The Fertility & Gynaecology Academy

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

The service ensured patients’ care, treatment and support achieved the best possible care and promoted a good quality of life, based on the best available evidence.

We saw that outpatients’ care and treatment reflected patients’ needs. Staff monitored patients’ outcomes and worked together to encourage patients in their ongoing care.

The last assessment of this service on 16 January 2014 was under an old methodology and was not rated.

We have not rated Effective in line with the methodology for inspecting an outpatient service.

We have not awarded this service a score for Effective.

Find out about when we will not publish a key question score and what we look at when we assess Effective.

The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Staff completed a health assessment for all patients during their first appointment. The 3 sets of patients’ records reviewed all had a health assessment taken and a record of patients’ suitability for treatment. Care plans were developed meeting the individual needs of the patient offering different treatment options depending on the patients’ reasons for attending the clinic.

Patient’s notes were handwritten and later uploaded into a digital record by the administration team. The notes we reviewed were clear, signed and dated and prescriptions were clearly recorded. Paper notes were placed in confidential waste to dispose of. We saw bags of confidential waste securely tied waiting to be disposed of. However, the room where the confidential waste bags were stored was not always locked and we found the door propped open on occasions. The practice manager told us confidential waste was collected regularly when bags were full. On the first day we were visited the service, we found full confidential waste bags which were still there when we returned 2 weeks later. We were not assured confidential waste was collected regularly.

Patients we spoke with told us that they were made aware that some treatments were time sensitive which might impact on their suitability as a treatment plan. This meant patients had an understanding of the strict protocols to follow before treatment started.

The service did not always plan and deliver people’s care and treatment using effective methods to encourage learning and effective guidance.

Managers did not always identify the learning needs of staff, and not all staff had received a yearly appraisal. One member of staff told us they had received an appraisal before but could not remember when and there was no record of this. The service did not have a log of yearly appraisals, and it was not clear when an appraisal had taken place or when one was due. We were not assured yearly appraisals were an embedded part of the practice.

There was no record of regular meetings between staff and managers to discuss staff performance or how learning needs would be identified and met. Therefore staff might not be made aware of any performance issues and there was no record to show what action staff needed to take to improve. However, all staff had written into their contract they could access funding for further training and the staff we spoke with knew this was an option available to them, providing opportunities to develop their skills and knowledge. Staff we spoke with had not accessed this funding.

Managers did not always ensure that staff received the necessary specialist training for their roles. The nursing staff did not have records in their employee files to show what training they had received or what competencies they had completed in order to care for patients meaning they might not work effectively.

Policies and SOPs were stored electronically and accessible to all staff. We reviewed over 10 policies and found they were not dated and did not have version control noted on the document, however the document made reference to the version on the providers electronic storage. This meant we were not assured we reviewed the most up to date policy. We found the policies referenced national guidance and relevant legislation when necessary. Staff we spoke with knew how to access policies and the quality manager told us any updates were shared at team meetings. We requested the team meetings minutes, but these were not provided and we did not see evidence policy updates were shared with staff. Therefore, it was not clear if staff were made aware of updates which could impact patient care.

All the policies and SOPs we reviewed included a footer noting that hard copies of the document were uncontrolled. This meant staff were made aware that any printed copy might not be the most up to date version. We did not see any printed copies of policies and SOPs while we were in the clinic.

Staff participated in clinical audits and benchmarking against other providers for treatment carried out under activity regulated by HFEA. The outcomes of these audits were displayed publicly on the HFEA website for members of the public to see. The leaders of the service told us how important it was to participate in these audits in order to maintain compliance with HFEA and show their results in a transparent way. The service did not undertake any audits related to activity regulated by the CQC.

The team included specialists required to meet the needs of patients in the service. The consultants were specialists in their areas of expertise. We saw a full employment history of 1 consultant showing a career working in this area meaning patients were seen my medical staff with experience and expertise in reproductive health.

The service worked well across teams and services to support people.

The service operated with a small team who worked well together. We observed staff working together in a friendly and professional way. The service was made up of 4 different areas, the clinic rooms, recovery, theatre suite and laboratory, only the clinic rooms were used for activity regulated by the CQC. Nursing staff rotated between the outpatient clinic, recovery and theatres meaning they worked with all clinical staff and built-up strong working relationships. Staff told us they worked well together internally and with external partners. Staff told us about external partners and how they were able to access services to benefit the patients. A local provider offered same day appointments for blood tests meaning patients did not have to travel to several appointments on different days.

Patients could request a copy of test results that were sent to another provider of their choice, including their GP. One patient we spoke with told us they had requested a copy of their scan as reference for any further treatment and were happy this was available to them.

The service did not always support people to manage their health and wellbeing and support people to live healthier lives.

The clinic did not support them to live healthier lives. Patients had their body mass index (BMI) recorded but they were not provided with guidance on healthy eating or smoking cessation which could impact on their reproductive health.

The service routinely monitored people’s care and treatment to continuously improve it.

Staff used partners to support patients effectively. The service had an agreement in place with a local laboratory to process blood tests in a timely manner. This gave patients access to results quickly in order to make decisions about possible ongoing treatment.

The service did not participate in any national audits related to activities regulated by the CQC. The service submitted data for benchmarking against other providers for activity regulated by HFEA in line with their requirements.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff took practical steps to enable patients to make their own decisions. Staff we spoke with understood the importance of recording patient consent. We reviewed 3 sets of patients’ notes and found consent was recorded each time. Patients we spoke with told us they had their treatment fully explained and felt comfortable with the information provided and they felt informed about the choices they were making.

Different consent forms were used for different treatment options. We reviewed 2 consent forms and found detailed information about the procedure, what the patient was consenting to and links to legislation relevant to the treatment.

The service did not see patients who did not have capacity to make their own decisions.