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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 July 2015, 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 Parkway Hospital

 

 

Safe

 

All relevant staff will be re-trained on how to use Datix which is our incident reporting system.  Consultants have also been informed that they too are able to report incidents electronically onto the Datix system.

 

 

All consultants cover arrangements now uploaded to our computer.

Software and monitored for non-compliance.  Our latest score is 98%. All non-compliant consultants are contacted and the information requested. 

 

 

All infections are fully investigated and a Root Cause Analysis completed if required.  We have invited the Infection Control Nurse from Solihull Clinical Commissioning Group into Parkway.  She has now carried out two reviews at Parkway looking at our infection control practices.  We are keen to continue with this relationship.

 


Effective

 

All training both mandatory and external is now logged on the new e-learning system which makes reports available in real time and we have maintained an absolute focus on all training throughout the year. Currently we stand at 96% of staff trained.

 

 

We are delighted to say that Multi-Disciplinary Team compliance over the last 12 months has been at 100% compliant across all cancers.  This is monitored by the Head Oncology Nurse.

We are also in current negotiations with Heart of England Foundation Trust to set up a formal Service Level Agreement with them around these discussions. 

 


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

 

The single patient record was introduced on the 5/09/2016 and is now completely embedded into our processes.

 

 

All communication to consultants regarding hospital information and instructions will be initiated by the Hospital Director or in his absence the Matron. This will be done via the formal route of the MAC and also directly by email, where required. Sometimes, however, more direct action must be considered and cases dealt with on an individual basis.

 

 

The risk register is reviewed monthly.  The high level risks are reviewed every month at the Senior Management Team Meeting, the intermediate risks are reviewed bi-monthly at the Combined Health, Safety and Risk Meeting and the low risks are reviewed annually with the Heads of Department. 

 

 

The Medicine Management Policy was reissued to all clinical staff.

A multi-disciplinary Medicines Management Committee has been set up which feeds into the Clinical Effectiveness Committee.  Regular audits are completed for all appropriate areas to identify any learn from outcomes.

 

 

A full review of the clinical audit plan has taken place across all hospital departments.  This will ensure a robust audit programme with identified Heads of Department responsible for their individual areas. 

Outcomes of these audits will be closely measured trends and analysis noted and appropriate actions taken. 

 

 

The Lone Working Policy has been re distributed in to all clinical and non-clinical staff. All Head of Departments are aware to carry out risk assessments if appropriate and put in control measures. 

 

 

Spire’s values, vision and strategy have been discussed at regular Staff communication sessions throughout the year.

 

 

A full refurbishment programme of both the wards and all in-patient rooms has now taken place. A lot of the soft furnishings, ie carpets, curtains etc. have been removed. 

Refurbishment of outpatient department has now almost been completed at the time of filling this report in Dec 2017.

 


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.

Care Quality Commission

CQC logo

Spire Parkway Hospital latest CQC inspection report: 23 December 2015

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 Parkway 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 (2017) 2.0
1.0
0.00
1.40
0 Spire Parkway 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 (%), 2017 1.0%
 
0.00
0.60
0.60
0 Spire Parkway 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 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, 0.05% of patients required an unplanned return to theatre for further treatment before they were discharged home from Spire Parkway 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 re-admission

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 re-admissions by dividing the number of re-admissions by the number of patients we have discharged from the hospital.

In 2017, 0.07% of patients required unplanned readmission for further treatment within 31 days of their discharge from Spire Parkway 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 GP's with prompt and comprehensive information

Patient satisfaction

100% of patients would recommend Spire Parkway 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.

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