When we inspected Spire Bushey Hospital we found it to be visibly clean. People we spoke with told us that staff were 'excellent’ and ‘that is why I came back here for my operation’. We were told that people were asked for their consent ‘several times'. We saw that staff were available to assist people and staff we spoke with told us that they 'loved working here’, and they were well supported.

We found that the provider was meeting the regulations we inspected. Patients were being cared for in a clean and well maintained environment. Patient files contained detailed information about the person and their procedure and the provider had gained consent from people at each stage of the process. Staff we spoke with and the records that we received also confirmed that staff were well supported to provide patients with a high level of care and support.

People we spoke to were generally satisfied with the care they received and found the staff to be friendly and helpful. People told us how they were involved in decisions around their treatment and that they received a ‘cooling off’ period prior to committing to any treatment. One person told us, “The nursing staff are very good and caring”.

People on the inpatients ward told us that there was a good choice of food, although the quality of food was not always the standard they expected. One person told us, “The food is average and portion sizes are small”.

The majority of staff told us that there was adequate staffing in order to meet patients’ care needs and that Spire Bushey was a nice place to work.

People told us how their privacy and dignity was respected and that staff always closed the doors when they’re helping with personal care

We observed the hospital to be visibly clean on the day, all the patients appeared to be comfortable in their surroundings.

Overall standards were being met, we identified a small number of issues which we discussed with the manager at the end of our visit for example record keeping for non-mandatory training and the overall standard of the food. We were assured that required action would be taken.

People we spoke with during our visit to the hospital on 25 January 2012 told us of the excellent care they had received from the staff at the hospital. People couldn’t speak highly enough of the caring and kind attitude of staff; one person told us that staff ‘couldn’t be better’, and another called themselves ‘a very satisfied customer’. People told us that staff were available whenever they needed them and that staff checked on them regularly to ensure they were ok.

People told us they had been very well informed about procedures and operations they were having performed at the hospital, both in the outpatient department and during their stay at the hospital. People told us they had been able to ask any questions of the staff to help them make decisions about their care. People we spoke with during our visit did not have any concerns about the equipment being used in their care, and told us that equipment was clean and that staff appeared competent in using it. People told us they were aware of the opportunity to raise any concerns through the patient questionnaire given to them during their stay.

We carried out an announced inspection on 26 and 27 July, 12 September 2016 and 13 December 2016, with an unannounced 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 care were 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.
• 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 to staff.
• 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 planning and 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 treatment they had received.
• The hospital wide Friends and Family survey, which included both NHS and private patients scored consistently above 97%.
• Staff recognised the need to provide patients and their families with emotional support and the hospital had a list of multi-faith contact details should patients require these.
• The hospital had a ‘Pink Petals’ peer support group which provided patients with a number of opportunities to access 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 single use 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 of services provided for cancer support. Part of the assessment related to having a caring and supportive environment where 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 of flexibility, 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 to complaints.
• 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 were dirty 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 were unreliable 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 a clinical 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 an accessible 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’s Services’, (2013) .
• Ensure there is access to a registered nurse (child branch) available to advise on the management and care 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.

In addition the provider should:

• Ensure effective governance processes are in place and that termination of pregnancy services audits reports to a committee to review results and action plans.
• The hospital should ensure that all audits relating to the termination of pregnancy service accurately reflect findings in patient records.
• The hospital should ensure that it is documented within patient notes following a termination of pregnancy whether consent 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 department in line with latest infection control guidelines.
• Consider the floor covering in consultation rooms and in patient bedrooms which were non-compliant with infection control 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.

Professor Sir Mike Richards

Chief Inspector of Hospitals

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