Spire Wellesley Hospital

Updated 6 March 2023

Spire Wellesley Hospital is operated by Spire Healthcare Limited and is 1 of the organisation’s 39 hospitals located across England.

The hospital offers a wide range of care and treatment within surgery, medical care, outpatients, and diagnostic imaging to private and NHS patients. We undertook this inspection as part of a random selection of services which have had a recent Direct Monitoring Approach (DMA) assessment where no further action was needed to seek assurance about this decision and to identify learning about the DMA process. As part of this process, we inspected and rated the surgery core service.

Surgery includes a dedicated pre-operative assessment unit, 3 operating theatres, a 33-bedded inpatient ward, 8 day-case beds, and 9 recovery bays. Two theatres have laminar flow air exchange equipment fitted for higher risk surgeries. The hospital offers over 15 surgical specialties, including urology, ear, nose, and throat (ENT), hips and knees, and oncology. The hospital has its own sterile services department.

All surgery is elective and takes place after a pre-assessment process. Most surgical care is carried out on a day case basis, with overnight admission available for more complex cases or longer recovery periods.

The service is registered to carry out the following regulated activities:

• Diagnostic and screening procedures
• Surgical procedures
• Treatment of disease, disorder or injury
• Family planning

At the time of our inspection the service did not have a registered manager in post. The hospital had recruited a new hospital director, who had completed their application with CQC to become the registered manager. While they waited for confirmation of their registration, this individual carried out the expected duties of a registered manager, with support from the director of clinical services.

We last inspected surgery in May 2016. We rated the core service good overall, with good in safe, effective, caring, and responsive. We rated well led as requires improvement. This was due to a need for improved management and more consistent use of policies, improved incident investigations, better staff safeguarding knowledge, and broad changes in governance relating to the risk register and records management.

At this inspection we found staff had addressed these concerns and implemented a wide range of initiatives that resulted in higher standards of consistent care and practice.

We rated this service as good overall and rated well led as outstanding. This reflected the extensive and sustained improvements the hospital team and leadership had made.

Updated 6 March 2023

Our rating of this location stayed the same. We rated it as good because:

• The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them.
• Leaders ran services well using reliable information systems and supported staff to develop their skills through an extensive programme of engagement. Staff understood the service’s vision and values, applied them in their work, and used provider standards to challenge the status quo. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care and creating a working environment that promoted innovation and encouraged challenge.
• Staff were clear about their roles and accountabilities. The service engaged meaningfully with patients, the local community, and regional health services to plan and manage care. All staff were committed to improving services through quality improvement strategies and the exploration of new evidence-based practice.

Updated 19 December 2016

We rated the medical care service as good across all five domains: safe, effective, caring, responsive, and well-led.

Nursing staff knew how to report and escalate concerns and incidents. Identified lessons were shared back to staff. Nursing and medical staff were aware of their responsibilities under duty of candour.

Infection control practices were in place and the environment was visibly clean. Staff adhered to ‘bare below the elbow’ policy and good practices of hand washing and sanitation.

All equipment and medicines were stored correctly in line with the Nursing & Midwifery Council (NMC) standards for medicines management guidelines. Staffing was adequate and specialist knowledge provided by four oncology specialist nurses. They had sufficient training and were proactive in their professional development.

Oncology services were effective and provided a 24-hour advice line. Staff used the UK Oncology Nursing Society (UKONS) triage tool, allowing them to work to safe and clear guidelines. Staff were innovative and used internal audits to improve patient records and communication with other departments. Pain relief was well managed and patients’ nutrition and hydration needs were met.

Nursing staff provided compassionate and caring support. Additional support was available via a Macmillan counsellor and palliative care consultant when required. Patients were involved in their care and could attend coffee mornings or drop in sessions to provide feedback on the service, ask advice or discuss concerns.

The service was responsive to patients’ needs. Patients had no concerns regarding waiting times and could pick an appointment that suited them. Staff were aware of the vision and values of the service. Staff felt that the senior management were approachable and supportive. The department engaged with patients and actively sought feedback.

However:

Some medical records used were inconsistent, leading to confusion and potential risk of medication mistakes.

Staff had completed training in Mental Capacity Act and Deprivation of Liberty Safeguards, However, there was limited need to reflect this in practice and staff were unable to explain the practical application of Deprivation of Liberty Safeguards. This was escalated as a concern and staff were provided additional training.

Updated 12 September 2018

Children and young people’s services were a small proportion of hospital activity. We rated this service as good because it was safe, effective, responsive, caring and well-led.

Updated 19 December 2016

Outpatient and diagnostic imaging services at Spire Wellesley Hospital were rated as good overall. We inspected, but did not rate, effective.

Areas of good practice included effective processes to ensure equipment was checked, serviced and ready for use and radiology and pathology reports and results were available to appropriate staff via secure electronic systems.

Data provided showed that 100% of outpatient and diagnostic staff and completed their annual appraisal for 2015

Patients were seen and treated within national guidance timeframes and were very happy with the level of care they received.

We saw that staff interactions with patients were polite, friendly, and helpful and the hospital was mindful of the needs of patients from various religions and backgrounds and translation services were available.

“You said, we did” notices were displayed in patient waiting areas, showing changes made as a result of complaints received.

However:

The procedures for monitoring medication fridge temperatures were not adhered to.

Patient records were not always fully complete or legible. The hospital did not hold a copy or summary of consultants’ records held off site however this was accessible on request.

Incident reporting was minimal within the diagnostic imaging department.

Incident information was provided to heads of department regularly but this data was across the hospital and not specific to individual departments.

There was a lack of oversight in relation to the management and development of hospital policies.

Updated 6 March 2023

We rated this service as good. Please see the main summary.