St Clare Medical Centre

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• 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

We looked for evidence that people were protected from abuse and avoidable harm.

This is the first assessment for this service. This key question has been rated Requires Improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of Regulation 12: Safe care and treatment as sufficient medication was not available in case of emergencies in line with national guidance.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

We scored the service as 2. The evidence showed some shortfalls. The service did not always have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The service had not reported serious incidents prior to our inspection. However, we were made aware of a serious incident which had occurred before our site visit, in which a patient experienced a surgical complication. Although a manager informed us they had encountered difficulties in reporting this to CQC, we were not able to verify this.

However, staff we spoke with understood what constituted an incident and how to escalate concerns to managers. The service developed systems for raising issues both formally and informally and confirmed any concerns identified within the service were discussed as a team. Regular safety briefings and theatre meetings took place to share information and learning. Staff were not aware of any recent near misses but told us they would feel confident reporting them and understood if concerns were reported, they would be investigated and learning shared across the team.

Staff demonstrated awareness of the Duty of Candour and understood the importance of being open and transparent with patients when things did not go as planned. They told us they would provide an honest explanation, apologise, and keep patients informed of any actions taken. Managers told us they followed their Duty of Candour policy during the last serious incident.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

We found many policy documents contained information which was not relevant or reflective of the service provided at this location. This meant staff did not always have accurate information, as well as guidance to support safe care. The service did not have an effective policy to ensure staff could detect and escalate deteriorating patients. The “Deteriorating Patient Policy (version 2)” did not provide staff with clear instructions for the assessment, detection, and escalation of patients whose condition was deteriorating. The policy lacked a clear purpose, scope, definitions for identifying deteriorating patients, including detailed reference to early warning scores or clinical indicators; it lacked clear steps for the monitoring of patients with potential to deteriorate, including observation frequency and documentation standards. The policy lacked a clear escalation protocol with defined timeframes, actions, and roles, so staff knew who to contact and when to act to keep patients safe. As a result, staff did not have comprehensive, practical guidance to support timely recognition and response to clinical deterioration. This increased the risk of delayed or inappropriate escalation of care. Failure to provide this guidance could lead to delays in treatment and poorer patient outcomes.

However, the service had developed admission processes designed to ensure all essential patient information was captured to confirm whether individual needs could be safely met. The service had a clear policy outlining the criteria for admission of patients, based on clinical indicators like body mass index and overall health. Staff worked collaboratively with patients to provide continuity of care, ensuring patients had post operative care provided by the same members of staff involved in their surgical procedure which was operational outside normal office hours.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not always share concerns quickly and appropriately.

We reviewed the “Adult and Child Safeguarding Service Users Policy” and found it was not up to date and lacked clear, detailed steps for staff to identify and escalate safeguarding concerns. The policy did not provide practical guidance to help staff determine when a safeguarding issue should be raised with the local authority or police. Additionally, the policy referenced roles that did not exist within the service structure and instructed staff to contact these roles if a safeguarding concern involved the registered manager. This created ambiguity and could result in delays or failures in escalating safeguarding concerns appropriately. This meant staff did not have clear information about how to report safeguarding matters when the registered manager was implicated.

However, staff were trained in safeguarding and were able to describe the steps to follow to raise alerts when appropriate. The medical director acted as the designated safeguarding lead and was trained to Level 4, while almost all staff had completed safeguarding training for adults at Level 2 or 3. Staff we spoke with could describe how they assessed psychological factors in their patients during pre-assessment checks and described the steps they took to assess whether patients might have been coerced into undergoing surgery. The lead surgeon told us when concerns about a patient’s mental health arose during pre-assessment, he liaised with the patient’s GP regarding psychological fitness for surgery. Their approach focused on protecting patients and their families’ right to live free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The service did not consistently provide patients with timely and comprehensive information about anaesthetic risks to enable informed decision-making. We also found gaps in the consent process. Some consent forms only listed risks associated with general anaesthesia, which the manager confirmed was not used at this location. This meant patients did not receive all the information they needed to make an informed decision about their care.

However, care was designed to be supportive, and tailored to individual needs, enabling patients to achieve outcomes that mattered to them. The service carried out comprehensive, surgical pre-operative consultations and assessments. The service provided thorough information about surgical procedures and their inherent risks so patients could form a clear opinion about their surgery and what to expect. Feedback was consistently positive. As a private cosmetic surgery service, patients paid for their treatment. Managers explained they only admitted patients who were found to have low clinical risk at this location. Patients were assessed at their initial consultation to confirm suitability for surgery which was completed by the specialist consultant. If a patient was found to have more complex needs due to co-morbidities, they would be referred for surgery at another BYC Surgery location in a different part of the country. During our inspection, staff showed us how they completed the World Health Organization (WHO) surgical safety checklist. This checklist ensures critical safety checks are performed before and after surgery. Their completeness was thorough, demonstrating it was embedded in practice. Clinical observations were recorded during and after surgery, and these were documented in the patient records we reviewed.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The design of the clinic environment, the operating theatre, the consultation rooms and recovery room were spacious and followed national guidance. All clinical and non-clinical areas were clean and well maintained. Staff completed daily safety checks of specialist equipment, including the resuscitation equipment. Environmental checks were completed at regular intervals. These checks were clearly documented in their audits. The sterilisation of surgical equipment, restocking of PPE, emergency trolleys restocking, waste management (including tissue), water testing, fire checks, portable appliance testing of electrical equipment, and the general maintenance and cleaning of the service was under the responsibility of the landlord of the premises, St Clare Medical Centre. The premises had a backup generator providing 60 minutes of power, plus an additional 30 minutes on battery, ensuring sufficient time to safely complete surgical procedures during an electrical outage. The service had a fire plan and appointed fire wardens. There was a designated refuge area for disabled people to wait in the building in the event of a fire.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The service made sure there were enough qualified and experienced staff to provide safe care. Staff worked well together and were supported through regular supervision and training to keep their skills up to date. At the time of our inspection, the service employed 6 staff members and used flexible working arrangements to ensure adequate cover for the surgical list when required. The team included one theatre nurse, one pre-op nurse (both of which also functioned as scrub nurses when required), one operating department practitioner, one patient coordinator, one patient advisor, one anaesthesiologist consultant and one cosmetic surgeon consultant who was also the registered manager. The surgeon and the anaesthetist worked under “practising privileges” This system allows doctors to work in hospitals and clinics under strict checks and agreements. We reviewed the practicing privileges files and found all required checks had been completed to ensure doctors could work at the service. Bank staff received a thorough induction before starting work, which included a period of supervision signed off by a senior staff member to confirm they were safe to work independently. All staff had completed mandatory training relevant to the care and type of surgeries provided at the service. We reviewed staff recruitment files and found the service was compliant with legal requirements under Schedule 3 of the Health and Social Care Act.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service took measures to prevent and manage the risk of infection. Staff followed infection control principles, including proper handwashing, and audits confirmed good compliance with hand hygiene standards. Staff were bare below the elbow, and uniforms were visibly clean. Cleaning records showed clinical areas were cleaned regularly, and cleaning and decontamination audits for different types of equipment were maintained. All medical equipment was well maintained and kept clean. Clinical waste was disposed of safely and managed in conjunction with the waste from the rest of the site.

The premises were tidy, hygienic, and appropriately furnished, including storage spaces, consulting rooms, and the operating theatre. Floors were in good condition and visibly clean. The location had a purpose-built theatre which was clean and hygienic, and the air ventilation system helped maintain a sterile environment. The clinic met the national standards for infection control set out in Health Building Note (HBN) 00-09.

Sterilisation of surgical instruments was organised, overseen, and managed by the GP practices operating from the same location. BYC Surgery staff were responsible for sending equipment for sterilisation and then logged the equipment back, verifying and documenting the integrity of the surgical packs upon return.

We scored the service as 1. The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

We found medication required for the treatment of serious complications of liposuction was not available in the service’s trolleys. The provider used tumescent local anaesthesia (TLA), which is a technique commonly used in liposuction procedures. Providers using these anaesthetic methods must demonstrate compliance with safety guidelines for managing complications linked to these anaesthetic agents. Current guidance from the Association of Anaesthetists (Great Britain and Northern Ireland) requires providers to have a clear pathway for managing patients with severe toxicity related to TLA and to ensure lipid emulsion is immediately available for the treatment of local anaesthetic systemic toxicity (LAST). We reviewed the contents of the anaesthetic and crash trolleys at this location and found no evidence of lipid emulsion being kept. Furthermore, the provider did not have a risk assessment to justify the absence of this treatment.

We found no evidence of risk assessments for patients using weight-loss drugs to identify, reduce or mitigate the risk of aspiration during anaesthesia. These medicines can slow down how quickly the stomach empties, which can increase the risk of aspiration.

We also found no evidence the service actively checked whether patients were using this type of medication during pre-operative consultations or at admission before surgery.

However, controlled drugs were stored within the premises and were disposed of safely in line with legal requirements. Medicines requiring refrigeration were kept in the theatre fridge, and temperature checks ensured they remained within the correct range. Pain relief was prescribed and recorded accurately in patient notes. Patients were given antibiotics if needed, along with clear instructions for taking them at home. Follow-up calls and appointments included checks on how patients were managing their medicines.