3rd, 4th & 14th February 2015
During a routine inspection
Spencer Private Hospitals (Ashford) is a 4 bedded unit that was opened in 2008 within the local NHS trust and is one of two sites run by East Kent Medical Services Ltd.
In December 2012 the local NHS trust re-purchased the shares in Healthex (the holding company of East Kent Medical Services Ltd) that they originally purchased in 2008 and then sold in 2009 because of limits on private purchase income by Monitor.
The Board of East Kent Medical Services Ltd is made up of two executive directors and seven non-executive directors five of whom are local NHS trust directors. The Board is chaired by a retired orthopaedic consultant.
The Care Quality Commission (CQC) carried out a comprehensive inspection on 3rd and 4th February 2015 and undertook an unannounced inspection on 14th February 2015.
We inspected this hospital as part of our second wave independent hospital inspection programme, using the Care Quality Commission’s new inspection methodology.
This location has been given a shadow rating. Shadow ratings apply to inspections which are undertaken during the development of our approach and before our final methodology is confirmed and published.
Services for operating theatres, intensive care, high dependency, coronary care, pathology, medical records, estates and maintenance, supplies, x-ray and diagnostic imaging, pharmacy and medical gases are procured by the hospital from the local NHS trust under a service level agreement (SLA).
Referrals are received from self-funding patients, patients with medical insurance, and NHS patients through a contract with the local NHS trust. The majority of the hospital’s work is NHS-funded through 'Choose and Book', commissioned by the Clinical Commissioning Group (CCG).
The unit provides for adult elective surgery, a small amount of medical in-patient care and children and young person’s services including minor surgery.
For the purpose of the comprehensive inspection we undertook an on-site review of surgery and outpatient services and have included our findings of the small volume of medical care, children and young person’s services and end of life care within these core services. The hospital does not provide maternity or termination of pregnancy services.
The on-site element of the inspection involved a team of specialist clinical advisors (experienced healthcare professionals) and CQC inspectors.
Prior to the on-site inspection, the CQC considered a range of quality indicators and we sought the views of a range partners and stakeholders.
The inspection team make an evidence-based judgment to ascertain if services are:
• Safe
• Effective
• Caring
• Responsive
• Well-led.
Overall the rating for the Spencer Private Hospitals (Ashford) was good.
Our key findings were as follows:
• CQC have received no complaints, safeguarding concerns or alerts or whistle-blower enquiries in the last 12 months.
• East Kent Medical Services Ltd had a robust process for appointing medical staff to the service under practicing privileges arrangements.
• Robust Clinical Governance processes are in place with no 'Never Events' occurring within the last year.
• Serious incidents including anaesthetics, surgical site infections and all mortality and morbidities were monitored, reported and lessons learnt.
• There was a robust complaint management process that included Duty of Candour. East Kent Medical Services Ltd is a member of the Association of Independent Healthcare Organisations (AIHO) which gives access to the Independent Sector Complaints Adjudication Service (ISCAS) for Non-NHS patients and the provider liaises with the local Clinical Commissioning Group (CCG) for patients whose care is funded by the NHS.
• Patients complete a 'Patient Experience' survey upon discharge and areas requiring improvement are fed back to the appropriate staff at departmental meetings.
• MRSA and C. Difficillle are monitored and there have been no hospital-acquired cases in the last 12 months.
• East Kent Medical Services Ltd has an admission policy that sets out safe criteria for people using the service.
• There are systems for the effective management of staff which included an annual appraisal, including medical staff with practising privileges.
• East Kent Medical Services Ltd carry out a number of audits to monitor and improve services including collecting patient reported outcome measures (PROMS) hip and knee replacement surgery and infection control data.
• There is an organisational risk register for all risks including clinical, H&S, and financial risks.
• There is a business continuity plan is in place, this includes an agreement for the transfer of patients between the local NHS trust and the hospital in the case of an emergency.
• East Kent Medical Services Ltd is accredited with ISO 14001 Environmental Standard and management systems.
• East Kent Medical Services Ltd is accredited to ISO9001 quality management systems.
• East Kent Medical Services Ltd is accredited as an 'Investor in People'.
• East Kent Medical Services Ltd exceed the national standard for harm free care.
However, there were also areas where the provider needs to make improvements.
The provider should:
• Review the arrangements for delivering safeguarding training to staff against the intercollegiate framework for safeguarding children which recommends face to face training at level 3.
• Ensure that care pathway documentation be reviewed to include references to NICE or Royal College of Surgeons Guidelines.
• Audit DNA CPR forms to ensure these are meeting appropriate standards.