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Our healthcare standards

At Spire Healthcare, clinical standards are our first and foremost priority. We continuously monitor our performance against the standards set by the Care Quality Commission and strive for continuous improvement and outstanding patient care.

At our last inspection in December 2016, the CQC identified certain areas where we could improve. We have taken these seriously, immediately addressing any concerns highlighted. A summary of our response is outlined below:

 

CQC inspection area

 

Action taken by Spire Alexandra Hospital

 

 


Safe

 

Spire Healthcare competency assessments are in place for all current core services and roles which were available at the time of inspection and compliance is monitored by the heads of departments, through national peer review and via the hospitals governance systems.

 

 

A hospital Risk Champion has been appointed. The risk register is reviewed and updated monthly by the Senior management team and reported at both local and corporate levels.

Non-compliance is now reported as an adverse incident on the electronic reporting system for more effective oversight and ongoing visibility to enable appropriate action to be taken.

 

 

Regular monthly audit is being undertaken with associated action plans being closed out. Regular spot checks by managers are taking place.  There is a clear process in place for managing any performance concerns.

Staff have also received Medicines Management refresher training.

 

 

We have provided additional staff training to ensure all staff are clear on latest policy and guidelines. 

Regular environmental observational audits are undertaken by the Infection Prevention and Control lead nurse with action plans in place to improve and maintain performance. 

Waste management meetings have been established and an Infection Prevention and Control Audit Dashboard has been introduced. 

Improved signage specifying Clean and Dirty utilities has been put in place.

 

 

Although the guidelines do not apply to independent hospitals, a full risk assessment of current provision of hand washing sinks has been carried out and a refurbishment programme has been put in place. 

Quarterly hand hygiene audits are carried out with consistently excellent results.

 

 

Cleaning schedules have been put in place in all departments to state the relevant manufacturer's cleaning guidance. Compliance to cleaning schedules is audited by the Infection prevention and control lead.

Equipment co-ordinators have been established in all clinical areas with responsibility for departmental equipment.

 

 

We have introduced an audit programme to ensure the checks are carried out before use. Compliance is now consistently 100%.

 


Effective

 

We have reviewed all patient information leaflets to ensure they are fit for purpose and removed older leaflets where appropriate.

Spire corporate leaflets are standardised and in use across the hospital. 

All consultant specific information must now be approved through clinical governance process to avoid any variation in information provided. 

 

 

We have reviewed the hospital agency staff induction sheet against the Spire Healthcare corporate agency staff induction sheet to reduce duplication and have implemented across clinical departments.

 


Caring

 

Rated as Good therefore no specific action required however, we’re committed to continually improving our clinical and service standards to ensure we provide the best possible care.

 

 

Responsive

 

We have strengthened the Spire Alexandra Safeguarding Team. This team is lead by Matron who has level 4 safeguarding training. Posters and information cards about Domestic abuse are being displayed throughout the hospital.

 

 

We have reviewed the access to medical records including images and following this have put in a new protocol which sets out for our staff how to access medical records including images at all times.

 


Well-led

 

The hospital has a clear action plan in place to work towards JAG Accreditation and active recruitment is underway for an Endoscopy Lead to support this project.

    

 

The Spire Alexandra has become a member of the Local Dementia Action Alliance network – with in-house quarterly dementia friends training sessions open to all staff.

Level 3 safeguarding adults training has been undertaken by each member of the New Safeguarding Team and level 2 training is mandatory for all other staff. The safeguarding Team are promoting safeguarding awareness across the hospital – including a Focus Topic for each quarter such as FGM.

 


We are fully engaged with our local CQC team and look forward to our next inspection as an opportunity to evidence our excellent care.

Clinical performance

We're proud of the cleanliness of our hospitals and centres. And because we want our patients and GPs to make informed choices, we were one of the first private hospitals to publish clinical performance and patient reported outcomes on our website including information on our rates of MRSA blood infection and clostridium difficile infection. This is just one part of our programme to improve our already high standards of clinical quality and safety.

All Spire hospitals are registered with the Care Quality Commission (CQC) and are required to meet the rigorous standards set for registered hospitals. This includes the quality and safety of treatment, cleanliness of the hospitals, staff recruitment and training and information available to patients. As part of their inspection programme, the CQC asks whether every service they inspect is safe, effective, caring, well-led and responsive to people's needs.

Visit Care Quality Commission website

CQC logo

Spire Alexandra Hospital latest CQC inspection report: 6 September 2017

Overall rating - Requires improvement

Full details of the inspection report

Every Spire hospital publishes several performance measures including: MRSA blood infections, clostridium difficile infections, wound infections after hip and knee replacement surgery, unplanned returns to theatre and unplanned readmission to hospital.

MRSA blood infections

MRSA is a type of bacteria that is resistant to some antibiotics. A healthy person can carry MRSA on their skin and it won't harm them. But if MRSA gets into the blood stream of a weaker person, perhaps if they have had surgery or are recovering from an illness, it can cause infection.

MRSA can be treated with a range of different antibiotics in line with national UK guidelines.

The rate of MRSA infection is measured in a standard way across all UK hospitals. It is measured by dividing the number of cases of MRSA blood infection by the total number of days that all of our patients have been in hospital, called the number of bed days.


MRSA bloodstream infections

MRSA infection rates at Spire hospitals are extremely low

 

Rate per 10,000 bed days (2017)0.2
0.1
0.00
0.08
0 Spire Alexandra NHS Hospitals (average)*

* NHS hospitals typically face additional challenges as they admit emergency patients via A&E who cannot be screened before admission.

MRSA bloodstream infection (also called MRSA bacteraemia) is the most serious type of MRSA infection. Hospitals in England send data to the Health Protection Agency on confirmed MRSA bloodstream infections. The figures published here do not include the numbers of people colonised with MRSA (where MRSA is carried naturally in the nostrils or on the skin) or superficial infections (where the MRSA infection is limited to the skin and does not enter the body).

How do we keep our MRSA rates so low?

  • Most rooms are single occupancy.
  • We train all staff in exceptional hand hygiene.
  • We employ our own teams of cleaners, not outside companies.
  • We screen all high-risk patients.
  • Operating theatres use filtered air for major orthopaedic operations.

The data for each Spire hospital relates to reported MRSA bacteraemia across all Spire hospitals. NHS data taken from the Public Health England.

Clostridium difficile

Clostridium difficile is a type of bacteria that can cause severe and frequent diarrhoea, abdominal pain and fever. In some cases, it can cause a life-threatening inflammation of the bowel. This is known as clostridium difficile associated disease or CDAD for short. In mild cases of CDAD, no specific treatment is required, although any antibiotic treatment may be changed or stopped. More severe cases require treatment with additional antibiotics.

The rate of CDAD infection is measured in a standard way across all our hospitals. It is measured by dividing the number of cases of CDAD by the total number of days that all of our patients have been in hospital (called the number of bed days).


Clostridium difficile infection

Clostridium difficile infection rates at Spire hospitals are negligible

 

Rate per 10,000 bed days (2017)2.0
1.0
0.00
1.40
0 Spire Alexandra NHS Hospitals (average)*

*Patients with more complex needs requiring longer lengths of stay at NHS hospitals are likely to increase clostridium difficile rates.

How do we keep our CDAD rate low?

  • Appropriate use of antibiotics
  • Most rooms are single occupancy
  • We train all staff in exceptional hand hygiene
  • We employ our own teams of cleaners, not outside companies

The data for each Spire hospital relates to clostridium difficile infection across all Spire hospitals. NHS data taken from the Public Health England.

Wound infection

Hip and knee replacement operations are very common procedures and for most people the benefits are great. However, all surgery carries a risk of infection in the wound created by the operation and this is known as surgical site infection. Wound infections can be treated with dressings and/or antibiotics.

The rate of wound infection is measured by dividing the number of cases of infection by the number of hip or knee replacement operations completed by the hospital.


Wound infections

Surgical site infection rates at Spire Hospitals are very low

 

Wound infections following hip and knee replacement surgery (%), 2017 1.0%
 
0.00
0.60
0.60
0 Spire Alexandra NHS Hospitals
(Hip replacement average)
NHS Hospitals
(Knee replacement average)

How do we keep our wound infection rates low?

  • Most rooms are single occupancy
  • We train all Spire Healthcare staff in exceptional hand hygiene
  • Patients mobilise as soon as possible to speed recovery
  • Operating theatres use filtered air for joint replacement operations

The data for each Spire hospital relates to surgical site infections reported by that hospital during 2017 (where this infection was identified when the patient was an inpatient or following a readmission to that hospital). NHS surveillance rates for surgical site infections (hip and knee replacement 2012–2017) are taken from Public Health England.

Returns to theatre

A return to theatre is when a patient has surgery and needs to return to theatre for an unplanned procedure during the same stay at the hospital.

We measure the rate of returns to theatre in a standard way across all hospitals, by dividing the number of returns to theatre by the number of procedures we have performed.

In 2017, 0.24% of patients required an unplanned return to theatre for further treatment before they were discharged home from Spire Alexandra Hospital.


Unplanned returns to theatre

Unplanned return to theatre rates at Spire Hospitals are low.

How do we keep our return to theatre rates so low?

  • All treatment is delivered by a consultant on the General Medical Council's Specialist Register.
  • Every patient undergoes comprehensive assessment prior to surgery.
  • Every hospital has a dedicated post-operative recovery area.

Unplanned readmission

Occasionally, you might need to return for additional treatment following your stay in hospital. Although this is sometimes unavoidable, our good discharge planning and the clear health information we provide helps to minimise the likelihood of this occurring.

An unplanned re-admission is when a patient is re-admitted to the hospital within 31 days of being discharged. The reason for the second admission should be related to the first.

We calculate the rate of unplanned readmissions by dividing the number of readmissions by the number of patients we have discharged from the hospital.

In 2017, 0.15% of patients required unplanned readmission for further treatment within 31 days of their discharge from Spire Alexandra Hospital.


Unplanned readmissions

Patients at Spire Hospitals are, on average, at low risk of requiring a readmission for further treatment / return to theatre for further treatment.

How do we keep our unplanned readmission rates so low?

  • Every patient has an individual discharge assessment.
  • By providing information to support a speedy recovery.
  • By referring to external services where it will help recovery.
  • By providing GPs with prompt and comprehensive information.

Patient satisfaction

99% of patients would recommend Spire Alexandra Hospital to their family and friends following their treatment (based on patient satisfaction data from 2017).

If you have any questions or would like more detailed information, please contact our hospital director.