarriedoutanannouncedinspectionon26and27July,12September2016and13December2016,withan