Spire Hartswood Hospital is part of Spire Healthcare Limited. Spire Hartswood offers comprehensive private and NHS hospital services to patients from Essex and surrounding areas. The hospital is located with easy access to main driving routes such as the M25 and A12 and is in close proximity to three NHS Trusts.

Healthcare is provided to patients with private medical insurance, those who self-pay and patients referred through NHS contracts. Hospital facilities include an outpatient service, diagnostic imaging service, a 25 bed inpatient ward which includes two extended recovery beds and a 26 bedded day case ward which includes five endoscopy pods. Theatre provision consists of three theatres, two with laminar flow and a sterile services department. From January to December 2015 there were 7,220 visits to theatre.

We inspected this hospital as part of our independent hospital inspection programme. This was the first comprehensive inspection of Spire Hartswood Hospital. The inspection was conducted using the Care Quality Commission’s comprehensive inspection methodology.

We carried out an announced inspection of Spire Hartswood Hospital on 3 May 2016. We also undertook an unannounced inspection on the 13 May 2016, to follow up on some additional information.

The inspection team inspected the following core services:

• Medicine (specifically oncology services)
• Surgery
• Outpatients and Diagnostic Imaging

During 2015, the hospital had provided in patient services for children and young people. However, at the time of our inspection, these services had been suspended pending a full quality review. We therefore did not inspect these services.

We rated Spire Hartswood Hospital as requires improvement overall, with core services achieving good overall in medicine and requires improvement overall in surgery and outpatient and diagnostic services.

Our key findings were as follows:

Are services safe at this hospital/service

• Staff were aware of the incident reporting system however incident investigation and route cause analysis’ (RCA) following incidents were often lacking detail.
• Adult and Child Safeguarding training was completed by 95% of all staff including bank staff across the hospital in 2015.Training records showed that 27% of Spire Hartswood hospital staff in February 2016 had completed the annual update of adult safeguarding training and 20.6 % for child safeguarding training against a quarterly target of 25%. The hospitals safeguarding policy had not been adapted for local use. Effective systems were in place for the management of medicines and the prevention and control of infectious diseases.
• Infection control and prevention mandatory training compliance for January and February 2016 were 33%, which is higher than the quarterly target of 25%. The hospital infection control lead carried out annual on-site refresher hand hygiene training for all staff and regular audits, including patient perception of healthcare workers hand hygiene. Reports were monitored through the Infection Control Committee, Clinical Governance Committee, Clinical Effectiveness Committee.

• Mandatory training compliance for 2015 at quarter four was 84%. This was below the target of 100% based on the trusts 25% quarterly target compliance. Between January 2016 and February 2016 overall mandatory training compliance was 18% (against quarterly target of 25%).

• The levels of compliance of multidisciplinary team (MDT) discussions for oncology patients were poor, ranging between 5% and 10%.However since the introduction of the new information technology system in December 2015, compliance for quarter four had increased to 100% for breast cancer patients.

• Documentation in nursing care pathways was not robust. Medical review details were often limited, lacked detail or not present.
• The hospital did not have a single or unified patient record. Consultants kept their own patient records to which the hospital did not have unrestricted access.

• The hospital collected data to support the safe running of the service. The clinical scorecard showed the hospital group target for aspects of care across all five domains. The hospitals clinical score card data was predominantly positive. Compliance with national early warning score (NEWS) completion and pain assessments were above Spire target.

Are services effective at this hospital/service

• Hospital clinical policies were evidenced based and used national best practice guidance and staff attended network events, such as infection control, to share learning and promote best practice.
• Patient reported outcome measures (PROMS) from April 2014 to March 2015 and National Joint Registry data was positive, with 93% of patients undergoing hip and knee surgery reporting an improvement in their health.
• New national guidance were discussed and minuted within clinical governance meetings and circulated to relevant clinicians, but not formally minuted for relevance to implementation within the hospital.
• Appraisal rates amongst staff exceeded the hospitals target of 75%. The Enhanced Recovery Unit (ERU) lead nurse was using an adapted and shortened National Competency Framework for Critical Care Nurses (NCFCCN) to up skill ward staff in the care of level one patients.
• Pain assessments were undertaken on patients and pain relief prescribed and administered as required.
• Patient’s had access to food and drink throughout their stay and dietary requirements were taken into consideration and provided for.
• Staff had good knowledge and understanding of Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS).
• Local audits were conducted for service improvements however there was a lack of scrutiny or challenge.
• The majority of consent was undertaken on the day of surgery. This followed an outpatient consultation where risks and benefits of treatment options are initially discussed and in line with Spire’s consent policy (FIN 07).
• Local audits were undertaken by individual areas own lead staff which meant that there was the lack of challenge or peer review.

Are services caring at this hospital/service

• Patient rating excellent for overall care and attention provided by staff in the patient experience data for 2015 was above the Spire target of 85%.
• Between July 2015 and December 2015, the hospitals Friends and Family Test (FFT) results were 100%.
• Patient feedback during the inspection was all positive with patients speaking highly of the care and treatment received. Patients and relatives felt involved in decision making and felt supported.
• Chaperone services were available and utilised to support patients when required.
• Videos and podcasts were available on the hospital website demonstrating what patients could expect when coming into hospital and providing consultant discussions about various conditions.

Are services responsive at this hospital/service

• Patients had access to care when they required it with referral to treatment time (RTT) for admitted patients consistent for the majority of 2015. RTT times were met for 11 of the 12 months of 2015 for outpatient and diagnostic imaging patients.
• Services were available for patients with additional needs and in house dementia training was being run by a member of staff who was also a ‘dementia friend’. However support for patients with pre-existing mental health conditions was lacking.

• Information could be obtained in other languages via a translation service, however staff were unsure how to utilise this.

• There had been a decreasing number of patient complaints, from 72 complaints in 2013 to 47 in 2015. Staff were unable to provide a specific example of when practice or procedures had changed following patient feedback, however posters entitled “you said, we did” were displayed in the patient waiting areas showing changes in practice which had happened as a result of complaints of incidents reported to the hospital.
• The Spire target for compliance with the pre-operative fasting guidelines was 45%. The hospitals clinical scorecard for 2015 showed results that ranged between 50% and 60% compliance. This meant that at least 40% of patients were at risk of extended periods of fasting prior to surgery.

Local audits on start and finish times in outpatients had been introduced in February 2016 to monitor delays and over runs. At the time of inspection ten weeks data had been collected, but data was not available for any themes or trends to be identified.

Are services well led at this hospital/service

• Whilst governance processes were in place at the hospital they did not work effectively or support a continuous learning and improvement culture. There was an inconsistent approach to learning from incidents and the quality of root cause analysis (RCAs) were poor. This meant that appropriate learning was not being identified in order to drive improvement.
• Senior management oversight of the hospital’s governance arrangements was limited. Formal processes for information sharing around governance issues were not well established and a key member of the leadership team was not well informed about pertinent issues facing the hospital.
• We reviewed minutes from the clinical governance committee and medical advisory committee and noted a lack of challenge and scrutiny at senior level.
• Risk management systems were not used appropriately. From the risk register dated March 2016 we found that controls to mitigate risk had not been identified. This meant that the effectiveness of mitigating actions could not be monitored.

• The 2015 staff survey showed a lack of staff confidence in senior leadership, working together, and service quality.
• Within oncology, audits were in place to monitor multidisciplinary meetings, as well as patient feedback surveys. There were a number of quality indicators that were in process of being introduced which included chemotherapy workload and scalp cooling audits. However, these were not in place at the time of our inspection.
• There were good processes to monitor consultants practicing privileges
• Staff felt engaged in the running of the hospital and were rewarded via the hospitals recognition scheme “Inspiring People” which gave staff the opportunity to be recognised and valued for their work.
• There were examples of innovation and sustainability such as plans to build a new hospital locally to deliver a modern, spacious and well-designed hospital.

We saw several areas of good practice including:

• Participation with networks to promote best practice. The hospital implemented and hosted the Essex group discussion of complex knee surgery.
• Pod-casts presentations were available for patient and public access in relation to a variety of clinical procedures offered, via the hospital website.
• It should be noted that the hospital responded to areas of concerns raised during the inspection and undertook some immediate responses. An action plan was produced however changes need to be embedded and monitored

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

Importantly, the provider must:

• Adopt a single patient record system, ensuring that all patient records are up to date, contain relevant information, include medical and nursing notes, patient risk assessments and administration pathway records. The hospital must also make sure records are available and legible.

In addition the provider should:

• Review governance process to ensure a greater level of management oversight. Including the role of the MAC
• Review the process for root cause analysis (RCA) and ensure a robust, consistent approach to analysing incidents and identifying lessons to be learnt. Improve process for sharing lessons and actions following incidents.

• Ensure completion of refurbishment to remove all carpets from areas where clinical interventions may take place such as patient rooms.
• Review the methodology currently in use for monitoring hand hygiene and consider undertaking hand hygiene audits to evidence effectiveness of hand washing.
• Ensure the quality of records is improved and monitor to ensure documentation content is clear, legible and accurate. Improve the recording of review by medical staff within the patient care record.
• Review preoperative fasting arrangements for patients and ensure regular monitoring to evidence improvement.
• Ensure fire escapes are left clear and review storage options for mobile imaging equipment to ensure these are not a hazard.

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Professor Sir Mike Richards

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Chief Inspector of Hospitals

We spoke with four people who used the service. They told us that they had been involved in deciding the course of treatment that they received. One person told us, "When I saw the consultant they told me exactly what would happen. They discussed the other options that were available and told me about the possible side effects of the treatment."

People were very satisfied with the care and treatment that they had received. One person told us, "The staff are lovely, really nice and very friendly. They put you at ease."

On the day of our inspection we saw that the premises were clean and bright. The reception area was bright and welcoming. Rooms were clean and bathrooms and toilets all had liquid soap and paper towels for hand-washing.

We spoke with two staff members. They told us that they had received regular supervision and appraisal. They said that they were encouraged and supported to undertake training suitable for their jobs and to enable them to progress in their careers.

People told us that they would recommend the service to other people. One person told us that they had used the service as a friend had recommended it to them. The service undertook an annual customer satisfaction survey of people who had used the service. The results for the year 2013 showed that people had rated their experience as excellent or very good in approximately 90% of the responses received.

People using the service were given clear information on which to make informed decisions and give consent. One person said, “I was given a good explanation and a booklet that was very understandable. I signed the consent when I was admitted.”

Records that we looked at showed people’s needs were assessed and care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare.

People told us they received care and treatment that meet their needs. One person said, “I have received fantastic care and treatment here. They are very attentive and nothing is too much trouble. Staff respond really quickly if you ring the bell.”

We saw that the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. This included staff training and guidance and safe recruitment practices.

There was an effective complaints system available. Comments and complaints people made were responded to appropriately.