Everyone we spoke with told us that they had been treated with respect by staff and that they were aware of the treatments that they needed. This told us that people’s privacy, dignity and independence were respected.

The individual care pathways seen were linked to the procedure carried out and demonstrated a holistic approach to care. We noted that any variations to planned care were recorded and actions to address these documented. This showed us that people experienced care, treatment and support that met their needs and protected their rights.

We saw that the hospital was clean and that the provider was paying due regard to the code of practice for health and adult social care on the prevention and control of infections and related guidance. This meant that people were protected from the risk of infection because appropriate guidance had been followed.

The records seen showed us that there were sufficient staff on duty to meet the needs of the people receiving care and treatment during the inspection. We saw that people who needed additional assistance received this from staff. This showed us that there were enough qualified, skilled and experienced staff to meet people’s needs.

We noted that any complaints received had been managed in line with the provider’s policies and procedures. Each complaint had been investigated fully and responded to. This demonstrated to us that there was an effective complaints system available.

We spoke with six people who were receiving care and treatment in this service. They reported that they were aware of the treatment they were having and confirmed that they been involved in discussions with their consultant surgeon and their consultant anaesthetist regarding their specific surgical procedure. They confirmed that they had signed the relevant consent form for their surgical procedure. They also spoke highly of the support shown by nursing staff and confirmed that if they had any questions or queries; these were addressed promptly.

People also reported that they were satisfied with the level of care and attention shown by staff and some people were complimentary about the food provided and the kindness shown by individual staff.

We also spoke to some visitors to the service and they confirmed that they were happy with the standard of care that they had observed whilst visiting their relative.

Spire Norwich Hospital is part of Spire Healthcare Limited. Spire Norwich offers comprehensive private hospital services to patients from Norfolk and East Anglia. The hospital is located on the outskirts of Norwich with easy access to main driving routes and the local NHS Trust.

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, 49 bed inpatient ward, six day case beds, two chemotherapy chairs and five chemotherapy beds. There were also three high dependency beds (HDU) advertised for use within the hospital. Theatre provision includes three theatres, two with laminar flow and a sterile services department. From April 2014 to March 2015 there were 6,262 visits to theatre.

Inpatient services for children under the age of 16 are not provided at Spire Norwich. Children are seen within the outpatient and diagnostic imaging departments for consultation appointments.

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

We carried out an announced inspection of Spire Norwich Hospital on 13 April 2016. Following this inspection we also undertook an unannounced inspection on the 26 April 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

All services at this hospital were inspected during our visit.

We rated Spire Norwich Hospital as ‘Good’ overall with all core services achieving a good rating. However safety was rated as requires improvement within medical services and outpatient and diagnostic imaging services.

There was a cohesive, responsive senior management team that supported and empowered staff to deliver a high standard of patient focused care.

Our key findings were as follows:

Are services safe at this hospital/service

• There was a good incident management system at the hospital. Staff across all core-services were aware of incident reporting requirements and there was evidence of learning and improvement following serious incidents.
• 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. In Q1 2016 the Spire Norwich hospital was achieving or exceeding target in 82% of areas measured (32 of 39 measures were green which indicated results above the Spire target)
• Effective systems were in place for the management of medicines, the prevention and control of infectious diseases and ensuring equipment and the environment was maintained.
• Nurse staffing levels across the hospital were planned and met consistently.
• Safeguarding procedures were in place and staff received regular safeguarding training (combined level 1 and 2). However, staff in oncology services could not describe circumstances in which they would escalate safeguarding concerns.
• Staff in outpatients had been trained to safeguarding children and young people, levels one and two combined, and not level three as is required by national guidance. The outpatient manager was level 3 trained but there was a risk that, at times, that there may be no staff on site with the appropriate level of training.
• Spire Norwich had a resource in place for children’s appointments to have staff from another Spire site attend but there was no mechanism to check that these staff had appropriate level of training.
• We identified a number of out-of-date sealed sterile packs during our inspection. We brought this to the attention of the management team who took immediate action and implemented a process to prevent recurrence.
• There were processes in place to report, investigate and monitor surgical site infection and VTE compliance alongside incidences of DVT.
• Mental Capacity Act (MCA) training and Deprivation of Liberty Safeguards (DoLS) training was included within the mandatory training program. However, nursing knowledge of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) was limited. None of the staff spoken to with were able to describe the practical application of the MCA or DoLS within their role.
• Not all records, including consent forms, were fully legible with amendments appropriately documented.
• A single patient record was not held on site although the hospital was taking steps to address this. However at time of inspection not all consultants’ records were readily available and documentation that was available was limited in content.

Are services effective at this hospital/service

• Hospital policies were evidence based and referenced national guidance and legislation where applicable.
• Food and drink was available throughout the day and patient’s dietary requirements were taken into consideration and provided for.
• There was good multidisciplinary team (MDT) working across the hospital. All services worked closely with the local NHS Trust to ensure consistency in patient care for NHS patients.
• The hospital met 100% of its CQUIN targets for 2015/16.
• Patient reported outcome measures (PROMs) data from April 2014 to March 2015 showed satisfaction, in line with the national average, in relation to patient outcomes following hip and knee surgery.
• Bed occupancy was below 80% throughout 2015 meaning access to beds and flow through the hospital was achieved easily.
• There was a good level of local auditing taking place across the hospital.
• There were good processes in place to obtain consent from patients.
• However, the hospital did not participate in all national audits for which it was eligible, particularly in relation to oncology services.
• The Spire target for compliance with the pre-operative fasting guidelines was 45%. The hospital was meeting this with results ranging between 50 and 70% in 2015; however this meant that up to 30% of patients were at risk of having fasted for a prolonged period.

Are services caring at this hospital/service

• Patient feedback received in person, on-line and via CQC feedback cards was positive. Patients felt able to ask any questions they had in relation to concerns and felt that these were answered appropriately by consultant or nursing staff.
• Friends and family Tests data (FFT) showed that 97% patients who responded in January 2016 were likely to recommend the hospital.
• A chaperone service was available to support patients undergoing intimate examinations.

Are services responsive at this hospital/service

• Outpatients had no waiting lists for patient’s due to attend clinics.
• Services were available for patients with additional needs, for example translation services and the ability for relatives to stay in the hospital with patients who require additional support.
• Formal training on dementia was provided to all staff within the ‘Compassion in Practice’ mandatory training module and at the time of our inspection, and 92% of staff had completed this module.Staff also had a clinical briefing on Dementia produced by the central team. Two senior members of staff were acting as dementia leads and a point of contact for staff requiring more information about dementia issues. It was not common for people living with dementia to be admitted to this hospital and a further training programme was due to be rolled out within the hospital from May 2016.
• The oncology service was flexible and able to provide additional days and sessions should the demand for the service increase.
• Medical review was available 24 hours a day seven days a week via clinics, the on-call system and via the respnsible medical officer (RMO).
• There was a robust system for dealing with, and learning from patient complaints. Spire Norwich had been asked to share their processes with other hospitals in the group to share best practice.

Are services well led at this hospital/service

• The hospital group had a clear vision and strategy underpinned by a set of core values for staff to follow. Staff we spoke with were aware of the vision, values and strategy for the service.
• Governance processes were well established. This included incident management, audit, policy management and learning from complaints. Information flow between key committees was well documented and there was a cohesive staff force with regards to issues and actions being taken to improve services.
• Robust systems were in place for ensuring consultant’s practising privileges were monitored and reflected scope of practice.
• There was an open transparent attitude to serious incidents which involved both duty of candour to the patient, but also an open learning environment for staff with the support from senior management.
• Within 2015 Spire Norwich held 13 educations seminars for the general practitioner (GP) community and 51 GP practice-based educational events, such as ‘radiology and urology update’ which was an hour’s evening session, and a lunch and learn training session delivered by a consultant urologist which were free events and could be used to build continued professional development (CPD) credits.
• The oncology service achieved MacMillan Cancer support accreditation for being a good environment to be treated for cancer in 2014.
• However, the service had been advertising a level 2 critical care service, when this service was not being provided. This was brought up during our inspection and an evaluation of the service was taking place. At the time of our unannounced inspection agreement had been reached to rebrand the service as an enhanced recovery service. This appropriately described the services on offer.

We saw several areas of outstanding practice including:

• Diagnostic imaging services used two software packages to allow both internal and external based staff the ability to view imaging and reports. There was a web based secure connection for consultants and radiographers to access imaging and reports whilst not located in the hospital. This software allowed secure access to documentation and images via iPad and mobile phones.
• There was a robust system and database in place which was used to record and monitor consultants competencies, completion of mandatory training, continued professional development, personal development review, indemnity, and revalidation. This information was considered as part of a rolling programme within the medical advisory committee (MAC) meetings, before being signed off by the hospital director and matron in order to re-establish consultant practising privileges.
• There was an exceptional senior management team leading the hospital. The Hospital director, matron and MAC chair had clear oversight on the running of the hospital. They were all aware of the key risks and challenges as well as united in the future of the hospital. Staff had nothing but praise for the management team, stating they were visible, approachable and promoted an open culture.

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 have a robust system of monitoring the quality of records.
• Ensure that all staff that care for children complete level 3 safeguarding children training, in line with the intercollegiate document published by the Royal College of Paediatrics and Child Health. Ensure that there are suitably trained staff on duty, at all times, when children are seen and treated.

In addition the provider should:

• Ensure that all staff have access to major incident training and drills.
• Ensure staff understand the requirements and practice of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.
• Review governance processes to ensure a greater level of management oversight with regards to oncology services.
• Consider participation in national audits related to cancer services where possible.
• Ensure that the quality of records, including consent forms, is improved to ensure documentation is clear, legible and accurate.
• Ensure that all departments are aware of risk management policies and procedures for the hospital. Furthermore, the provider should satisfy itself that all relevant risks to the safety and wellbeing of staff and patients have been identified and are being managed.
• Ensure that the medicines cupboards are locked at all times.
• Review preoperative fasting arrangements for patients and ensure regular monitoring to evidence improvement.
• Ensure there is a clear and well understood service specification for the provision of enhanced recovery care.
• Ensure auditing of RMOs awake periods during the night to assess safety of 24/7 working pattern and compliance to the European working time directive.
• Ensure that there is a system in place which allows people with specific needs, for example people with learning disabilities or dementia, to be identified prior to admission and flagged to appropriate staff so that additional needs can be considered.
• Review the safeguarding training and procedures to ensure that all staff are aware of what would constitute a safeguarding concern.

Professor Sir Mike Richards

Chief Inspector of Hospitals