Spire Clare Park Hospital is operated by Spire Healthcare Limited. The hospital provides surgery, medical care, out patients and diagnostic imaging services for adults, children and young people. Following national guidance, inpatient surgical services and outpatient physiotherapy services were only offered to children age three and above.

We carried out the inspection on 30 May 2018.This was a focussed (follow up) inspection to assess whether the service had made required improvements to the children and young people’s service, following our previous inspection of the service in August 2016.

We gave the hospital seven days’ notice of the inspection, to ensure staff representatives from the children and young people’s service were available on the day of inspection.

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.

Services we rate

We rated children and young people’s services as good. This was an improvement from the previous rating of requires improvement.

There were systems and processes in place and followed by staff to keep children and young people safe and safeguarded from abuse. There were sufficient numbers of staff with relevant skills and experience and up to date mandatory training in safety systems, processes and practices to deliver safe care to children and young people. Risks to children and young people were assessed and staff acted to reduce identified risks. There was a good track record on safety and staff under stood their responsibilities to raise concerns and incidents.

Children and young people’s care and treatment was delivered in line with current evidence based guidance and standards. The service monitored the effectiveness of care and treatment and used the findings to benchmark against other similar services and improve services. Consent to care and treatment was obtained in line with national guidance

Staff cared for children, young people and their families with compassion. Feedback from patients and their parents was positive about the way staff treated them. The emotional needs of children, young people and their parents were fully considered. There was effective use of distraction activities to reduce anxieties in children and young people. Staff involved children, young people and their parents in decisions about their care and treatment.

The service was planned around meeting the needs of the local population, with appointments and admissions offered to meet the individual circumstances of each patient.

There was clear leadership of the children and young people’s service. A lead nurse had responsibility and accountability for all the children and young people’s services in the hospital. There was identified medical leadership. Governance and risk management processes supported improvements to the service. There was an inclusive culture, with staff of all professions across the hospital working together to deliver quality care to children and young people. There were processes for children, young people and their parents to feedback about their experience of care and treatment at the hospital. Staff acted on this feedback to make improvements to the service.

However, we found that although the quality of inpatient and some outpatient records were monitored, there was no process to audit the quality and content of outpatient records held solely by consultants and not shared with the hospital.

Staff took account of the distress carrying out observations may have on children. However, when they did not carry out formal observations to reduce children’s distress, they did not always record this reason. Staff did not record the informal visual observations that they carried out to determine the child’s condition was stable and the child was not at risk of deterioration.

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.

We rated children and young people’s services as good. This was an improvement from the previous rating of requires improvement.

Spire Clare Park Hospital is purpose built and opened in 1984, it is currently run by Spire Healthcare Limited.

The hospital provides a range of services to patients of all ages who are NHS funded, self-pay or use private medical insurance. Services offered include general surgery, cosmetic surgery, orthopaedics, dermatology, physiotherapy, gynaecology, endoscopy and diagnostic imaging.

The on-site facilities include three operating theatres (two with laminar flow), two wards with 34 registered beds (used flexibly for inpatients and day care) and a three bedded enhanced recovery unit. All the beds are in single rooms with en-suite bathrooms. Extended recovery services are provided and there is no emergency department at the hospital.

The outpatient department has ten consulting rooms, two treatment rooms, an audiology booth and an exercise ECG room. The diagnostic imaging department offers X-ray, ultrasound, digital mammography, MRI and CT scans. Physiotherapy treatment is offered as an inpatient and outpatient service. There is an accredited sterile services department and a pharmacy on site.

We inspected the hospital as part of our planned inspection programme. This was a comprehensive inspection and we looked at the three core services provided by the hospital: surgery, outpatients and diagnostic imaging and services for children and young people. The endoscopy service was reported under the surgery core service report as the hospital provided only a very small medical service. The hospital also provides a weight loss service which we did not inspect as part of this inspection. This service will be inspected separately in the future.

The overall rating for this service was ‘good’.

Are services at this hospital safe?

• Patients were sufficiently protected from avoidable harm and abuse across surgical services and in outpatient and diagnostic imaging., However, there were concerns about the safety of children and young people at the hospital. Individual patient rooms posed some risks to children; these were not accurately assessed or mitigated.

• Staff reported incidents and openness about safety was encouraged.Incidents were monitored and reviewed. We saw examples of changes in practice that occurred as a result of learning from incidents. However, the children and young people’s service lead did not have oversight of the small number of incidents reported within their own service.

• Staffing numbers (nursing and medical) were sufficient to provide safe care and treatment in all areas. Staff completed mandatory training and they were on track to achieve their target of all staff to have completed all required training by the year end. In services for children and young people, staffing did not always meet recommended guidance. There was no process to ensure a registered children’s nurse was identified to hold responsibility and accountability for the whole of the child’s pathway, including their pathway through the outpatient’s services.

• Most areas inspected were visibly clean and tidy though we found some areas of dust in the outpatient’s department. Staff adhered to bare below the elbows guidance.Equipment was well maintained. However, there was insufficient regard or mitigation of the infection risk associated with children’s’ toys used in some areas of the hospital.

• Medicines were stored safely and staff mostly administered medicines within the hospital’s policy.However, we found that anaesthetic cream was being administered to children without being prescribed.In surgical services, there had been inconsistencies in the management of controlled drugs which the hospital manager was taking action to address.

• Clinical staff identified and responded to changes in patient’s risks appropriately. When needed, arrangements were in place to ensure patients could be safely transported to a local NHS hospital.

• Staff received regular simulation training and we saw where individual learning needs in relation to safety scenarios were identified, and responded to, following this.

Are services at this hospital effective?

• Care and treatment followed best practice and evidence based guidance across services for adults.

• Patient outcomes were mostly monitored with joint replacements monitored through the National Joint Registry. Outcome data for gastrointestinal procedures was collected but not used to improve patient outcomes. The gastrointestinal endoscopy service was due to move into a newly developed unit and the reporting tool was in place to better use this data following the transition.

• There was no clinical audit plan for children and young people’s services. A clinical scorecard was in use but did not benchmark clinical effectiveness across a wide range of measures.

• Ionising Radiation (Medical Exposure) Regulations 2000 IR(ME)R audits were undertaken in line with regulatory requirements. Results indicated the service performed in line with national standards.

• Patient’s pain was appropriately monitored and a variety of pain relief was offered when required.

• Patient’s nutrition and hydration needs were met. The hospital offered a wide range of food choices and individual dietary requirements were accommodated.

• The Medical Advisory Committee were actively involved in reviewing patient outcomes and the renewal of practising privileges of individual consultants.

• Staff were competent and sufficiently skilled to deliver effective care and treatment though adult trained staff did not always receive appropriate additional training in the care of children and young people.

• The hospital provided training for staff in Mental Capacity Act, 2005, and Deprivation of Liberty Safeguards.Staff routinely considered patients’ mental capacity to make decisions about their care and treatment.

• With the exception of one consultant, staff demonstrated understanding of consent procedures. .

• Multidisciplinary services were available to patients seven days a week, including physiotherapy, pharmacy and x-rays.

• Staff had access to clinical information and guidance to support patient care.However, parents/carers were not requested to bring their child’s health record to appointments.

Are services at this hospital caring?

• Patients and their relatives were consistently positive about the care and treatment provided at this hospital. Friends and Family Test data and the hospital’s own patient survey showed consistently high levels of patient satisfaction.

• We observed staff delivering kind and compassionate care that offered respect and dignity to patients.Staff worked hard to ensure that both patients and their relatives were comfortable and had their needs met throughout their appointment or procedure.

• Patients were mostly included in decisions about their care and treatment.

• Staff worked hard to ensure patients’ emotional needs were met. However, children were not routinely invited to attend the hospital prior to any procedure to reduce potential anxiety associated with an unfamiliar setting.

• The outpatient department offered a chaperone service to all patients so they could be emotionally supported throughout their appointment.

Are services at this hospital responsive?

• Services for adults were planned and delivered to meet the needs of local people.

• The importance of flexibility and choice was reflected across the services with appointments and procedures being organised at times to suit patients and their carers.

• Staff made adjustments to provide care for patients with additional individual needs such as people living with mental illness or a learning disability.

• The hospital had not met national referral to treatment targets for three months out of 12 between April 2015 and April 2016 for NHS surgical patient due to a staff vacancy. Following a successful apoointmen,action taken to improve this had ensured they met the target in August 2016.

• Complaints and concerns were taken seriously, responded to in a timely way and improvements were made to the quality of care as a result.

Are services at this hospital well led?

• The leadership team actively shaped the culture through effective engagement with staff, people who use services and their representatives, and other stakeholders. Patient forums, staff surveys and stakeholder feedback results were used to drive improvements.

• Staff valued recent changes within the leadership structure and found senior managers to be visible and accessible. There was an open and supportive learning culture.

• Staff were familiar with the organisation’s vision and values and understood the future priorities within their own departments.

• Overall, there was a clear governance framework to monitor quality, performance and risk at department, hospital and corporate level. Staff told us they were aware of the risks, and action taken to mitigate these risks for their individual departments. However, there was a lack of clarity about the overall leadership of children and young people’s services provided across the whole of the hospital. The children and young people’s governance arrangements were newly implemented at the time of our inspection so had not, at that time, supported quality monitoring or improvements. It was not clear who had oversight of, or responsibility for, identification of risks associated with providing a children and young people’s service at the hospital..

• The Medicines Advisory Committee (MAC) reviewed the practising privileges of consultants through quarterly meetings but attendance at the MAC did not reflect the range of specialities within the hospital.

Our key findings were as follows :

• Senior leadership at this hospital was strong. All staff were positive about their senior managers and recent changes in leadership. However, there was a lack of clarity regarding the local and senior leadership of the services for children and young people. Governance arrangements for this service were newly implemented and, as such, not fully embedded.

• Adult patients were sufficiently protected from avoidable harm and abuse. There were concerns about the safety of children and young people in some areas of the hospital. Individual rooms posed risks that we were not assured were sufficiently mitigated and we found some areas with toys we were not assured could, or had, been cleaned effectively to reduce the potential spread of infection.

• Staffing was sufficient in numbers to provide safe care and treatment in all areas. Staff completed mandatory training and were on track to meet the hospital’s year-end target of 95%. However, adult registered nurses did not always receive appropriate training in the care of children and young people and paediatric staffing did not always follow national guidance.

• The hospital environment was mostly clean and tidy and infection prevention procedures were mostly good. Staff adhered to bare below the elbows guidance across the hospital.

• Patient’s nutrition and hydration needs were met. The hospital offered a wide range of food choices and individual dietary requirements were accommodated.

• Patients reported that staff managed their pain effectively and staff offered a range of pain relief when required.

There were areas of poor practice where the provider needs to make improvements -

Action the hospital MUST ensure;

• The ‘five steps to safer surgery’ checklist is always appropriately completed.

• The storage and management of medicines, including controlled drugs, meets the requirements of current legislation, hospital group policy and standard operating procedures.

• Risk of transmission of infections from children’s toys is mitigated.

• Risk assessment processes identify all risks posed by the environment of the hospital to children and young people are identified and appropriate mitigating action is taken.

• The hospital’s medicines management policy is adhered to and staff must not administer medicines that have not been prescribed.

• There is a clear and visible leadership structure which covers all areas of children and young people’s care at the hospital in place to support staff in caring for children and young people.

• Staff must know who to contact outside the organisation in the event of a safeguarding concern and the hospital safeguarding lead is not available.

• Consider national guidance when planning staffing levels for children and young people’s services in all departments of the hospital.

• All nursing staff that look after children and young people must complete competency assessments appropriate to the care and treatment they provide to children and young people.

• All clinical areas are visibly clean and free from dust and cleaning schedules displayed in public areas.

Action the hospital SHOULD ensure;

• Consultants should plan how they are going to use endoscopy outcome data to improve patient outcomes.

• Referral to treatment times are captured accurately and national targets are consistently met.

• Medical Advisory Committee meetings should be attended by representatives from a wide range of specialities across the service.

• Consider asking parents of young children to bring their personal child health books in for outpatient appointments and hospital admissions.

• There is a clinical audit plan in the children and young people’s service that supports the clinical scorecard to measure a broad range of outcomes for children and young people. 

• Further consider how to ensure the environment is inviting and child-friendly to all age ranges in all areas of the hospital where children and young people receive care. 

Professor Sir Mike Richards

Chief Inspector of Hospitals