6 September 2016
During a routine inspection
Dr Yannis Alexandrides, trading as 111 Harley Street is a small independent hospital offering cosmetic surgery services to privately funded adult patients at this location since 2001. The hospital was previously inspected by the Care Quality Commission (CQC) in November 2013. When the report was published in December 2013 we had concluded the location had met all of the standards inspected.
On this occasion we inspected the hospital on 6 September 2016 as part of our independent hospital inspection programme. The inspection was conducted using the CQC’s comprehensive inspection methodology and was a routine planned inspection. The inspection focussed on the regulated activities of surgical procedures and treatment of disease, disorder or injury. Procedures not currently subject to regulation were not part of the inspection.
The inspection team was led by a CQC inspection manager supported by a CQC inspector.
We have not published a rating for this service. CQC does not currently have a legal duty to award ratings for those hospitals that provide solely or mainly cosmetic surgery services.
Are services safe at this service
We found there were systems to report and investigate safety incidents and to learn from these. Risks, including those related to infection prevention control measures, medicines, and equipment were understood and actions were taken to mitigate them. There were sufficient numbers of staff with the necessary skill, qualifications and experience to meet patients’ needs.
The service needed to improve staffs compliance with the completion of the World Health Organisation (WHO) surgical checklist. Additionally, staff safeguarding training required updating.
Are services effective at this service
Care was planned and delivered in accordance with current guidance, best practice and legislation by suitably skilled and competent staff. There was a programme of audit, which was used to assess the effectiveness of services and to maintain standards. Patients’ pain was well controlled, and their nutritional needs were met.
Are services caring at this service
Patients were treated with kindness and respect. Patients gave positive feedback and said they were treated well by staff, and with compassion and dignity.
Are services responsive at this service
Services were planned to meet the needs and choices of patients, and the arrangements for treatment were prompt. There were arrangements to ensure the individual needs of patients were fully considered, assessed and met. Complaints were appropriately acknowledged, investigated and responded to in a timely way.
Are services well led at this service
The service had a well-established leader, who had an excellent working relationship with their staff.
Staff understood what the values and purpose of the service were, and what was expected of them. They were committed to meet the requirements of their patients.
Patents and staff were encouraged to feedback on the quality of services.
The governance arrangements provided assurance of systematic monitoring of the quality of services.
However, although risks were managed, a formal risk register was not in use to capture such information.
Our key findings were as follows:
• There were adequate systems to keep people safe and to learn from adverse events or incidents.
• The environment was visibly clean and well maintained and there were measures to prevent and control the spread of infection.
• There were adequate numbers of suitably qualified, skilled and experienced staff to meet patients’ needs, and staff had access to training and development, which ensured they were competent to do their jobs.
• There were arrangements to ensure patients had access to suitable refreshments, including drinks.
• Treatment and care was delivered in line with national guidance and the outcomes for patients were good.
• Patient consent for treatment and care met legal requirements and national guidance.
• Patients could access care in a timely way, and had choices regarding their treatment day.
• Staff ensured patients privacy and dignity of patients was upheld.
• The leadership team were visible and appropriate governance arrangements meant the service continually reviewed the quality of services provided.
However, there were also areas of where the provider needs to make improvements. The provider should:
- Review the arrangements and practices for the completion of the World Health Organisation safer surgery checklist.
- Provide staff with the correct level of safeguarding training.
- Consider improving staff knowledge of mental capacity, dementia awareness and deprivation of liberty safeguards.
- Consider introducing a formal hospital risk register.