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Inspection Summary

Overall summary & rating


Updated 21 August 2019

This service is rated as Good overall.

The service had previously been inspected in November 2017 and was found to be providing services in accordance with relevant regulations. However, at that time independent providers of regulated activities were not rated by the Care Quality Commission.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We carried out an announced comprehensive inspection at AMS Clinic Bradford on 30 June 2019 as part of our inspection programme.

The clinic provides circumcision to patients aged from two weeks up to two years of age for both cultural and religious reasons. Patients also have access to post-procedural reviews at the clinic and access to an aftercare helpline available 24 hours a day.

One of the directors of the clinic is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the clinic is run.

The clinic made use of patient feedback to monitor and improve the service. They produced their own surveys and regularly monitored feedback through google review.

In addition; we received nine Care Quality Commission comment cards. These were all very positive about the care delivered by the service.

Our key findings were:

  • The clinic was offered on a private, fee paying basis only and was accessible to people who chose to use it.
  • Circumcision procedures were safely managed and there were effective levels of patient support and aftercare.
  • The clinic had developed materials for parents which explained the procedure and outlined clearly the recovery process.
  • Parents received daily text messages providing advice for 13 days following the procedure to outline what to expect and give advice about aftercare.
  • The clinic had systems in place to identify, investigate and learn from incidents relating to the safety of patients and staff members.
  • There were systems, processes and practices in place to safeguard patients from abuse.
  • The clinic always communicated with the GP service with which patients were registered via letters sent with the parents following the procedure.
  • There was a clear leadership structure, with governance frameworks which supported the delivery of quality care.
  • Communication between staff was effective with regular documented meetings across both sites.

The areas where the provider should make improvements are:

  • Review and improve the process for communicating with the patient’s own GP following the procedure.
  • Review and improve the process for the documentation of medical indemnity and staff immunity status.
  • Review and improve the process for checking the oxygen supply.
  • Review the systems in place for direct clinical observation to assess surgical technique.
  • Review the arrangements for onsite access to the legionella risk assessment.

Dr Rosie Benneyworth BM BS BMedSci MRCGPChief Inspector of Primary Medical Services and Integrated Care

Inspection areas



Updated 21 August 2019

We rated safe as


Safety systems and processes

The service

had clear systems to keep people safe and safeguarded from abuse.

  • The clinic had systems to safeguard children and vulnerable adults from abuse.
  • Policies were regularly reviewed and were accessible to staff. They outlined clearly who to go to for further guidance.
  • The provider had processes in place to confirm with parents prior to the procedure, if a child was on a child protection register, as well as confirming their parental authority to consent to the circumcision or any aftercare treatment. The form had a clear statement for both parents to sign to confirm they had parental authority.
  • The clinic explained to us how, if required, they would work with other agencies to support patients and protect them from neglect and abuse.
  • Staff took steps to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect.
  • The provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate. Disclosure and Barring Service (DBS) checks were undertaken where required. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).
  • All staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns. Staff who acted as chaperones were trained for the role and had received a DBS check.

  • There was an effective system to manage infection prevention and control and they carried out regular infection prevention and control audits. We inspected the procedure room where the circumcisions were undertaken and found this to be in a clean and well-maintained condition.
  • The clinic held a contract for clinical waste disposal including sharps bins and soft clinical waste.
  • We were informed that the clinic had access to the legionella risk assessment for the premises and was aware of the control measure in place (Legionella is a bacterium which can contaminate water systems in buildings).
  • The provider ensured that facilities and equipment were safe, and that equipment was maintained according to manufacturers’ instructions.

Risks to patients


were systems to assess, monitor and manage risks to patient safety.

  • There were arrangements for planning and monitoring the number and mix of staff needed. Staffing for the service was planned around the scheduled patient appointments.
  • Staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention. They knew how to identify and manage patients with severe infections, such as sepsis.
  • The clinic had access to emergency medication and oxygen. We looked at these on the day of our inspection and saw that the regular checks were carried out to make sure that the emergency medication was in date. However, the oxygen was past it’s expiry date. We discussed this with the provider during our inspection and were advised that this would be rectified. We noted the provider did not have a defibrillator; however, an emergency resuscitation box was located in the clinic.
  • Records held by the provider confirmed that all staff were up to date with necessary training, this included basic life support.
  • All staff had received moving and handling training to support the safe transfer of patients between floors. However, we discussed this with the provider on the day of inspection and were advised that the parents usually did this.
  • Clinical staff had indemnity cover sufficient to meet the needs of the service. However; some of the healthcare assistant files that we reviewed only had a signed declaration from the employee to confirm this was in place.
  • Staff records and recruitment files contained some key information. However; it was noted that the service had only limited assurance with regard to the immunity status of staff in respect of measles, mumps, rubella and varicella.

Information to deliver safe care and treatment


had the information they needed to deliver safe care and treatment to patients.

  • Individual care records were written and managed in a way that kept patients safe. The care records we saw showed that information needed to deliver safe care and treatment was available to relevant staff in an accessible way.
  • The clinic carried out health checks on both the child and mother prior to the procedure. This was to check that there were no health issues with the mother that may affect the procedure. For example, if the mother was on anticoagulants and breast feeding, there was a risk this may result in excessive bleeding for the child.
  • The clinic had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment. We saw that the clinic provided parents with a letter to take to their GP following the procedure.

Safe and appropriate use of medicines

The clinic

had reliable systems for appropriate and safe handling of medicines.

  • Emergency medicines were within date and were stored safely and securely. However, the oxygen was past it’s expiry date.
  • Staff prescribed medicines to patients and gave advice on medicines in line with legal requirements and current national guidance.
  • There were effective protocols for verifying the identity of patients including children.

Track record on safety and incidents

The clinic

had a good safety record.

  • There were comprehensive risk assessments and processes in place to manage safety issues.
  • The clinic monitored and reviewed activity. This helped it to understand risks and gave a clear, accurate and current picture that led to safety improvements.

Lessons learned and improvements made

The clinic learned and made improvements when things went wrong.

  • The clinic had clearly defined and embedded systems, processes and practices in place to identify, record, analyse and learn from incidents and complaints.
  • There was a system in place for reporting and recording significant events. We saw that a significant event process was embedded, and all staff were clear about how to record incidents and how these would be investigated.
  • We were told that any significant events and complaints received by the clinic would be discussed by the clinicians involved in delivering the service. We were able to review one complaint that had been received by the provider and it was subsequently reviewed and investigated as a significant event.
  • The clinic acted on and learned from external safety events as well as patient and medicines safety alerts. The service had an effective mechanism in place to disseminate alerts to all members of the team.
  • The provider was aware of and complied with the requirements of the Duty of Candour. The provider encouraged a culture of openness and honesty. The clinic had systems in place for knowing about notifiable safety incidents.



Updated 21 August 2019

We rated effective as



Effective needs assessment, care and treatment

The provider had systems to keep clinicians up to date with current evidence-based practice. We saw evidence that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance (relevant to their service)

  • Patients’ immediate and ongoing needs were fully assessed. Parents using the clinic had an initial consultation where a detailed medical history was taken for both the patient and mother. If the initial assessment showed the patient as unsuitable for the procedure this would be documented, and the patient referred back to their own GP.
  • Parents of the patient were able to access detailed information regarding the process and the procedure used by the clinic. The clinic provided a book containing post-operative pictures to assist the parents of patients in knowing what to expect following the procedure.
  • After the procedure, parents were requested to stay in the recovery room with their child for an hour to ensure there was no initial bleeding or complications. Clinicians also discussed after care treatment with parents and sought to inform them of what to expect over the recovery period. In addition, the clinic sent daily text messages to parents for the 13 days after the procedure, advising them what to expect each day and how best to support recovery following the procedure. They told us that this had reduced the number of calls they received from anxious parents following the procedure.
  • The clinic offered post-operative support via a 24-hour aftercare line when parents could contact a clinician via a mobile phone number.
  • We saw no evidence of discrimination when making care and treatment decisions.
  • At the time of our inspection the clinic had introduced a WhatsApp booking application via the website to enable parents to communicate with the on-call clinician and book appointments.

Monitoring care and treatment

The service was actively involved in quality improvement activity.

  • There was evidence of a commitment to quality improvement including accreditation by the ‘Greater Manchester Safeguarding Infant Male Quality Assurance Services’ at the Manchester location. This was a self-assessment process and information submitted by the clinic was assessed against required standards and guidance such as The General Medical Council personal beliefs and medical practice guidance in order to become quality assured. The clinic was required to submit audits and attend annual workshops. The provider told us they applied the same standards across both the Manchester and Bradford locations.
  • The clinic made improvements through the use of completed audits. Clinical audit had a positive impact on quality of care and outcomes for patients. For example, the clinic carried out regular audits to monitor post-procedural bleeding or infection. We found there to be a very low rate of complications. There was clear evidence of action to resolve concerns and improve quality.

Effective staffing

Staff had the skills, knowledge and experience to carry out their roles.

  • All staff were appropriately qualified. The clinical team who carried out the procedure was composed of an acute nurse (who also worked in a secondary care accident and emergency department) and a healthcare assistant. All staff members had a wide range of experience in delivering circumcision services to children.
  • Staff working at the clinic also had access to advice from a consultant urologist from secondary care, who had provided training for all staff employed by the clinic to carry out the procedure.
  • Relevant professionals (medical and nursing) were registered with the General Medical Council (GMC) or Nursing and Midwifery Council (NMC) and were up to date with revalidation

Coordinating patient care and information sharing

Staff worked together, and worked well with other organisations, to deliver effective care and treatment.

  • Whilst the opportunity for working with other services was limited, the clinic did so when this was necessary and appropriate. For example, the clinic gave parents a letter which they were asked to give to their own GP. The letter explained that a circumcision procedure had been carried out and gave the clinic contact details should the GP wish to contact them for further information or advice.
  • Before providing treatment, doctors at the service ensured they had adequate knowledge of the patient’s health, any relevant test results and their medicines history. We saw examples of patients being signposted to more suitable sources of treatment where this information was not available, to ensure safe care and treatment.

Supporting patients to live healthier lives

Staff were consistent and proactive in empowering patients and supporting them to manage their own health and maximise their independence.

  • Where appropriate, staff gave parents advice, so they could self-care.
  • Risk factors were identified, highlighted to patients and where appropriate highlighted to their normal care provider for additional support.
  • Where patients needs could not be met by the service, staff redirected them to the appropriate service for their needs. Since the last inspection the clinic had made the decision to only provide circumcision to patients aged two years and under. This was because the previous consultant urologist no longer performed operations for the clinic. They told us how they signposted patients over two years of age to another registered provider who delivered services locally.

Consent to care and treatment

The service obtained consent to care and treatment in line with legislation and guidance


  • The clinic had developed protocols and procedures to ensure that consent for the circumcision had been given by both parents (unless it was proven that the mother had sole parental responsibility for the child). The consent form had been updated following our inspection in November 2017 to include checks regarding whether the child was on the child protection register.



Updated 21 August 2019

We rated caring as



Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • We reviewed surveys which had been undertaken by the provider and through online reviews. The feedback from patients was positive about the way staff treated people.
  • We reviewed nine Care Quality Commission comment cards which were all positive regarding the treatment received. Many mentioning caring and helpful staff.
  • Staff understood patients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all patients.
  • The service gave patients timely support and information.

Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about care and treatment.

  • Telephone interpretation services were available for patients who did not have English as a first language.
  • A pictorial information book had been produced by the clinic and was discussed with parents prior to the procedure.
  • The clinic sent daily text messages to parents for 13 days following the procedure. This was to provide aftercare information and advise them what to expect each day and how best to support recovery following the procedure.
  • Staff communicated with people in a way that they could understand, for example, communication aids and easy read materials were available.

Privacy and Dignity

The service respected patients’ privacy and dignity.

  • Staff recognised the importance of people’s dignity and respect.
  • Doors were closed during consultations and conversations taking place in these rooms could not be overheard.
  • Parents were given a private recovery room to use with their child.



Updated 21 August 2019

We rated responsive as



Responding to and meeting people’s needs

The service organised and delivered services to meet patients’ needs.

It took account of patient needs and preferences.

  • The clinic operated on a private, fee-paying basis only, and as such was accessible to people who chose to use it and who were deemed suitable to receive the procedure. If it was decided that a potential patient was unsuitable for circumcision, then this was formally recorded and was discussed with the parents of the child.
  • The facilities and premises were appropriate for the services delivered.
  • The clinic had developed a range of information and support resources which were available to service users.

Timely access to the service

Patients were able to access care and treatment from the service within an appropriate timescale for their needs.

  • The clinic operated over one to two sessions per clinic, and clinics were held on Sundays.
  • Following the procedure, parents had access to a 24-hour aftercare helpline should they have any concerns regarding the recovery process.
  • Follow-up appointments were available as and when clinically necessary.

Listening and learning from concerns and complaints

The service took complaints and concerns seriously and had systems in place to respond them appropriately to improve the quality of care.

  • Information about how to make a complaint or raise concerns was available. We were able to review one complaint that had been received by the clinic and saw that this had been responded to and investigated as a significant event. Appropriate changes had been made as a result of the complaint and a full explanation and apology given to the complainant.
  • The service had a complaints policy and procedures in place.



Updated 21 August 2019

We rated well-led as


Leadership capacity and capability

Leaders had the capacity and skills to deliver high-quality, sustainable care.

  • Leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them. For example, the clinic offered training opportunities for other clinicians who wanted to develop their knowledge and skills when carrying out circumcisions.
  • There was a clear leadership structure in place. Directors were responsible for the organisational direction and development of the service and the day to day running of the clinic was the responsibility of experienced clinicians.
  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.
  • The provider had effective processes to develop leadership capacity and skills, including planning for the future leadership of the service. For example, at the time of our inspection the clinic was in recruitment discussions with another operator to support the expansion of the Manchester location.

Vision and strategy

The service had a clear vision and credible strategy to deliver high quality care and promote good outcomes for patients.

  • There was a clear vision and set of values. The service had a realistic strategy and supporting business plans to achieve priorities.
  • Staff were aware of and understood the vision, values and strategy and their role in achieving them
  • The service monitored progress against key priorities.


The service had a culture of high-quality sustainable care.

  • Staff felt respected, supported and valued. They were proud to work for the service.
  • The clinic focused on the needs of patients and their families.
  • Leaders and managers acted on behaviour and performance inconsistent with the vision and values.
  • The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.
  • There were processes for providing all staff with the development they needed. This included appraisal and career development conversations. All staff had received regular annual appraisals in the last year. Staff were supported to meet the requirements of professional revalidation where necessary.
  • Clinical staff, including nurses, were considered valued members of the team.
  • There was a strong emphasis on the safety and well-being of all staff.
  • The service actively promoted equality and diversity.
  • There were positive relationships between staff and teams.

Governance arrangements

There were clear responsibilities, roles and systems of accountability to support good governance and management.

  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective.
  • Staff were clear on their roles and accountabilities. We saw that staff personnel records contained details of job roles and responsibilities. However, we noted that not all of these records contained copies of the medical indemnity documentation and updated immunity status.
  • Leaders had established proper policies, procedures and activities to ensure safety and assured themselves that they were operating as intended.

Managing risks, issues and performance

There were clear and effective processes for managing risks, issues and performance.

  • There was an effective, process to identify, understand, monitor and address current and future risks including risks to patient safety. However; there were some minor areas where the processes had failed. For example; we saw that the oxygen was past it’s expiry date.

  • The service had processes to manage current and future performance. Performance of clinical staff could be demonstrated through audit of their procedures. Leaders had oversight of safety alerts, incidents and complaints.
  • Clinical audit had a positive impact on quality of care and outcomes for patients.
  • The provider had plans in place and had trained staff for major incidents.

Appropriate and accurate information

The service acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance. Performance information was combined with the views of patients. For example, the provider contacted all parents a month after their child’s procedure to obtain feedback on the service they had received.
  • Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information.
  • The service used performance information which was reported and monitored, and management and staff were held to account
  • The information used to monitor performance and the delivery of quality care was accurate and useful.
  • There were robust arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.

Engagement with patients, the public, staff and external partners

The service involved patients, the public, staff and external partners to support high-quality sustainable services.

  • The provider attended an annual workshop led by ‘Greater Manchester Safeguarding Infant Male Quality Assuring Service’ where they could share ideas and learn best practice from other like-minded colleagues. The requirements of the quality assurance service were implemented in the Bradford clinic.
  • The service encouraged and heard views and concerns from the public, patients, staff and external partners and acted on them to shape services and culture. For example, the provider proactively requested feedback following completion of the procedure and via the clinic’s website. We reviewed these and found that all coments were positive about the service received.
  • The service was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

There were systems and processes for learning, continuous improvement and innovation.

  • There was a focus on continuous learning and improvement. For example, the clinic had made a number of improvements following our previous inspection in November 2017 including updating the aftercare advice leaflet to advise parents of the correct dosage of paracetamol to give as pain relief following the procedure (dependent on the child’s weight). The consent form had also been updated to discuss any child protection issues or social services involvement prior to the procedure taking place.
  • Leaders and managers encouraged staff to take time out to review individual and team objectives, processes and performance.
  • There were systems to support improvement and innovation work.