We inspected Spire Harpenden Hospital and found it to be visibly clean and staff were available to assist people on arrival. We saw that the hospital had an out-patients department and also short stay and long stay wards. We were told that nursing staff would work in both the long stay and short stay wards in order to gain full experience of the different types of nursing care required for people.

People we spoke with told us that the hospital was 'fine' and they had 'no complaints' about the care that had been provided to them. We were told that the hospital provided them with all the information they needed to make an informed decision about the procedure they would be undertaking, and that the consultants 'checked everything' before they went into surgery. People said that the nursing staff were 'lovely and kind' and that they 'couldn't fault them'.

We found that the provider was meeting the regulations. People were asked for their consent before any treatment was carried out. Medication was stored and dispensed in a manner that protected people from any risks. Staff at the hospital told us that they felt supported by the provider and that there was sufficient numbers of suitable qualified staff to care for people’s needs. The provider also had a detailed complaints procedure in place and worked with people to improve on the service that was provided to them.

The people we spoke with said they were provided with useful information and felt involved in the discussions and decisions made about their care and support. They said they had received an assessment of their needs and felt well supported by a caring and friendly staff team who were always available for them and always knew what to do to assist them. The people we spoke with said they had no concerns about the service, but had seen information on how to raise concerns if they needed to.

During our visit we found people's contribution to discussions and decision making about their care to be documented. We saw that people received an assessment of their needs and these were updated regularly. We saw that an adequate staff team was available to meet the needs of the people who use the service. Staff were completing a program of mandatory training and were knowledgeable in such things as protecting people from the risk of abuse.

We found that the service had quality monitoring systems in place and people had a variety of methods available for them to share their views and opinions about the service. We noted that where actions to prevent the recurrence of incidents or changes to improve the service were required these were completed.

One person said of her experience of Spire Harpenden Hospital: "It's a very good service and if needed I would happily use it again." Another person said: "I would recommend this place to everyone."

We carried out an announced inspection visit on 12 and 13 April 2016 and an unannounced inspection on 25 April 2016.

Our key findings were as follows:

Overall the hospital was rated as good.

Are services safe at this hospital?

• 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. However in surgery we found that ‘I am clean’ stickers were not always dated.
• 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.
• Staff were suitably qualified and skilled to carry out their roles effectively and in line with best practice.
• Systems were in place for the prescribing, storage and administration of 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 consultants.
• Safeguarding systems were in place and staff knew how to respond to safeguarding concerns. However, not all staff had been trained to the right level.

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.
• Patient outcomes were audited in surgery; however we found that they were not always formally captured in medical care.
• 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. There was an RMO providing medical cover for patients and clinical support to staff.
• There were arrangements to ensure 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 and had received training.
• 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 identified individual training needs. 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 Friends and Family Test response rates across services were better than the national average. The percentage of patients that would recommend the hospital to family and friends varied between services.
• 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.

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.
• Services included other organisations and general practitioners in planning patient care to ensure a holistic approach.
• Appointments were scheduled according to the patient’s condition and could be arranged as telephone appointments if preferred.
• Appropriate facilities were provided to meet the needs of patients requiring wheelchair access and hearing loop. 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 no toys or books available in the waiting areas specifically for children when they attended outpatients, physiotherapy or diagnostics appointments.

Are services well led at this hospital?

• The hospital had a vision and a set of values. The hospital also had a clear governance structure and a clinical governance committee that met monthly 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 management staff 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.
• Services were being actively progressed through the development of Joint Advisory Group (JAG) accredited endoscopy department and planning palliative care services within chemotherapy.

We saw an area of outstanding practice including:

• Oncology services offered a high standard of personalised care for a variety of patients. This included bespoke appointments, support out of hours and access to specialists. Treatment options were inclusive of new medications and not limited by clinical commissioning. Patients experience was individualised and supportive of their decision-making.

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

Importantly, the provider must:

• Staff who have responsibility for potentially assessing, planning, intervening and evaluating children’s care, must be trained to level three in safeguarding.

In addition the provider should:

• Although there were clinical hand basins in utility areas, there were no clinical hand basins in patients’ rooms. Therefore staff were using these patient sinks at the point of care when it was necessary to wash their hands. Clinical sinks should be available at point of care.
• The floor coving in patient bedrooms and bathrooms was not compliant with infection control guidelines.
• Medicine cupboards in theatres were being left unlocked for convenience when theatres were in use.
• Medication was found to have been prepared in advance and stored in an unlocked fridge.
• When changes were made to theatre lists, the lists were reprinted and the wards informed of the changes. However, the lists were not reprinted on different coloured paper, which is not best practice. This meant that there was an opportunity for errors to occur if there had been multiple changes in list orders. By the time of our unannounced visit, work was underway to rectify this.
• Medical representatives visiting theatre did not have their identification routinely checked, as they and the companies they represented, were well known to the theatre staff.
• Patient outcomes in oncology were not formally captured.
• Consider the effective management processes required for out of hour endoscopy emergencies.
• Although there was some participation in national audits, this was not comprehensive, particularly in medical care and the hospital should consider formally collecting patient outcomes and participate in national audit programmes to enable benchmarking against national standards.

Professor Sir Mike Richards

Chief Inspector of Hospitals