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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 September 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 Fylde Coast Hospital

 

 


Safe

 

The WHO checklist is embedded in daily practice and is audited on a regular basis, with scores in excess of the Spire target for 2017.

 

 

Since the inspection a new blood fridge has been purchased and 2 units of O negative blood are now stored on site at Spire Fylde Coast. An annual major haemorrhage scenario is undertaken. This has demonstrated that blood can be transported from the local NHS Trust within 9 minutes.

 

 

Following the inspection a daily audit programme was introduced to identify and address the areas of non-compliance in relation to medicines management. A monthly audit is also completed by the Pharmacy department to provide the assurance that medicines are being managed appropriately. These audits have demonstrated a marked improvement in the scores since the inspection.

 

 

All areas that fall below the high clinical standards expected by Spire Fylde Coast have a robust action plan in place. Immediately following the inspection any areas of non-compliance were added to a daily audit programme, with additional staff training being provided where required. Fylde Coast Hospital are now in a much better position, with a higher proportion of audit results now meeting or exceeding the required targets.

 

 

The last never event at Fylde Coast was in 2015. This related to a wrong site anaesthetic block. Since this incident the “STOP before you block” campaign was adopted at Fylde Coast. Audit result undertaken in 2016 and 2017 have demonstrated 100% compliance with this process.

 

 

All contracted staff performing the role of surgical first assistant (SFA) have completed the appropriate qualification. There is a log book for non-contracted SFAs, with checks being completed to confirm that they have the necessary qualifications before they perform the role. The log is checked on a regular basis as part of the theatre compliance checks.

 

 

The AFPP guidance for safe staffing have been added to the theatre policy.

A daily “board” meeting has been added to the theatre routine. Staffing levels are discussed at this meeting, before theatre lists are signed off as safe to proceed.

 

 

All staff completed their mandatory training in 2016 in line with Spire’s year end targets and Fylde Coast are on track to hit the year end targets in 2017.

 

 

Since the inspection in 2016 all hospital departments use a single incident reporting system. This is an electronic system which gives the senior management team oversight. Trends can be identified and are acted upon as necessary.

 

 

There is currently a full bedroom refurbishment programme underway at Fylde Coast, which includes providing sinks that meet the Department of Health standards.

 

 

An equipment checklist has been introduced in theatre. The completion of this is checked on a regular basis with any non-compliances being escalated to the Head of Clinical Services.

 

 

Since the inspection access to all flammable cupboards has been restricted, with the introduction of key pad access to the theatre department.

 

 

All theatre doors have been replaced as part of the 2017 refurbishment programme. The new doors have key pad access.

 

 

Efficacy of pain relief is audited on a regular basis. The most recent audit showed that analgesia was given to all patients in an appropriate time frame.

 

 

Immediately following the inspection this was added to the daily audit programme. The results for pre-operative fasting have exceeded the targets set by Spire for the whole of 2017.

 

 

All theatre staff have had an appraisal in 2017.

 

 

Spire Fylde Coast treats low numbers of patients living with dementia. Despite this there is equipment available to adapt facilities for patients with dementia to support their care needs.

 


Effective

 

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.

 

 


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

 

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.

 

 


Well-led

 

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.

 

 


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 Fylde Coast Hospital latest CQC inspection report: 30 May 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 (2016)0.2
0.1
0.00
0.09
0 Spire Hospitals 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 (2016)2.0
1.0
0.00
1.32
0 Spire Fylde Coast Hospital 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 surgical site infections reported by that hospital during 2016 (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 2011 – 2016) are taken from 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 (%), 2016 1.0%
 
0.68
0.50
0.50
0 Spire Fylde Coast Hospital 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 2016 (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 2011 – 2016) 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 2016, 0.04% of patients required an unplanned return to theatre for further treatment before they were discharged home from Spire Fylde Coast 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 2016, 0.24% of patients required unplanned readmission for further treatment within 31 days of their discharge from Spire Fylde Coast 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

98% of patients would recommend Spire Fylde Coast Hospital to their family and friends following their treatment (based on patient satisfaction data from 2016).

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