St Anthony's Hospital

This was the first comprehensive inspection of Spire St Anthony's Hospital, which was part of CQC's ongoing programme of inspection of independent acute hospitals. We carried out the inspection on 13 and 14 September 2016. Following this, two unannounced visits took place on 20 and 22 September 2016.

Spire St Anthony's hospital is an acute independent hospital that provides outpatient, day care and inpatient services. The hospital is owned and managed by Spire Healthcare Limited. A range of services such as physiotherapy and medical imaging are available on site. The hospital offers surgical procedures as well as rapid access to assessment and investigation. Services are available to people with private or corporate health insurance or to those paying for one off treatment. Fixed prices, agreed in advance are available. The hospital also offers services to NHS patients on behalf of the NHS through local contractual arrangements.

The inspection reviewed how the hospital provided outpatient services (including to children), medical care, surgical services and critical care, as these were the four core services provided by the hospital.

Just before the planned inspection, the hospital's senior management team took the decision to stop treating and admitting children under the age of 18, including as outpatients and to stop providing critical care at levels 2 and 3.The hospital had a long history and had been run as a charity for 100 years. Spire took it over in late 2014 and had to make significant changes to modernise premises and practices, which included building six new theatres. While acknowledging that many improvements had been made over the previous 20 months since Spire took over the hospital, there was considerable work still to do, so overall we rated the hospital as requires improvement.

We rated outpatients and diagnostic imaging as good and surgery as requires improvement. We were unable to rate medicine as there was not sufficient data provided about medical care and the medical ward itself was closed for refurbishment at the time of the inspection. We also could not rate critical care, as the service was not operating at the time of the inspection.

Are services safe?

By safe we mean people are protected from abuse and avoidable harm.

• The hospital was not reporting all serious incidents promptly to national bodies. A never event had not been reported as such and the hospital's process for investigating serious incidents lacked rigor.
• There was an appropriate system for reporting clinical and non-clinical incidents, but there was limited evidence of staff learning from incidents.
• The hospital had slightly higher rates of falls, venous thrombo-embolism and pressure ulcers than its target.
• Staff were aware of their responsibilities regarding safeguarding vulnerable adults and children and knew who to contact if they had any concerns.
• Mandatory training was up to date in most areas.
• The hospital had three resident medical officers (RMOs), who covered the wards, cardio-thoracic patients and critical care.
• 331 consultants had practising privileges. 10.6% (36) consultants had not carried out any clinical activity in the past year.
• The hospital used paper records for patient care, which were mostly adequately completed.
• Medicines were managed and stored safely.

Are services effective?

By effective, we mean that people’s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence.

• National guidance was mostly followed.
• Improvements were needed to ensure all surgical patients had a full pre-operative assessment and the WHO safety checks were routinely carried out.
• We could not benchmark the hospital nationally for patient outcomes, although we saw some information to compare the hospital with other Spire hospitals across a range of indicators.
• Staff development was taking place in theatre processes and in critical care.
• There was limited internal multidisciplinary working.
• Medical and surgical staff were required to have practising privileges to work at the hospital and these were appropriately checked and maintained by the Medical Advisory Committee as necessary. We saw evidence of consultant contracts being discontinued or being suspended, if they did not meet the practising privileges criteria. 
• We found staff mostly had a general awareness of the Mental Capacity Act and Deprivation of Liberty Safeguards.
• Patients were happy with the choice of meals and drinks.

Are services caring

By caring, we mean that staff involve and treat patients with compassion, dignity and respect.

• Most patients we spoke with reported a positive experience of their care. They reported staff were kind and maintained their privacy and dignity.
• Patients and their families reported being involved in their care, including being informed about potential costs in most departments.
• Patients understood the care and treatment choices available to them and were given appropriate information and support regarding their care or treatment.
• 92% of staff (hospital-wide), up to September 2016, had attended compassion in practice training which was mandatory at the hospital. The deadline for remaining staff was the end of December 2016. This was a high completion rate.
• The hospital was rated very positively in patient feedback provided.
• Staff offered support to patients and families who wanted or required it, and there was strong chaplaincy support.

Are services responsive?

By responsive we mean that services are organised so they meet people’s needs.

• Patient flow through the hospital was generally smooth, although targets for discharge were not always in place at the time of admission.
• The service was generally responsive to patient needs although there was limited support for those living with dementia.
• The hospital met and exceeded targets for responding to patient needs such as referral to treatment times.
• Complaints were mainly well-managed, but the number of complaints about payment was a concern. Self -paying patients needed to be given clearer information about costs, and the hospital's billing process was not always accurate.

Are services well-led?

By well-led, we mean that the leadership, management and governance of the organisation, assure the delivery of high-quality person-centred care, supports learning and innovation, and promotes an open and fair culture.

• The hospital director had been in post for nearly two years. Some of the senior management team (SMT) had been in post a year or less. However, staff described that the management made a positive impact on the hospital and said the hospital director and other senior managers were visible to staff and patients.
• There were plans for the development of services in most departments, although we did not see a defined vision for medical inpatient services.
• Governance and performance monitoring was in place across most services, although some of this was very new and it was too early to judge its effectiveness.
• The senior management team (SMT) were aware of what needed to improve and were working on this. They were aware of the risks, but a stronger process was needed to ensure risks were accurately rated and actions were in place to mitigate the risks.
• The culture of the services was mostly positive and staff felt engaged in how the hospital was to improve.
• The SMT decided the week before our inspection to suspend paediatric services and critical care services. These decisions had been taken quickly and evidence showed if the hospital had carried on these services, there could have been some safety risks.
• Auditing of the services provided was improving, although information was not provided at sufficiently detailed level in some areas.

We saw outstanding practice including:

• The design of the new theatres and the training programme for staff being developed.

However, there were also areas of where the provider needs to make improvements. The provider must:

• Improve all its governance processes, so that patients receive safe and effective care. For example: ensure there are effective systems to monitor and review all patient deaths and other adverse events, including involving the medical advisory committee; ensure risks are tightly managed with clear mitigation; ensure compliance with practising privileges policies.
• Implement a robust governance structure for paediatric services and ensure that hospital staff and consultants are all appropriately trained prior to re-starting all paediatric care.

The provider should:

• Review and close incidents and complaints promptly to ensure learning to improve the service is identified at the earliest opportunity,
• Assess all risks and record, monitor and review actions to control risks,
• Ensure effective multidisciplinary working take place across all specialities.
• Review the process of pre-operative assessment to ensure all patients requiring one have this sufficiently far ahead of the surgery procedure date for results to be available.
• Continue to control surgery bookings so that procedures do not overrun and that doctors do not add patients late to the list.
• Ensure staff receive feedback about incidents and complaints to help them learn and improve.
• Ensure nurse documentation of patient observations is accurate.
• Staff should review the appropriateness of a cross on the wall in patient rooms.
• Staff should consider a means of capturing informal complaints raised by patients, and improve the timeliness of complaints handling.

• The hospital should review its support elderly patients and those living with dementia to ensure staff have an understanding of how to assess and meet the needs of this group of patients.

Professor Sir Mike Richards

Chief Inspector of Hospitals