Archived: Clifton Lane Clinic

Updated 10 October 2017

Clifton Lane Clinic is operated by Clifton Lane Clinic Ltd. The hospital was registered with CQC in December 2013. It is a private hospital in Rotherham, South Yorkshire. The hospital formed part of a wider clinical group that provided cosmetic surgery services for patients in the North West and Yorkshire (New Birkdale Clinic). The hospital is registered with the CQC to provide surgery and

diagnostic and screening procedures. The hospital has not had a registered manager in post since July 2016. A new manager had requested that they be registered by the CQC in August 2016.

The hospital consisted of an outpatient consultation area, a ward with five bedrooms and an operating theatre.

A responsive inspection carried out in March 2017 identified concerns and a warning notice was issued relating to good governance.

Updated 10 October 2017

Clifton Lane Clinic is operated by Clifton Lane Clinic Ltd. The hospital specialised in cosmetic surgery procedures. Facilities included; one ward, one operating theatre and outpatient and diagnostic facilities.

After an unannounced responsive inspection carried out in March 2017, the provider was issued with a warning notice in regard to Regulation 17: good governance. We also issued requirement notices in regard to compliance with Regulation 12: staffing, particularly regarding in theatres and Regulation 15: environment, particularly in relation to the operating theatre. We carried out this focussed follow up inspection on 19 July 2017 in order to ensure the provider had taken action to comply with the regulations. At this inspection, we found there had been improvements made; however, there was still more work to do in some areas.

We found the following improvements had been made:

• Hospital wide governance, medical advisory committee and staff meetings took place at regular intervals.
• There was a formal risk register in place.
• The theatre environment was clean and there were no environmental risks. New equipment had been ordered.
• The controlled drug record book was completed appropriately, audits carried out and no discrepancies were seen.
• New staff had been appointed on the ward and in theatres.

We found the following areas where the provider still needed to improve:

• There were still some improvements that needed to be made to the investigation of incidents and to ensure learning took place.
• There was no evidence of regular review of the risk register or discussion of risk at governance meetings.
• Audits needed to be more robust, with appropriate accompanying action plans that were regularly monitored and reviewed.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. Although there had been improvements in governance, for example, the introduction of a risk register and regular governance meetings scheduled, there were still issues remaining about the systems and processes in place. We therefore issued the provider with a requirement notice concerning good governance to ensure effective systems and processes were in place for investigating and learning from incidents and to improve the safety and quality of the service.

Ellen Armistead

Deputy Chief Inspector of Hospitals (North)