Archived: Clifton Lane Clinic

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)

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.

In response to information received via enquiries from members of the public, we carried out an unannounced responsive inspection of the hospital. In line with the intelligence we had received, we inspected the safe and well-led domains in surgery using our comprehensive inspection methodology.

We carried out the unannounced inspection on 2 March 2017. We then returned to the hospital for an announced follow up on 15 March 2017.

We regulate cosmetic surgery services but we do not currently have a legal duty to rate them. We highlight good practice and issues that service providers need to improve and take regulatory action as necessary.

We found the following issues that the service provider needs to improve:

• Incidents were appropriately reported, but we found limited evidence to show that incidents were robustly investigated or that learning was effectively shared.

• Some equipment was not regularly checked, and even when checking was confirmed as being complete, we found checks had not been accurate.

• The theatre environment was not clean and there were environmental risks.

• There was no formal guidance in place to assist clinical staff in determining the acuity or suitability of patients for surgery.

• Take home medication was not appropriately labelled and we found some gaps in medication fridge temperatures being monitored.

• There was no formal agreement in place for the transfer of critically ill patients and there were gaps in the policy concerning the identification of critically ill patients.

• There was also no formal agreement in place concerning the cover arrangements for offsite consultants and anaesthetists by local colleagues when they were unable to return to the hospital.

• Governance processes were not robust and there was a lack of assurance and leadership on governance issues. Hospital wide governance, medical advisory committee and staff meetings did not take place in line with hospital policies or at regular intervals.

• There was a lack of engagement from staff in governance processes, particularly in relation to representation from theatres.

• There was no proactive management of risk and no formal risk register in place for the service.

• We saw that audit activities were not always effective and poor audit outcomes were not escalated or acted upon by the hospital leadership.

We also found the following areas of good practice:

• Medications were appropriately stored and dispensed.

• Staff had appropriate life support training in place and suitable medical cover was available on site for patients undergoing surgery.

• Records were of a good standard and we saw evidence that safe care was being provided.

• Surgical site infection rates were in line with what we would expect and were appropriately recorded and investigated.

• Staff spoke positively about the new hospital manager and felt that the service was improving.

• We saw that patient feedback was positive.

• The hospital was also an early adopter of the NHS Digital Implant Registry.

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. We also issued the provider with a warning notice in regard to good governance and requirement notices in regard to theatre staffing and the theatre environment. Details are at the end of the report.

Ellen Armistead

Deputy Chief Inspector of Hospitals (North)