Spire Wellesley Hospital is operated by Spire Healthcare Limited Spire Wellesley Hospital offers comprehensive private hospital care to patients from Southend-on-Sea and the rest of Essex. This includes patients with private medical insurance, those who self-pay and patients referred through NHS contracts. . Facilities include three operating theatres, a stand-alone endoscopy suite and X-ray, outpatient and diagnostic facilities.The hospital provides surgery, medical care, services for children and young people, and outpatients and diagnostic imaging. At our previous inspection of the hospital, 16 & 17 May 2016 we inspected surgery, medicine, outpatients including diagnostic imaging and services for children and young people. We rated surgery, medicine and outpatients as good and services for children and young people as inadequate. This inspection was to follow up on the specific concerns we found in children and young people’s services. The hospital suspended all surgical procedures for children and young people following our last inspection. The hospital reinstated a full service for children and young people in August 2017.

We inspected this service using our comprehensive inspection methodology. We carried out the announced inspection on 19 June 2018.

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 the Mental Capacity Act 2005.

The main service provided by this hospital was surgery. Services for children made up a small proportion of activity at the hospital from August 2017 to May 2018, 81 surgical procedures were conducted on children and young people.

Services we rate

We rated this service as good overall.

• There were risk assessments and procedures in place to safeguard children and young people from abuse. The service had robust incident reporting systems and there was evidence of learning from incidents.
• There were measures to monitor and manage children and young people including signs of deteriorating health. We found systems in place that reflected national, professional guidance and legislation to keep people safe.
• Staffing was planned and continually monitored in accordance with the needs of the service.

• Care and treatment was planned and delivered with current evidence based guidance and standards with a holistic approach to care. Relevant audits were used to assess compliance with best practice.
• Staff were qualified and had the relevant skills for their role and were encouraged to undertake specialist training in their field of expertise. We saw that staff had received an annual appraisal and were supported in the revalidation process.
• We saw that children and young people received care from a range of staff and services, which worked in collaboration to achieve the best outcomes for their patients.
• Children and their families reported that staff were kind and compassionate when tending to their needs. Staff consistently included their patients and families in the care delivery and promoted their dignity.
• The emotional needs of the patients were embedded in the care provided. Parents were able to accompany their child to theatre and be present in recovery to give extra emotional support.
• The services were flexible to meet the needs of children and their families with processes in place to ensure continuity of care. Children had timely access to appointments and procedures, which were arranged at a convenient time for children and their parents.
• The needs of individual children were taken into account when planning and delivering services. Staff had found innovative ways to use equipment as distraction to reduce anxiety.
• The hospital had a robust complaints procedure. We found that there had been no complaints about the service for children and young people from June 2017 to May 2018.

• There was strong leadership from the hospital director and department managers. The leadership team drove continuous improvement through actively seeking feedback from staff and service users.
• The hospital had a strategy to improve services for children and young people and the set objectives were being met.
• There was a clear governance structure and this demonstrated a proactive approach to managing risk and quality improvement of services.
• Staff were committed and cared about the services they provided and were supported by their managers. There were mechanisms in place to maintain staff and service user engagement. We saw that the hospital worked in close collaboration with the local NHS trust.

However, we also found the following issues that the service provider needs to improve:

• The service should make provision for a children’s waiting area in the outpatients department, however the hospital had plans to develop a children’s waiting area during planned refurbishment work.

Following this inspection, we told the provider that it should make improvements, even though a regulation had not been breached, to help the service improve.

Heidi Smoult

Deputy Chief Inspector of Hospitals

Surgery – Theatres

• There was evidence of lessons learned from incidents that had taken place with changes in practice. However the changes to practice were not fully embedded with some development required with staff training and competencies.
• Risks and incidents were shared with staff across the hospital and other hospitals in the provider group through staff meetings and alerts.
• Staff had received equipment training provided by manufacturers with records demonstrating this had taken place. However the records did not sufficiently detail who was trained to use the different equipment models or the content of the training provided.
• Laminated quick reference user guides were attached to safety critical equipment for staff to use when setting up the equipment.
• Theatre staff competency packs were generic and not role specific which limited manager oversight of the completion of competencies required for individual roles in theatres.
• The hospital had a comprehensive asset management register in place suitable for equipment management including staff training. However this was not being used to track staff asset training with a reliance on paper based competencies.
• Theatres had comprehensive risk assessments in place for safety critical equipment.
• The hospital risk register covered all departments to give the senior management team and heads of department oversight of the risk profile for the hospital. The risk entries had an allocated risk owner and action owner.
• There were four theatre practitioner vacancies in theatres that had not been recruited. The hospital was actively advertising these posts.

Spire Wellesey Hospital is a privately run hospital in Southend on Sea, Essex. The hospital is one of 39 hospitals run by the private healthcare group Spire Healthcare Ltd.

The Care Quality Commission (CQC) carried out a comprehensive inspection on 05 November 2014. The reason for undertaking this scheduled inspection was to assess the compliance at the service following an increased number of never event incidences in the previous year and ensure that outstanding compliance actions had been complied with. The two key identified risk areas which required follow up were never events around wrong site surgery and an increase in the number of pulmonary embolism’s post surgery.

For the purpose of the comprehensive inspection we undertook an on-site review of surgery and outpatient services. The on-site element of the inspection involved a team of experts by experience (service users), clinical associates (experienced healthcare professionals) and CQC inspectors. The team is divided into subteams, each of which looked at one the service lines described above. The subteams were led by an experienced inspector, supported by clinical experts.

Prior to the CQC on-site inspection, the CQC considered a range of quality indicators captured through our monitoring processes. In addition, we sought the views of a range partners and stakeholders. A key element of this are the focus groups with healthcare professionals and feedback from the public.

The inspection team make an evidence based judgment on five domains to ascertain if services are:

• Safe
• Effective
• Caring
• Responsive
• Well-led.

We have not rated this inspection as it was conducted as part of our piloting of the independent sector methodology.

Our key findings were as follows:

• Caring and compassionate care was evident in all areas.
• Staffing levels met the safe staff level guidelines, using national benchmarks, with the support of bank and agency number, additional staff support was arranged where patient need required it.
• The service had a robust process for appointing medical staff to the service with practicing privileges.
• The diagnostic service was very responsive to patient needs in relation to the turn around times for results.
• The high dependency service is part of the main surgical service and the facilities are underutilised which could affect staff competency and skills.
• The majority of areas throughout the hospital were visibly clean with the exception of the ground floor and first floor dirty utility and clean utility rooms.
• The service has a wide bore MRI scanner which is unique in the East Anglian region.
• Practice around the reporting and investigating serious incidents was improving but further work was needed to embed learning from incidents.

We saw the following areas of outstanding practice:

• Scan results were available quickly for the majority of patients. On the day of our visit a number of scans were reported within 60 minutes of the scan taking place.

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

Importantly, the provider must:

• The provider must improve the ground floor and first floor dirty utility and clean utility rooms to ensure they comply with regulation and provide a clean environment for the safe handling and disposal of medicines.
• The provider must ensure that learning from serious events is implemented to protect patients from avoidable harm.

In addition the provider should:

• The provider should consider opportunities and use of the wide bore MRI scanner to determine if it could meet patient demand in the East Anglian region.
• The provider should review the work undertaken by the high dependency unit (HDU)to ensure staff remained skilled in their HDU competencies.
• The provider should ensure that equipment stocked in clinical areas is within its expiry date.
• The provider should provide training to all staff on the Mental Capacity Act 2005.
• The provider should provide training to all staff on Dementia awareness

Professor Sir Mike Richards

Chief Inspector of Hospitals

This was a responsive review to follow up on the last planned inspection on the 10 October 2013 where we found that the provider was operating an ineffective system to monitor consultants' practising privileges. We also checked assessment practices and incident management systems as there had been a significant increase in the number of notifications regarding clinical incidences in the hospital in the last eight months.

We found that the provider had taken adequate steps to ensure that all consultants working at the hospital were robustly checked to ensure they were appropriately qualified and competent to provide safe care to patients.

We looked at assessment practices because of the number and types of incidents reported to us recently. We found that the provider had put in additional checks to improve patient safety regarding risks of developing blood clots post-surgery and also prosthesis checking practices for safe joint replacement surgery.

We found that the provider did not have a consistent effective incident management system in place to ensure changes to treatment or care provided was actioned in a timely manner to always protect patients from incidents that had the potential to do harm.

We spoke with three people who were recovering following surgery. Each person said that they had completed a consent form prior to undergoing treatment. They said they had been given good information about the procedure they underwent before they signed the consent form and that the doctor had checked that they were happy with the information they had been given the form to sign. They all felt that their pre-admission assessment had been very thorough and were pleased with the standard of care and treatment they received. They told us that staff were very caring.

People with whom we spoke said that staff were very helpful and respectful. They said they had received good information from the hospital about their treatment and options available. They were also made to feel comfortable about providing feedback. They said they were very happy with the standard of care and treatment they have received.

Spire Wellesley Hospital is part of Spire Healthcare Limited. Spire Wellesley Hospital offers comprehensive private hospital care to patients from Southend-on-Sea and the rest of Essex.

This includes 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 30 bed inpatient ward, eight day case beds and three extended recovery unit beds. Theatre provision includes four theatres, two with laminar flow and a sterile services department. From January 2015 to December 2015 there were 7525 visits to theatre. Spire Wellesley Hospital also provides elective routine surgery for children aged three years to 18 years with consultation appointments within the outpatient and diagnostic imaging departments.

The hospital had a comprehensive inspection in November 2014 following an increased number of never event incidences in the previous year. The hospital was not rated following this inspection as it was conducted as part of our piloting of the independent sector methodology.

We inspected this hospital as part of our independent hospital inspection programme. This was the second comprehensive inspection of Spire Wellesley Hospital. The inspection followed the Care Quality Commission’s comprehensive inspection methodology. It was a routine planned inspection.

We carried out an announced inspection of Spire Wellesley Hospital on 16 and 17 May 2016. Following this inspection we also undertook an unannounced inspection on 31 May 2016, to follow up on some additional information.

The inspection team inspected the following core services:

• Medical care

• Surgery

• Services for children & young people

• Outpatients and diagnostic imaging

We rated Spire Wellesley hospital as requires improvement overall, with all services rated as requires improvement except medical care which was rated good overall.

Children’s and young people’s services were rated as inadequate for safety following significant concerns. Subsequent to the inspection we served the provider a warning notice on 30 June 2016 under Regulation 13 (Safeguarding service users from abuse and improvement) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and told the provider they must make improvements. We will follow this up and report on our findings.

Our key findings were as follows:

Are services safe at this hospital:

• Incidents were not reported as required within the children’s service or diagnostic imaging service.
• The resuscitation equipment for children was not standardised across the hospital.
• There were no risk assessments in place to ensure the environment and access onto the ward was secure and provided safety for children. We raised this issue with senior hospital managers who responded and took immediate action.
• Whilst there was reference to child abduction in two of the provider’s policies there was not a specific child abduction policy in place, and staff were not aware of the hospital’s policies and procedures in relation to child abduction, nor where they could access these.
• Compliance with level three safeguarding training was poor across all staff levels and job roles.
• Where incidents were investigated, root cause analysis (RCA) reports had limited recommendations or action plans.
• There was a lack of hand hygiene practice observed in children & young people’s services.
• The hospital did not achieve its target for grade two pressure ulcers, inpatient falls or incidents of venous thromboembolism events (VTE) in 2015.
• Documentation was not robust. Consultant records were not always legible and were often brief and undetailed.
• A small number of Consultants kept outpatient medical notes for patients, including the initial referral letters, off site. However, the hospital has a process in place in order to access these documents on request.
• Security of patient information was not robust, notes were unattended and computer screens left unlocked. We raised this issue with senior hospital managers who responded and took immediate action.

Are services effective at this hospital:

• Oncology services worked to recognised national guidelines. Local audits had been undertaken and improvement made as a result.
• Pain management was appropriate to ensure adequate pain relief for patients. Oncology services worked with palliative care specialists to ensure end stage pain relief requirements were met.
• Nutrition and hydration was appropriately assessed.
• Patient Reported Outcome Measures (PROMs) data from April 2014 to March 2015 was above the England average following hip replacement and knee replacement.
• There were good processes in place to obtain consent from patients in children & young people’s services and medical care.
• Systems were in place to ensure safety checks and maintenance of equipment.
• One-hundred per cent of staff had received an appraisal in 2014 and 2015.
• Local service policies did not reference evidence based practice, relevant legislation and national guidance.
• Staff knowledge about the Mental Capacity Act and Deprivation of Liberty Safeguards was not consistent.
• We raised concerns during the inspection that written consent had not been undertaken in the outpatient department for a procedure involving injection into the joints. Senior staff took action following our concerns to improve practice.
• Multidisciplinary team meetings did not occur for children & young people’s services.
• There were no specific audits undertaken for children & young people’s service.

Are services caring at this hospital:

• Patients provided consistently positive feedback about the care that they had received.
• There were positive interactions between staff and patients in all areas.
• Friends and Family Test data (FFT) showed that 100% of patients who responded in March 2016 were likely to recommend the hospital. The hospital had consistently scored above 98% since March 2015.
• Within medical care services, each patient had a named nurse with overall responsibility for their individual care.
• Children had a dedicated registered nurse (children’s branch) who oversaw their care throughout their admission.
• “ISpire” children’s booklets explained information in a child friendly manner to help ensure children understood aspects of their care.

Are services responsive at this hospital:

• Patients had access to care when they required it.
• There was a resident medical officer (RMO) on site 24 hours a day, seven days a week, to provide medical care and advice.
• Provision of support services such as physiotherapy, radiography, pharmacy and theatres out of hours was via an on call system.
• In 2015 the clinical scorecard showed that 75% of patients felt prepared for discharge, which was above the Spire target of 71%.
• Oncology patients were provided with unique individual patient folders and could choose an appointment time that suited them.
• Staff were aware of equality and diversity and information was available for patients from varying cultures and religious beliefs.
• Provision was available to allow relatives and parents to stay overnight when required.
• There was evidence across services that feedback received from patients had been acted on and examples of this were displayed in waiting areas through “You said we did” posters.
• The children & young people’s service did not robustly capture and monitor the number of cancelled operations.
• There were no dedicated children’s play areas or waiting rooms throughout the hospital and a lack of toys and entertainment for children and young people.
• The hospital had received an increase in complaints between 2014 and 2015 which was comparative to an increase in patient volumes. There was no formal system for monitoring patient satisfaction with the complaints process.

Are services well-led at this hospital:

• There was a lack of effective governance and oversight at senior management level.
• We found significant concerns with regards to children and young people’s services, particularly in relation to the governance arrangements in place to ensure children and young people accessing services were safeguarded from abuse and improper treatment. Furthermore, there was a lack of medical leadership for children and young people’s services, no multidisciplinary team meetings took place for the service and children and young people were not well represented at the medical advisory committee (MAC) meetings. This meant there was no platform at senior level for challenge or scrutiny into the running of children’s services at this hospital.
• Policies and procedures were not reviewed regularly and there was a lack of oversight in relation to the management and development of policies and procedures. We raised this issue with senior hospital managers who responded and took immediate action.
• Risk management systems were ineffective. There were no risks on this register, or any separate register, which related to children and young people’s services although during our inspection we identified many risks which required addressing.
• Root cause analysis (RCAs) and subsequent actions plans were not always completed in detail. Root causes were not always identified which meant potential additional actions were missed.
• There was a reluctance to accept the seriousness of the concerns we raised following our inspection, specifically with regard to security of records and aspects of consent. However subsequent actions were taken by the senior team to address issues.
• The medical advisory committee (MAC) regularly reviewed consultant’s applicability, from a safety perspective, to continue treating patients under their practising privileges. We also saw evidence of clinical governance issues, including incidents that had been reported, being reviewed regularly at the MAC.
• Staff were aware of the vision, values and strategy for the service.
• Staff told us that they felt well supported by management, and members of the higher management were described as friendly and approachable. However, in the 2015 staff survey an average of only 64% of staff answered positively to questions about senior leadership and 58% of staff answered positively to questions about working together, although this was in line with the Spire average.
• Staff described an open culture at this service and felt able to raise concerns.
• The oncology service achieved MacMillan Cancer Support accreditation for being a good environment to be treated for cancer.

We also saw several areas of good practice which included:

• The care provided by staff to patients and their relatives was seen to be compassionate, kind and dignified.
• Feedback about the service from patients and relatives was consistently positive. The 2015 Friends and Family Test data demonstrated that between 99% and 100% of patients would recommend the hospital.
• The service benefited from a committed and loyal workforce that understood the vision and strategy for the hospital.
• There was strong local leadership within the oncology service.
• Nursing documentation was clear and up to date with all necessary care plans and risk assessments having been completed.
• Patients felt their pain was managed effectively.
• There were clear and understood procedures in place to support people living with a learning disability when they accessed the service.

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

Importantly, the provider must:

• The provider must ensure that a safeguarding children policy and an abduction policy are developed and implemented. These must reflect the requirements of the local children’s safeguarding board and other relevant local and national guidance.
• The provider must ensure that processes are in place to ensure appropriate safeguarding risk assessments are undertaken for children and young people accessing services.
• The provider must ensure that all staff working with or responsible for children and young people are trained to the appropriate level for safeguarding children and young people.
• The provider must ensure that there is an effective governance system which yields sufficient management oversight of all the services provided at the hospital.
• The provider must ensure there are effective systems which allow it to assess, monitor and improve the quality and safety of all services
• The provider must ensure there is an effective risk management system to protect the health, safety, and welfare of service users and others who may be at risk.
• The provider must ensure that records are stored securely at all times and that consultant entries are legible and contain all relevant information

In addition, the provider should:

• The provider should consider the environment where children and young people are cared for so it meets their needs with a separate waiting area and age appropriate materials.
• The provider should consider reviewing the arrangements in place to ensure the appropriate storage of medicines and blood products.
• The provider should consider reviewing the prescription arrangements in oncology where there were two systems running.
• The provider should consider reviewing infection control arrangements in relation to effective hand hygiene practices.

• The provider should consider improving staff awareness of the needs of patients living with dementia and for patients whom may need a translation service because their first language is not English.
• The provider should consider improving the level and quality of competency checks provided to staff to ensure they remain competent in their roles.
• The provider should consider additional training for all staff to ensure understanding and practical application of the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards (2009

Professor Sir Mike RichardsChief Inspector of Hospitals

Professor Sir Mike Richards

Chief Inspector of Hospitals