We visited the Spire Bristol Hospital on 4 March 2014. We met with a number of people throughout the day, including patients and their relatives, nursing staff and members of the management team.

We inspected four standards and found that the hospital was meeting these. Patients and their relatives spoke positively about different aspects of the service and their overall experience of the hospital. People were helped with making informed decisions about their care and treatment. One person, for example, told us “everything was fully explained”. Another person commented that they were “given plenty of time to talk things through”.

Suitable arrangements were being made for planning people’s care. People who used the service were appreciative of the support they received and how staff went about their work. We heard, for example, that the staff “have time for you” and were “very friendly”. A nurse described the hospital as a “happy place to work which aided people’s recovery”.

The process of recruitment ensured that staff were suitable for their roles and safe to be working with the people who used the service. Patients and their relatives had the opportunity to give feedback about the staff team and the quality of the service they received. We found that a range of surveys and audits were being undertaken so that there was good information about how well the hospital was performing and meeting people’s needs.

One person using the service told us "They told me absolutely everything and then gave me written information to back it up." Another person told us "I feel totally involved in my case." A third person using the service told us "I understood exactly what was happening and was involved in everything, including which sort of anaesthetic they would use."

People’s needs were assessed and treatment and care was planned to enable their individual needs to be met safely and effectively.

There were systems in place to ensure that people were protected from the risk of abuse. We were told by the Deputy Matron (DM) that individual members of staff volunteered as 'Protection of Vulnerable Adults' (POVA) representatives and they were acknowledged, by peers and managers, as the local resource who would be able to make appropriate decisions and contact the local authority safeguarding teams.

There were sufficient staff with suitable skills and experience to meet the needs of the people using the service. One person using the service told us "They're, absolutely, first-rate. I have real faith in them and their skill." Another told us "They're professional, but kind."

We were shown a variety of ways in which the provider used audit, complaints, feedback and incidents to make improvements to the service.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that treatment for the termination of pregnancy was not commenced unless two certificated opinions from doctors had been obtained.

We met and talked with 12 patients and their relatives, 11 members of the staff team across all departments and two consultants. We also spoke with the registered manager and matron of the hospital.

The hospital provides services to children with in patient treatment for people over the age of three years, and a consultation only provision for children under the age of three years. We saw that children's specific care needs and those of their parents were appropriately met to ensure their health and well-being. One family told us "the information and care has been excellent".

We visited every area of the hospital during our inspection. We saw all staff treated people with respect and took care to ensure that their privacy and dignity were promoted.

All 11 patients told us they had been well-informed and felt they had received "excellent" care during their time at the hospital. One person and their relative told us "the consultant told us all the treatment options. I felt I was given time to consider them and ask questions". Another person told us they had been made fully aware of the benefits and risks of their surgery and felt confident to go ahead with their procedure. People also told us their experience of the hospital had been positive and met with their expectations.

One person told us it had been their "best experience ever" of hospital treatment. Another person who had visited the hospital on a number of separate occasions said "the staff were extremely helpful". Two people told us they were apprehensive about being cared for in single rooms; however they had found the staff were very attentive and always “in and out” of their rooms as needed.

Another person told us the administration at the hospital was "excellent" and "my appointment was made very much to suit me and my other priorities." A third person told us "the information I have been given was clear. The staff are very knowledgeable and they have fully answered all my questions".

We were told, and observed; people were welcomed by the reception staff and were kept informed about any period of waiting. People told us members of staff had been "very caring" and "put me at ease". Patients also told us they were given plenty of information about their treatment and medication throughout their episode of care and were not rushed prior to being discharged.

The hospital was clean and in good decorative order. Corridors, patient rooms, clinical areas and other areas were clean, well appointed and equipped. The hospital was free from obstructions and clutter.

Staff we spoke with told us about working at the hospital and how they were supported in their delivery of care. They told us how management assisted them in maintaining their skills and knowledge through training and "enabling excellence" activities, for the benefit of patients care and welfare. Staff told us they receive ongoing training, development and appraisals. They told us they were encouraged to be part of how the hospital assessed and monitored care for the health and well-being of patients. For example two nurses told us of their involvement in auditing patient's notes, while the housekeeping staff spoke of their involvement in infection control audits.

The inspection of Spire Hospital Bristol – The Glen, was part of our programme of comprehensive inspections. We inspected the hospital on 14, 15, 16 September 2016 and unannounced on 29 September 2016.

Our key findings were as follows:

We rated the hospital as good overall. All of the key questions were rated as good in all areas that we rated. However,  we have not rated this service because we do not currently have a legal duty to rate this type of service or the regulated activities which it provides. The report is limited as there was insufficient evidence and a very small number of procedures carried out at the hospital. During the inspection the provider decided to withdraw the termination of pregnancy service at the hospital and removed this as a condition of their registration.

Are services safe at this hospital

• We rated the safety of the hospital as good although some improvements in record keeping were required.
• The hospital had a good safety culture. Staff throughout the hospital were supported and empowered to report incidents and there was clear learning and actions taken as a result of investigation.
• There were processes in place for the duty of candour, and we saw evidence that this occurred sensitively and in a timely manner where things went wrong.
• There were sufficient staff to meet patient needs. The hospital used a recognised nurse staffing tool to ensure sufficient planned staffing levels on inpatient wards. We observed that the actual staffing levels met this. Earlier in the year prior to our inspection, there had been a period of time where the ward had 10 nursing staff vacancies which had an impact on the continuity of care provided to patients, although safe staffing numbers had been maintained through the use of agency and bank staff. Subsequent recruitment had been successful and at the time of the inspection there was only one remaining vacancy.
• There were some radiography vacancies. However, staff were flexing their working patterns to cover this.
• There were sufficient medical staff within the hospital and processes in place to ensure that consultant cover was in place both out of hours and when the responsible consultant was on leave. There was also a resident medical officer (qualified to speciality training level 3 – ST3) on site 24 hours a day, to provide medical care to patients throughout the day and night.
• There were clear processes for recruitment and for engaging consultants under practising privileges. There was clear boundaries on each consultant’s scope of practice, with biennial reviews in place to monitor each consultant’s performance.
• We observed that the hospital was visibly clean and that there was hand washing facilities, hand sanitising gel and personal protective equipment available which staff used. Although there were auditing practices in place for the use of hand sanitising gel by staff, this was by weighing it rather than by observing and auditing staff hand hygiene practice.
• There were low rates of infection at the hospital, with no incidences of hospital acquired methicillin-resistant Staphylococcus aureus (MRSA), methicillin-sensitive Staphylococcus aureus (MSSA), E-Coli or Clostridium difficile. In addition the incidence of surgical site infections was lower than the national average for hospitals in England.
• Medicines were mostly secured safely within the hospital, although not all treatment room doors were locked on the wards and some patients own medicines were left on the reception desks during our inspection. Staff rectified this immediately it was drawn to their attention.
• The ordering, storage, and administration of controlled drugs was in accordance with the Misuse of Drugs Act 1971 and associated regulations.
• Patient records, risk assessments and observational documentation maintained by nursing staff were completed fully, although there were improvements required in the documentation of patient care rounds.
• The maintenance of a single patient record was identified as one of the top three risks in the hospital. This was predominantly as a result of consultants holding their own records which meant that there was not a full and complete record which remained in the hospital. There was an ongoing project in the hospital to rectify this. However, we saw the impact of this in records reviewed during the inspection with incomplete patient records for surgical patients, because consultants had not maintained the hospital patient record fully. This included missing pre-operative consultant records; no consultant record following a patient’s return to the ward from the high dependency unit and an illegible anaesthetic record. All of which contravened the General Medical Council record keeping standards. In addition, there was no evidence of, or consent for medical photography in applicable patient notes, which contravenes the Royal College of Surgeons Professional Standards for Cosmetic Surgery.
• Patient records stored by the hospital were secure and out of sight of patients and visitors.
• There were systems and processes in place to assess and respond to patient risk. The hospital used the national early warning score system (NEWS) and compliance with completion was 100%. In addition the hospital had a critical care outreach team to support ward nurses and patients who were discharged from intensive care.
• The hospital used the World Health Organisation (WHO) surgical safety checklist. We saw that this was fully used in the operating theatre and that surgical safety briefings took place prior to theatre lists in an open manner, including all staff. However, we found that although an amended WHO checklist was available within interventional radiology, this was not always used or completed. When we raised this with the hospital swift action was taken.

Are services effective at this hospital

• We rated the effectiveness of the hospital as good, although some improvement in the monitoring of patient outcomes was required.
• Relevant and current evidence-based practice, guidance and standards were incorporated and used to develop services, care and treatment throughout the hospital. This included the use of care bundles, which were linked to NICE (National Institute for Health and Care Excellence) and other best practice guidance, for example from Royal Colleges. Policies and procedures were also developed in this way.
• The clinical governance group provided sign off of new policies and guidance, linking in with the hospital medical advisory group (MAC), risk committee, quality assurance group and heads of department meetings as necessary. Variations to standard practice were also reviewed and approved or declined via this sign off process. For example, the hospital follows the British Orthopaedic Association guidance on venous thromboembolism chemo-prophylaxis rather than NICE guidance. This was in line with practice in a local NHS trust, but had been thoroughly reviewed in line with evidence prior to approval for use at the hospital.
• Proposed new procedures were authorised by the hospital director, only when reviewed and approved by the medical advisory committee.
• There was an audit programme in place which linked to the corporate and hospital scorecard. This monitored compliance and benchmarked performance against other Spire hospitals for the effectiveness of the service for areas such as: pain score monitoring; evidence of patients with cancer being discussed at an MDT meeting; monitoring compliance with venous thromboembolism (VTE) assessment and prophylaxis best practice. Data supplied showed that the hospital performed well in comparison with other Spire hospitals with the exception of VTE chemoprophylaxis because they used a differing protocol to other hospitals in the group.
• National safety standards for invasive procedures had been introduced in the hospital to ensure continued focus and compliance with the WHO surgical safety checklist. This was an ongoing process and would result in local safety standards for invasive procedures when embedded.
• Patients throughout the hospital received effective pain relief in a timely manner. Assessment tools were used and assessments were monitored and audited quarterly.
• Patients’ nutrition and hydration were monitored and assessed using the malnutrition universal screening tool (MUST). There were effective systems in place to ensure that patients were not ‘nil by mouth’ for extended periods of time.
• The hospital used a clinical scorecard to benchmark all of Spire hospitals key performance indicators, many of which were based on national external benchmarks. They also submitted data to the National Joint Registry, National Institute for Cardiovascular Outcomes Research and patient related outcome measures (PROMs) audits, although they did not always receive outcome data back in order to benchmark and drive improvement in services or patient outcomes. Information about the outcomes of patient’s care and treatment in critical care was not benchmarked against other similar units.
• There were processes in place to ensure that there were competent staff working in the hospital. There was a comprehensive system for approving and renewing practising privileges in the hospital and clear records in place to support this. Hospital staff were able to gain additional specialist training and qualifications associated with their role.
• There was excellent multidisciplinary working throughout the hospital and patient pathway, from prior to admission for a surgical procedure to following discharge. This included engagement at the weekly resource meeting where patients being admitted for a surgical procedure who may have complex or additional needs were highlighted, this included staff from all areas of the hospital including administrative, catering and hotel services.
• Consent was taken effectively for surgical procedures. However, not all consultants documented consent for medical photography. Nursing staff understood the complexities of consent and decision making.
• Staff understood the Mental Capacity Act 2005 and said that they would escalate any concerns to the ward sister or matron should any concerns arise.

Are services caring at this hospital

• Staff within the hospital were seen to be caring throughout, outpatient and diagnostic imaging services were rated as outstanding and all other services were rated as good.
• Throughout the hospital we saw that all staff were caring and compassionate towards patients and their relatives. All were treated with dignity, respect and professionalism.
• Patients spoke highly of the care received. The feedback provided through comment cards during the inspection window was unanimously positive about the whole patient journey. One patient commented that the service had been exceptional throughout. They also stated that “without exception, staff are warm, caring professional and thorough – reception staff, cleaners, catering staff, nurses, consultants – everyone.” A second patient commented that, by all staff, they had always been treated with respect and a listening ear. A third patient commented that the care they had received from the car park on arrival to leaving the hospital had been wonderful, friendly, efficient but not rushed. They also said that staff were happy to answer questions. Another patient said that staff were caring and treated them with dignity as well as medicines.
• The NHS Friends and Family Test was used for all NHS patients visiting the hospital. The response rates were above the England average and the scores were similar to the England average. In addition the hospital carried out their own patient satisfaction surveys which were monitored. Patients consistently rated their satisfaction at 98% or above.
• We observed a caring approach to patients throughout the hospital and there was no difference in the manner, standards or care provided to NHS and private patients. All patients were treated with the same level of care, dignity and respect.
• Patients were involved in their care and staff ensured that they understood what was happening. Carers and relatives were involved in discussions as patients wished, and we observed thoughtful and considerate discussions throughout.
• One patient commented that their fears and anxiety about their surgery had been allayed by the consummate professionalism and kindness of staff throughout the hospital.

Are services responsive at this hospital

• Services were planned and delivered to meet the needs of the population and also patients’ individual needs. Services were planned to complement those in the NHS as well as the needs of the private self-funding and insured patients within the area. This included the development of the cardiac catheterisation laboratory as well as plans to develop day case and endoscopy facilities further at the hospital.
• Services were tailored to patients individual needs during the weekly resource meeting, where all surgical admissions to the hospital in the following week were discussed and planned to ensure that staffing, equipment, catering needs and any key individual needs were made available.
• The hospital took account of and delivered effective care to patients with differing and complex needs such as those living with dementia. Staff were Dementia Friends and had received specific training to support patients living with dementia. They also provided tailored care to meet patients’ religious and cultural needs. Translation facilities were available in the hospital and staff had a clear understanding of how and when they needed to gain access to this support.
• Patients received timely access to assessment, care and treatment. The hospital mostly met the NHS constitutional standard for patients to begin treatment within 18 weeks of referral. There were relatively low levels of cancelled procedures in the year prior to our inspection. Most were rebooked within 28 days of the cancelled procedure. Those that weren’t were due to patient choice.
• Patient transfers from critical care to the ward did not occur outside of core hours, and on the rare occurrence of a delay in transfer from critical care patients were kept informed.
• There were processes in place for the management of complaints. We reviewed five complaints files and found that they were fully investigated, learning and actions were identified and circulated to staff by a number of means. Staff supported patients to make a complaint either formally or informally, although some patients were not aware of how to make a complaint. However, we saw leaflets displayed across all departments which provided this information, and further details were available on the hospital website. There were also posters displayed for patients in English and other languages on how to raise a concern

Are services well led at this hospital

• There was a clear vision and strategy within the hospital which was patient and quality focused. The values of the hospital were clearly articulated by all staff we spoke with throughout the hospital.
• There were very clear governance systems which engaged risk and quality measurement across the hospital. Risks were identified and responded to and quality was measured through the clinical scorecard. Incident and complaint monitoring was thorough and learning was very clear throughout. There was clear visibility of the escalation of issues and risk from wards and departments to the senior management team and feedback to staff within the hospital.
• There were some areas where this could be further strengthened and developed, for example in benchmarking of the quality, outcomes and performance of, in particular, the critical care service.
• The leadership and culture within the hospital was very strong. All staff we spoke with felt supported, not only by their immediate line managers but also by the senior management team in the hospital. There was an overwhelmingly positive morale within the hospital with staff not just proud of the work they did but also about working at the hospital.
• There was clear and visible leadership throughout the hospital. Staff held the leadership team in high regard, and there was a clear open door policy for all managers and leaders in the hospital.
• There was a strong emphasis on promoting the safety of patients and the wellbeing of staff within the hospital, which had developed over the year prior to our inspection. The hospital director and matron had set this tone.
• There was a collaborative working system within the hospital, with action taken to address behaviour and performance which was not consistent with the values of the hospital. There had been initiatives implemented to promote the collaborative working focused around developing a clearer understanding of the challenges and services offered in other departments.

We saw several areas of outstanding practice including:

• The weekly multidisciplinary resource meetings, which involved managing patient risk, staffing and proactive planning for admission and discharge to ensure effective use of resources.
• The provider had direct access to electronic information held by community services, including GPs. This meant that hospital staff could access up-to-date information about patients, for example, details of their current medicine.
• Senior leadership approach to engaging and empowering staff was outstanding. As was the leadership focus on patients and the quality of care delivered. Both staff and the senior management team were resoundingly complimentary of each other’s practices, commitment and ethos towards a shared goal.
• The physiotherapy team consistently went above and beyond their responsibilities in making sure NHS patients did not suffer adverse recovery due to a delay in receiving NHS physiotherapy.
• A new induction for outpatient staff had been developed in conjunction with staff and was tailored to suit their individual needs.
• In the children and young people’s service, nursing staff had two different coloured uniforms, bright pink or blue, and would ask older patients how they would like to be treated, as a child, teenager or adult and would therefore change their nursing uniforms to suit the patient.

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

Importantly, the provider must:

• The hospital must ensure that all patient records are accurate and fully completed records and ensure all surgeons record consent for medical photography and keep copies of photographs in the single patient record. The hospital must continue with its project to create a single clinical record across the hospital and reduce the need for separate inpatient and outpatient medical notes as quickly as possible.
• The diagnostic imaging department must make sure that the WHO surgical safety checklists for interventional radiology are fully completed for every patient and every procedure.

In addition the provider should:

• The hospital should consider the removal of the carpets in corridors where patients and staff have access.
• The hospital should ensure systems are in place to benchmark and compare patient outcomes with other similar critical care units.
• The hospital should take steps to ensure the internet provided has suitable measures in place to protect children and young people accessing inappropriate content.
• The diagnostic imaging department should ensure that they clearly document asking women of child bearing age about the possibility of them being pregnant before radiological procedures taking place.
• The diagnostic imaging department should work closely with the consultant staff to improve the compliance with the proper completion of imaging request forms

Professor Sir Mike Richards

Chief Inspector of Hospitals