Joseph House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safety was a priority for everyone and leaders embedded a culture of openness, collaboration and learning. There were clear roles and responsibilities for managing and improving safety. Leaders had a strong awareness of safety hazards and risks. Solutions were developed collaboratively, with the right people and partners to make improvements.

Staff and leaders responded positively when people raised concerns about safety, and ideas to improve care delivery were raised. The primary response was to view these as an opportunity to learn and improve. Leaders ensured there was enough skilled staff to deliver safe care.

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.

The service actively sought feedback from patients on their experience and suggestions for improvement. Patient responses were collected and analysed for themes.

Patients we spoke with said that they felt the booking process was good, and they had been given a ‘cooling off’ period to consider their decision and to ask questions about the surgical procedure and aftercare. Patients said they had access to consultants to discuss any concerns if needed and had been given details of who to contact for aftercare and advice on wound care. People said they felt they felt safe and well cared for during and after the procedure.

Staff received and kept up to date with their mandatory training and new staff had an induction. Staff told us training met their needs and was appropriate for their roles.

Mandatory training was comprehensive and met the needs of patients. Staff completed training on recognising and responding to patients with mental health needs, learning disabilities, autism, and Equality, Diversity, and Inclusion.

The service had processes in place to continuously learn, drive improvement and look for innovation on how to improve the service which patients receive. Leaders and staff we spoke with were able to give examples where they had used feedback from people using the service to make changes. For example, introducing post-operative support underwear.. Leaders monitored social media reviews of the service, responded and used them as a learning opportunity. There was a forum for people using the service for pre-operative and post-operative advice and experiences to be shared.

There was an incident policy in place which met the needs of the service, was in date and had been reviewed. There were processes in place for staff to follow when reporting incidents. Incidents were monitored and audits completed with learning and actions discussed as part of regular team meetings. Where learning was required, there were processes to follow for staff to ensure this was shared and embedded.

Staff we spoke with were able to explain the process for reporting incidents and gave examples of actions which had been taken to improve patient safety following incidents. Following our assessment, we reviewed one incident that had met the threshold for duty of candour and found no concerns with how the service had completed the process.

We reviewed 10 sets of patient records and found 1 set had 2 different patients’ details in the same file. We raised this with the registered manager who took immediate action, documented this as an incident, carried out an investigation, separated the records, communicated this with staff and planned to undertake a medical records audit as part of the audit programme. The service had a process for patients to feed back their experience and suggestions for improvement. Compliments and complaints were reviewed for themes, collected and fed back to staff.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

Staff could give examples of how to protect patients from harassment and discrimination. Staff knew how to identify adults and children at risk of, or suffering, significant harm. Staff knew how to make a safeguarding referral and who to inform if they had concerns. Staff told us they would raise any concerns to the registered manager.

Non-clinical and administrative staff had completed safeguarding training level 1 and

Reception staff told us that if a patient attended with children under the age of 18 years, they would ask them to return at another time without the children as they did not allow children on the premises. All patients were required to give proof of ID and age before commencing any procedures.

During our on-site visit we spoke with 3 patients, who told us that they had a good understanding of their care and treatment, and if they did not understand something the staff would explain their care to them. Patients told us that appointments were in a timely manner, and waiting times were short.

Patient told us they did not feel rushed or persuaded into making any decision and had time to think prior to making a final decision. Following the first consultation patient had at least a 2-week cooling off period before any surgery was booked.

We observed post operative information were given to patients, both written and verbally, and patients were given a copy of their GP letter. Patients were given advise relating to pain management and wound care and contact numbers if the patient needed to call for any advice.

Staff we spoke with were able to explain the risk assessment process which was completed prior to any procedure taking place. For example, advising patients they need to be nicotine free for at least 4 weeks prior to the procedure, assessing previous procedures the patient had and any complications, allergies, and assessing their mental health and wellbeing.

There was an appropriate discharge process in place. This included making sure the patient was alert and not disorientated, checking vital signs such as blood pressure, pain levels and pain management. Staff also gave post procedure information such as contacting the clinic or out of hours or to speak to the on-call nurse, wearing surgical stockings and other post operation surgical wear and how to take any prescribed medications.

The service had a process in place for managing and escalation of a deteriorating patient. Staff were able to explain the escalation policy and action to be taken. There was also a procedure for responding to life threatening emergencies such as cardiac arrest or fire.

Patients had access to call bells whilst in the bay and the service completed daily checks to ensure they worked.

The service provided a chaperone if they felt additional support was needed. Reception staff had specific training on chaperoning and would be available to help in consultations and clinics. Patients could bring a carer or family member with them if they felt they needed support.

Staff told us patients with mobility issues would be referred to another site within the company.

The service had suitable facilities to meet the needs of patients' families. The waiting area was spacious and there were enough seats. Beverages were available in reception and offered to patients and visitors by reception staff.

We checked 2 theatre packs and 10 consumables and found they were all in date. Substances deemed hazardous to health were locked in designated cupboards in the storerooms.

Breast implants were stored on open shelves in the administration area, some were on the tops of cabinets near to the staff rest area. We discussed the storage and safety with the registered manager as there was potential for the breast implants to be accidentally damaged. Following our assessment, leaders ordered new storage units for the implants.

Staff disposed of clinical waste safely. We saw clinical waste bins were emptied regularly and stored in a secure shed outside the main building.

Fire extinguishers were within date service checks and there fire exit signs throughout the service.

All areas were accessed by keypad codes, and we saw patients being escorted around the building by staff. The service had CCTV which covered the communal areas and car park.

The service had enough suitable equipment to help them to safely care for patients. The service had 1 resuscitation trolley on the ground floor. This was clean, tagged, and daily and weekly checks had been completed. There was a defibrillator, anaphylaxis set, and difficult airway set available in the theatre area. There was a list of equipment that was nearing expiration so this could be easily identified and changed when required. There was a resuscitation trolley on the second floor and the defibrillator from the ground floor could be brought upstairs if required. Oxygen and suction were available in the ward area and in theatre. A transfer slide board was on the second floor to assist with the transfer of any patients down in an emergency evacuation.

There was a process in place locally to ensure all equipment was safely managed.

We saw information for contact details for maintenance of equipment, services and electrical testing. Where any items were identified as broken and required repairs, there was a process in place to ensure this was managed safely and swiftly to ensure patients were not impacted by this.

In the event of a power failure there was back up for around 6 hours. This was on the risk register and reviewed monthly.

Water testing was carried out for both legionella and other bacteria. Recently there had been a positive sample for pseudomonas in some water taps. Actions taken included flushing and chemical treatment, following treatment, the service had taken more samples and showed the count had reduced but not eradicated the bacteria completely. The service had identified some pipework that could be removed, and this was being planned. In the interim bottled water was provided for both patients and staff, secondary preventative measures after handwashing, and sachets of sterile water for wound cleansing if water is required. This was on the risk register and reviewed monthly. We saw this was discussed at the governance meetings and a company with expertise in this area was being consulted.

There was data to evidence that all electrical equipment had been tested and maintained. There was a folder available with contact numbers for equipment maintenance and domestic services.

There was a service level agreement in place for an external company to complete equipment checks.

The service had enough staff to care for patients, they had a good skill mix. They employed registered nurses, operating assistants, scrub nurses, health care assistants, support staff and administration staff. Staffing was planned to meet patient needs in line with the theatre sessions, overnight stays and clinics. Staff we spoke to said they felt the staffing levels for the service were safe and that staffing was planned in advance.

Staff told us that they were supported to learn and develop. They were offered opportunities to develop and learn within their roles.

Anaesthetists and the RMO were trained in advanced life support. Clinical staff were trained in immediate life support and all other staff were trained in basic life support.

We observed staffing levels and how staff interacted with patients. There were enough staff of all levels and experience. We observed staff were competent and had the skills to carry out their roles.

We saw clinics and theatres were planned in advance and staffing levels and skill mix planned to meet the needs of the service.

There were processes to ensure there were enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. The service ensured staff were competent for their roles. We saw the provider checked that staff were registered with the Nursing and Midwifery Council and General Medical Council and within expiry dates. The service had processes to monitor staff sickness, vacancies and turnover. The sickness rate for 2024 was 5.8%. Staffing levels were planned and booked in advance. Bank and agency staff were used and booked in advance. The provider tried to use regular bank and agency staff who were familiar with the service. Staffing levels and skill mix was on the risk register and reviewed monthly at governance meetings.

We saw there was a manager on call 24 hours a day. Each day there was a list circulated to inform staff who was on call and contact numbers, this included consultant, anaesthetist, nurse and manager. There was 1 registered medial officer (RMO) who worked night shifts to care for patients that stayed overnight. Overnight admissions were planned in advance. When patients stayed overnight, the RMO and 1 registered nurse were on duty. If more than 1 patient stayed overnight, an additional registered nurse would be allocated to work. This was an improvement since our last inspection. Staff could contact managers, consultants and anaesthetists 24 hours a day for advice and support. All consultants and anaesthetists had practicing privileges. Consultants had dedicated clinics and theatre sessions which were planned in advance.

There was a dedicated wound care clinic Monday to Friday and a newly appointed registered nurse led this clinic. The service was open on a Saturday for planned care, patients could attend if required. At the time of the assessment, there was 1 vacancy for a recovery nurse and a new position for an infection control /tissue viability nurse.

Staff told us they completed infection prevention and control (IPC) training and that leaders fed back outcomes of IPC audits.

Staff worked effectively to prevent, identify and treat surgical site infections.

Staff used records to identify how well the service prevented infections. There was an online tracker that identified patients 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.

Staff cleaned equipment after patient contact and labelled equipment to show it was clean and ready for use. Staff were able to explain the process for cleaning the environment and equipment.

Decontamination and sterilisation of equipment was carried out an external company. Clean and sterile equipment was stored in a clean storage area.

All areas were visibly clean and tidy and had suitable furnishings which were clean and well-maintained. There were adequate storage facilities which were tidy and free from clutter. We saw cleaning wipes and alcohol wipes were available throughout the clinic.

Staff followed infection control principles including the use of personal protective equipment. Hand-washing and sanitising facilities were available for staff and visitors. We observed staff hand washing and using hand sanitising gel appropriately. Staff were bare below the elbows.

Staff cleaned rooms daily and completed checklists. They used labels to show rooms were clean. Staff cleaned equipment after each patient contact. Theatres was cleaned in between each patient and at the end of the day

Clean and sterile equipment were stored separately close to theatre. Sharps boxes were not over filled and labelled correctly.

Staff wore theatre scrubs in the ward and theatre areas. Changing facilities were provided and staff changed on arrival and before they left work.

There were policies and processes in place for staff to follow to ensure the risk of infection was controlled well.

Water testing was on the risk register and reviewed monthly at the governance meetings. There had been an increase in the water testing due to positive results.

Infection rates and wound care were on the risk register and reviewed monthly at governance meetings. An online tracker had been implemented for wound care which was reviewed weekly. The weekly wound care meeting did not have minutes recorded but the leaders told us they planned to do so in future.

We saw minutes of governance and medical advisory committee meetings where water testing and infection rates were discussed.

Leaders/staff carried out monthly audits including hand hygiene and uniform compliance and quarterly audits for cleaning, waste management, sharps, decontamination, control of substances hazardous to health (COSHH), personal protective equipment (PPE) and housekeeping. There was good compliance and actions in place when needed.

From January 2024 to October 2024 the surgical site infection rate was 2.65%. Leaders monitored infection rates and compared them against another clinic in the group. Infection rates were similar to the other clinics.

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

Following a review of incidents, leaders planned to appoint an infection control/tissue viability nurse. All clinical staff would attend a tissue viability course.

Staff were able to describe the systems and processes to prescribe and administer medicines safely. Checks were made to ensure out-of-date medicines were disposed of. Controlled drugs were stored in a separate locked cupboard in the theatre. Medicines were prescribed by medical staff.

Staff checked fridge temperatures daily, and if these were not within range this was escalated and reported via the correct procedure.

Staff stored and managed medicines and prescribing documents safely. Medicines were stored neatly and securely in locked cupboards. Keys for the drug cupboard were held by registered staff only.

There was a store cupboard in the main storeroom with excess drugs that was locked and only clinical staff had access. Any drugs taken out were documented.

Staff completed medicines records accurately and kept them up to date. We viewed 10 patient records where medicines had been prescribed and saw that all medicines prescribed were signed for by medical staff. Patients were given verbal and written advice on medication when discharged.

The service had a medicines management policy, which ensured staff practices were in line with national guidance. Quarterly audits for medicine management and monthly audits for control drugs and expired drugs were all 100% compliant.