Spire Regency is operated by Spire Healthcare Limited. The hospital has 31 beds for inpatients and day cases. Facilities include two operating theatres, the Byron suite which has 18 en-suite bedrooms, the Coleridge suite with either single en-suite rooms or a room that can accommodate two people, and outpatient and diagnostic facilities. There is also an endoscopy unit.

The hospital provides surgery, a very small medical care service and outpatients and diagnostic imaging. We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 11 and 12 October 2016, along with an unannounced visit to the hospital on 19 October 2016.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led. Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with legislation

The main service provided by this hospital was surgery. Where our findings on surgery, for example, management arrangements, which also apply to other services, we do not repeat the information but cross-refer to the surgery core service.

Services we rate

We rated this hospital as ‘Good’ overall. This is because;

• There were adequate systems in place to protect people from avoidable harm and learn from incidents.
• The hospital was visibly clean and well maintained. There were systems in place to prevent the spread of infection.
• There were effective systems in place to ensure the safe storage, use and administration of medicines.
• There were adequate numbers of suitably qualified, skilled and experienced staff to meet patients’ needs. There were effective arrangements in place to ensure staff had, and maintained the skills required to do their jobs.
• People received nutrition and hydration that met their preferences and needs.
• Care was delivered in line with national guidance and outcomes for patients were good.
• There were arrangements for obtaining consent ensuring legal requirements and national guidance was met.
• The individual needs of patients were met including those in vulnerable circumstances such as those living with a learning disability or dementia.
• Patients could access care when they needed it and were treated with compassion. Their privacy and dignity was maintained at all times.
• The hospital management team had the confidence of patients and their team. Staff felt motivated and supported by the management team.
• There was appropriate management of quality and governance at a local level and managers were aware of the risks and challenges they needed to address.

However, we found areas of practice that required improvement across the hospital;

• Duty of candour processes were not always being followed as outlined in the hospital policy.
• Some of the root cause analysis investigation reports reviewed did not always adequately record the learning to improve standards of care.
• There was no process in place at the hospital to risk assess or check areas of non-compliance with all National Institute of Health and Care Excellence (NICE) guidance.
• There was still work to do in terms of agreeing target risk ratings and identifying actions to mitigate all risks identified on the risk register.
• Written information to patients, such as discharge letters and leaflets, was available in other languages or formats on request.
• Although there was a clear committee structure to support governance and risk management, we saw that the quality of the committee minutes and attendance was variable.

In surgery:

• The theatre and the wards did not have entrances that were locked to prevent access by unauthorised personnel.
• The hospital did not use the Q-PROM’s recognised tool to collect data for patients undergoing cosmetic procedures such as breast augmentations.
• A new competency toolkit designed to support the development of staff undertaking the role of a surgical first assistant was still in the draft phase and none of the staff had started or completed an accredited qualification. However, they had been signed off by a consultant as competent to undertake the role and had a mentor.

In medical care:

• The hospital policy regarding the destruction of controlled drugs did not meet all the standards in the Safer Management of Controlled Drugs and Royal Pharmaceutical Society Guidance and the practice within the hospital was not consistent. Some areas were following hospital policy and some were following the national guidance.
• The hospital were not auditing patient outcomes undergoing medical procedures.

In outpatient and diagnostic imaging:

• The turnover rate of nurses was high at nearly 40% in the outpatient department but this figure represents three staff who left in the 12 month period as a proportion of 7 outpatient staff. The turnover for healthcare assistants was low.
• The hospital did not use the World Health Organization (WHO) surgical safety checklist when undertaking minor procedures. However, as the hospital was beginning to undertake more complex procedures they were considering introducing it. The WHO checklist was designed for use in an operating theatre as a safety checklist to reduce the number of potential incidents during surgery.

Following this inspection, we told the provider that it should make other improvements, even though a regulation had not been breached, to help the service improve. Details are at the end of the report.

Ellen Armistead

Deputy Chief Inspector of Hospitals (North)