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Inspection Summary


Overall summary & rating

Updated 7 March 2016

MYA St Luke's Hospital was acquired by MYA Cosmetic Surgery Limited in May 2014. This location had not been previously inspected by the Care Quality Commission (CQC) and the inspection was part of our regular inspection programme. We inspected the location over three days between 29 September 2015 and 1 October 2015. The inspection was announced to the provider a number of weeks before and followed our comprehensive inspection methodology.

The inspection team was led by a CQC inspection manager, supported by CQC inspectors including a pharmacy inspector. In addition, the inspection team had a number of clinically qualified specialist professional advisors in the fields of plastic surgery, anaesthesia and surgical nursing.

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 hospital

The services at MYA St Luke's Hospital had good systems and processes in place to protect patients from avoidable harm. Managers and staff had good systems to report incidents and were encouraged to learn from these and make improvements. There were enough medical and nursing staff to provide care and treatment for patients. Staff were competent and well trained but there was a high turnover of staff and frequent use of staff from nursing agencies.

Patients received good clinical practice; they were protected from potential hazards, such as infections or having to have the operation repeated. There were agreements in place with local NHS hospitals to transfer pateints who became ill.

Are services effective at this hospital

The service provided care and treatment in accordance with evidence based practice and nationaly recognised standards. Patients were provided with good information that allowed them to make informed decisions about surgery.

Most patients were positive about the cosmetic results of their surgery. The hospital was proactive in sharing its results with other providers in the sector and with the public. There were rigorous processes in place before a surgeon was given practicing rights at the hospital.

Are services caring at this hospital

Staff at this hospital treated patients with care and compassion and provided patient-focused care that met individual needs. The vast majority of the patients we spoke with were very satisfied with their treatment and the outcomes. However, patients were not always clear about the point at which they could cancel their treatment and receive a refund of their deposit if they changed their mind.

Are services responsive at this hospital

The hospital had good processes in place to ensure that it only selected patients who were physically and mentally suited to have cosmetic surgery. We found a number of examples where surgery had been declined because the patients did not meet the clinical suitability and exclusion criteria, or were not supported medically from their relevant specialists/GPs. However, the hospital was not addressing delays in outpatient clinics caused by surgeons arriving late.

Are services well-led at this hospital

There was generally good leadership at the hospital. However, we were concerned that the Medical Director did not have time to fully lead the medical services in the two days each month he spent in the hospital, athough he carried out aspects of the role remotely, and was contactable at all times for any urgent and routine medical assistance and advice. The hospital needed to further develop its clinical governance structures and ensure a clearer connection with the medical advisory committee. We were concerned that the MAC only met twice a year. It was not clear to see how key issues linked into the hospital’s medical advisory committee. The hospital showed innovation in the way it used social media to reach out to people.

Our key findings were as follows:

  • Staff understood how to report incidents and did so promptly and consistently. Managers then investigated incidents in a clear and rigorous way. They shared any lessons learned from these with all staff. There was a low number of infections.

  • The hospital employed enough medical and nursing staff to meet patients needs and protect them from avoidable harm. However, too many of these staff were from nursing agencies and do not work at the hospital all the time. The hospital reduced this risk by using agency staff who worked regularly at the hospital.

  • Theatre and ward staff had emergency on-call rotas; however, the hospital did not have a formal on-call rota for anaesthetists, and surgeons were responsible for agreeing cover.

  • The limited size of the second theatre increased the risk of infection during invasive surgery. To date, there have been no incidents of patients contracting infections.

  • Clinical staff at the hospital followed national guidance and good practice on cosmetic surgery when they treated patients.

  • Staff were competent and well trained to care for patients. This meant that the right procedures were followed, and staff knew what to do in different circumstances, including emergencies.

  • The staff at the hospital cared for and treated patients with compassion.

  • The hospital did not have a clear cancelation policy setting out when patients could get their deposit back, if they changed their minds.

  • Surgeons were arriving late at their outpatients clinic which meant some patients waited too long to be seen.

  • Managers of the hospital had a clear vision of its purpose and future development.

  • Managers had set up a number of clinical governance processes, which were working, but needed further development. For example, the Infection Prevention and Control Committee had not yet held a meeting.

We saw areas of outstanding practice including:

  • The way the hospital used social media to reach out to patients. This means potential and actual patients could access information, and make comments using the internet.

However, there were also areas of poor practice where the provider needs to make improvements.

The provider must:

  • Review and improve the governance processes of the hospital to ensure clinical risks are properly managed.

The provider should:

  • Reduce the time that patients are waiting to see the surgeons in outpatients

  • Develop a formal on-call rota for anaesthetists and surgeons.

  • Ensure that pre-printed medicine labels contain the hospital contact details

  • Review the ability of the medical director to carry out this role in the two days per month allowed for that purpose

  • Review the use of theatre two for invasive surgery and the potential risk of infection to patients

  • Make sure the cancellation policy is clear to all patients, and clearly sets out the ‘cooling off’ period.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Updated 7 March 2016

The services at MYA St Luke's Hospital had good systems and processes in place to protect patients from avoidable harm. Managers and staff had good systems to report incidents and were encouraged to learn from these and make improvements. There were enough medical and nursing staff to provide care and treatment for patients. Staff were competent and well trained but there was a high turnover of staff and frequent use of staff from nursing agencies.

Patients received good clinical practice; they were protected from potential hazards, such as infections or having to have the operation repeated. There were agreements in place with local NHS hospitals to transfer patients who became ill.

Effective

Updated 7 March 2016

The service provided care and treatment in accordance with evidence based practice and nationally recognised standards. Patients were provided with good information that allowed them to make informed decisions about surgery.

Most patients were positive about the cosmetic results of their surgery. The hospital was proactive in sharing its results with other providers in the sector and with the public. There were rigorous processes in place before a surgeon was given practicing rights at the hospital.

Caring

Updated 7 March 2016

Staff at this hospital treated patients with care and compassion and provided patient-focused care that met individual needs. The vast majority of the patients we spoke with were very satisfied with their treatment and the outcomes. However, patients were not always clear about the point at which they could cancel their treatment and receive a refund of their deposit if they changed their mind.

Responsive

Updated 7 March 2016

The hospital had good processes in place to ensure that it only selected patients who were physically and mentally suited to have cosmetic surgery. We found a number of examples where surgery had been declined because the patients did not meet the clinical suitability and exclusion criteria, or were not supported medically from their relevant specialists/GPs. However, the hospital was not addressing delays in outpatient clinics caused by surgeons arriving late.

Well-led

Updated 7 March 2016

There was generally good leadership at the hospital. However, we were concerned that the Medical Director did not have time to fully lead the medical services in the two days each month he spent in the hospital, athough he carried out aspects of the role remotely, and was contactable at all times for any urgent and routine medical assistance and advice. The hospital needed to further develop its clinical governance structures and ensure a clearer connection with the medical advisory committee. We were concerned that the MAC only met twice a year. It was not clear to see how key issues linked into the hospital’s medical advisory committee. The hospital showed innovation in the way it used social media to reach out to people.

Checks on specific services

Surgery

Updated 7 March 2016

The MYA St Luke’s Hospital opened in May 2014 and provides elective cosmetic surgical procedures to male and female patients primarily between the ages of 18 and 35 years. The hospital carries out most of its cosmetic surgical procedures Monday to Friday and is able to provide inpatient care seven days a week.

The Hospital admits patients using direct and indirect referral systems. The indirect referrals come from consultations carried out in MYA clinics across the UK. The hospital carried out 2,483 cosmetic procedures between July 2014 and June 2015 and saw 2672 patients within the outpatient service. The hospital has 11 bedrooms spilt into six single and five double bed rooms, and provides 24-hour nursing and medical cover.