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 2018, 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 areas

 

Action taken by Spire Leeds Hospital

   

Safe

 

We have completed a full review of our incident management processes, provided additional training for staff and recruited additional staff to the governance team.

 

 

For areas where local audits show non-compliance with policy, we have set up working groups, reviewed and updated action plans and introduced daily/weekly audits to address concerns. 

 

 

Following completion of the refurbishment works in our children’s ward, all children are now admitted to this secure area with dedicated children’s nurses.

 

 

All works have been completed to our theatre ventilation systems in response to the external audit report received.

 

 

We have recruited a new resuscitation officer, responsible for daily checks of all emergency equipment and can now demonstrate full compliance in this area.

 

 

Compliance with medical record keeping continues to improve, as noted in the CQC report.

 


Effective

 

We have reviewed out VTE prescribing policy, previously aligned to our local NHS Trust, to be in line with NICE guidelines.  This was put in place late in 2018 and since this time compliance has significantly improved.

 

 

We have a national dashboard in place to capture, report and benchmark audit and activity data for our children and young people’s service which shows high level of compliance with all key performance indicators.

 

 

We are reviewing our patient information and internal processes for scheduling theatre lists to ensure patients are optimally hydrated on arrival at the hospital and when going to theatre.  We are working with our anaesthetists to ensure we improve and can show steady improvement over the past 12 months with this measure.

 

 

All patients who have a procedure at Spire Leeds have a written consent form in place.  We are reviewing processes to ensure that these forms meet the expected standards with all parties signing and dating the forms in the correct places to ensure full compliance in this regard.

 


Caring

 

We are establishing a patient experience committee to ensure feedback from patients is systematically reviewed and acted upon. We already call patients who raise concerns through our survey, but a more structured process to act on feedback will ensure we can demonstrate improvement more effectively.

 


Responsive

 

We have reviewed our meeting agendas and report formats to ensure we capture and document learning from complaints more robustly moving forward and will continue to share action taken with patients and visitors on our patient boards.

 


Well-led

 

We have added additional resource to the management team to ensure all concerns raised by the CQC have been addressed in the most recent report.

 

 

We have undertaken a full review of governance processes at the hospital, appointed a new governance lead and are recruiting for extra resources to support the team.  Support is also being provided in the interim by staff from other Spire hospitals and the central teams to ensure new staff are aware of the standards and processes required, and that new starters have a thorough induction.

 

 

Our risk register has been fully reviewed to ensure it is aligned to our current highest risks, including new areas of concern highlighted by our regulator.

 

 

Despite very high levels of staff engagement in our engagement surveys, we have put in place additional listening events / staff forums and the leadership team are attending team meetings to ensure staff have every opportunity to raise concerns.  Our Freedom to Speak Up Guardian is also visible if staff want to raise a confidential concern at any time.

 

 

All of our committee terms of reference, schedules and agendas have been reviewed and updated to ensure timely flow of information, with new trackers to ensure meetings go ahead as planned with the right staff at the right time. Action plans have been reviewed and strengthened to ensure key concerns are addressed in a more timely manner moving forward.

 


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

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.

CQC logo

Spire Leeds Hospital latest CQC inspection report: 3 July 2019

Overall rating - Requires improvement

Full details of the inspection report

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 (2018)0.2
0.1
0.00
0.08
0 Spire Leeds Hospital 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 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 (2018)2.0
1.0
0.00
1.40
0 Spire Leeds 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 clostridium difficile infection across all Spire hospitals. NHS data 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 (%), 20181.0%
 
0.35
0.60
0.60
  Spire Leeds 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 2018 (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 2013 – 2018) 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 2018, 0.16% of patients required an unplanned return to theatre for further treatment before they were discharged home from Spire Leeds 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 2018, 0.21% of patients required unplanned readmission for further treatment within 31 days of their discharge from Spire Leeds 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

94% of patients would recommend Spire Leeds Hospital to their family and friends following their treatment (based on patient satisfaction data from 2018).

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