Joseph House

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

People were involved as much as possible in the assessment of their needs, and support was provided where needed to maximise their involvement. People were confident that their individual needs have been appropriately assessed and fully understood.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We observed staff chaperoning patient around the building. Patients we spoke to told us that staff were caring, kind and responded to their needs.

Patients told us that they could discuss their wishes with the consultant and were given time to think about surgery prior to making a decision. They had opportunity to ask questions and raise concerns.

Patients told us they received a phone call the day before their surgery to ensure they understood all the information and were prepared for surgery.

Patients were given verbal and written instructions post procedure and contact numbers to call if required.

Patient told us communication was good and they had enough information before and after surgery. One patient told us they phoned for more advice and were offered an appointment the same day.

Staff used a nationally recognised tool to identify deteriorating patients and escalated them appropriately. The service used National Early Warning Scores (NEWS) which were completed on paper documents then transferred to electronic records. The service did not audit NEWS documentation or compliance which would be good practice. Patients were assessed before any procedure to ensure they were fit for surgery. If patients deteriorated staff responded by calling the on-call staff and would support the patient to the local NHS trust by calling 999. Staff completed risk assessments for each patient on admission and arrival using recognised tools such as falls risk assessment and prevention of venous thromboembolism, and reviewed these regularly. Staff had access to a translation service. They identified at the patient’s first call with the service if they required communication support.

Staff followed up-to-date policies and protocols to plan and deliver high quality care according to best practice and national guidance. The service followed National Institute for Health and Care Excellence (NICE) guidelines. Policies and protocols we reviewed for example, the protocol on the prevention of venous thromboembolism and discharge and follow up protocol, were up to date and had been approved by the appropriate governance processes.

The service had a preoperative admission criteria to ensure patients were suitable to be treated at the clinic. Patients received a call the day before any procedure to ensure they were prepared and could discuss any changes or questions.

All female patients had a pregnancy test carried out on the day of surgery to ensure it was safe to proceed. Patients were tested for nicotine levels, and advice was given on smoking and potential risks of surgery and wound healing.

We saw staff following best practice guidance, for example, from the World Health Organization (WHO) to ensure patient care was safe during surgical procedures and a MRSA risk assessment form to be completed for each patient.

There were processes in place for staff to follow to assess and meet the needs of patients. The service used clinical tools which were relevant to the patient’s needs, for example WHO checklists and mobility and falls assessments, these were documented in a standardised care pathway.

We saw the WHO checklist was audited with good compliance and any actions were discussed directly with staff members.

There was a manager on call 24 hours a day for both patients and staff. Consultants and anaesthetists were available 24 hours a day for advice and support.

We did not look at Delivering evidence-based care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at How staff, teams and services work together during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

Service leaders told us they did not monitor waiting times as all patients were able to book an appointment at a time which was best suited to their own needs.



We observed staff chaperoning patient around the building.

Staff we spoke to explained that patients were able to discuss their wishes or concerns with a consultant and they had opportunity to ask questions. Patients received a phone call the day before their surgery to ensure they understood all the information and were prepared for surgery.

Service managers showed us a number of audits which were completed for example on surgical site infections and also customer satisfaction results. These were reported to leaders and discussed at team meetings with agreed action plan.

The service complied with the Competition and Markets Authority legal requirement to submit private patient episode data to the Private Healthcare Information Network.

Leaders and staff added patient details and implant information to the national breast and implant registry in line with good practice.

Managers and staff carried out a comprehensive programme of repeated audits to check improvement over time. Managers used information from audits and patient feedback to improve care and treatment.

Managers shared and made sure staff understood information from audits so that learning could be implemented.

There was a tracker that identified patient with wound infections and wounds of concern. This was updated following patient visits and included wound care information, treatment, antibiotics and swab results. A weekly meeting was held to review patients on the tracker. Infection rates were compared to another site within the company and discussed at the governance meetings.

We saw weekly and monthly audits were carried out including hand hygiene, uniform compliance and medical records and quarterly audits for consent, fasting, cleaning, waste management, sharps, decontamination, COSHH, PPE and housekeeping.

There was good compliance with monthly and quarterly audits and actions in place when needed. Leaders shared audit results with staff and were discussed at governance meetings. Audit results were benchmarked against other clinics within the group.

From January 2024 to October 2024 the SSI rate was 2.65%. The service monitored infection rates and compared them against another clinic in the group. The infection rates showed they were similar to the other clinic.

Any patient attending the wound care clinic would have a longer appointment and the consultant would receive an update on actions and progress.

Patients told us that they gave consent to care and treatment, and they understood why they were consenting to treatment. They were informed of the risks and what to expect post-surgery.

Consultants assessed patients for their suitability for surgery. Consultants provided patients with information on their treatment both verbal and written information.

Patients had at least a 2-week cooling off period to consider their option prior to consenting for surgery.

The service contacted all GPs for a summary of health for each patient. This identified if there were any mental health concerns and if required staff held discussions with patients to gain more information to assess if they were well enough to make decisions about their surgery.

The service provided Mental Capacity Act and Deprivation of Liberty Safeguards training for all staff. All staff were up to date with this training, apart from new starters who were in the process of completing all training.

There were processes in place to ensure staff supported patients to make informed decisions about their care and treatment. There were policies and processes which staff were aware of and followed to gain patient consent.

The service had a consent to care and treatment policy which was in date and reviewed at the governance meetings. The policy included information about the 2-week cooling off period and mental capacity.

We reviewed records of 10 patients notes who had been for surgery and found consent had been clearly recorded. They provided information on the potential risks.

Monthly consent audits were carried out with 100% compliance from February to August 2024.