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Thornley House Medical Centre Good

Inspection Summary


Overall summary & rating

Good

Updated 26 March 2020

We carried out an announced comprehensive inspection at Thornley House Medical Centre (also known as Manchester Circumcision Clinic) on 1 March 2020 as part of our inspection programme.

Manchester Circumcision Clinic is an independent circumcision service that provides circumcisions for patients aged from infancy through to adulthood for cultural and religious reasons under local anaesthetic. The service also provides post procedural reviews of patients who have undergone circumcision.

The service gathers feedback from parents and children where they are old enough to monitor and improve the service. This is done via a survey completed post treatment and the results are continually collated and reviewed. Results to date (653 survey completed) showed that 100% of respondents were treated with respect and 99% would recommend the service.

In addition, we received feedback from 17 parents. These were all very positive about the care and treatment received and thanked staff for the time taken to explain the procedure and aftercare.

Our key findings were:

  • The service 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. Care was taken to create a calming environment within the treatment room. Parents, as part the aftercare were also provided with liquid paracetamol and antiseptic cream.
  • The service had developed materials for parents/service users which explained the procedure and outlined clearly the recovery process.
  • The service 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.
  • Information for service users was comprehensive and accessible.
  • Patient outcomes were evaluated, analysed and reviewed as part of quality improvement processes.
  • Staff had the relevant skills, knowledge and experience to deliver the care and treatment offered by the service.
  • The clinic shared relevant information with others such as the patient’s GP and when required and safeguarding bodies.
  • There was a clear leadership structure, with governance frameworks which supported the delivery of quality care.
  • Communication between staff was effective and we and we saw regular meetings took place.
  • The service encouraged and valued feedback from service users via in-house surveys and the website.

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

Inspection areas

Safe

Good

Updated 26 March 2020

We rated safe as Good because:

Safety systems and processes

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

  • The provider conducted safety risk assessments. It had appropriate safety policies, which were regularly reviewed and communicated to staff including locums. They outlined clearly who to go to for further guidance. Staff received safety information from the service as part of their induction and refresher training. The service had systems to safeguard children and vulnerable adults from abuse.
  • The service had systems in place to assure that an adult accompanying a child had parental authority. For example, the clinic had a process in place to confirm the identity of parents when performing a procedure on a child or infant. This was verified by photographic evidence such as a passport or driving licence. The consent form for children and infants contained a statement which both parents had to sign to declare that they had the parental responsibility and the procedure was only carried out when there was full agreement from both parties. The practice also carried appropriate checks where a parent stated they had sole parental responsibility.
  • The clinic policy was for parents or a relative to be present during the procedure to provide comfort to the child and ensure that the child remained safe whilst on the treatment couch. There was a record maintained as to who was present during the procedure.
  • The service worked 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.
  • There was an effective system to manage infection prevention and control.
  • The provider ensured that facilities and equipment were safe and that equipment was maintained according to manufacturers’ instructions. There were systems for safely managing healthcare waste.
  • The provider carried out appropriate environmental risk assessments, which took into account the profile of people using the service and those who may be accompanying them.

Risks to patients

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

  • The clinic worked closely with the host location Thornley House Medical Centre and was made aware of any issues which could adversely impact on health and safety. The clinic adhered to the Thornley House Medical Centre health and safety protocol. The host was responsible for maintaining the building and equipment and the records were available to the provider where required.
  • There were arrangements for planning and monitoring the number of staff needed.
  • There was an effective induction system for staff tailored to their role.
  • 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, for example sepsis. The clinic operated an emergency 24-hour contact number, whereby a clinician was available for contact by parents of patients who had post procedural concerns or wanted additional advice.
  • There were suitable medicines and equipment to deal with medical emergencies which were stored appropriately and checked regularly.
  • There were appropriate indemnity arrangements in place

Information to deliver safe care and treatment

Staff 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 service had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.
  • The service had a system in place to retain medical records in line with Department of Health and Social Care (DHSC) guidance in the event that they cease trading.

Safe and appropriate use of medicines

The service had reliable systems for appropriate and safe handling of medicines.

  • The systems and arrangements for managing medicines, including emergency medicines and equipment minimised risks.
  • Emergency medicines were safely stored and were accessible to staff in a secure area of the clinic. We saw that the emergency medicine stock included adrenalin. Adrenalin is a medicine used for the emergency treatment of allergic reactions. Medication that we checked was stored safely and securely and was within date.

Track record on safety and incidents

The service had a good safety record.

  • There were comprehensive risk assessments in relation to safety issues.
  • The service 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 service learned and made improvements when things went wrong.

  • There was a system for recording and acting on significant events. Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • There were adequate systems for reviewing and investigating when things went wrong. The service learned and shared lessons identified themes and took action to improve safety and patient experience. For example, booking arrangements were amended to ensure they were aware of any learning disabilities or specific patient requirements, this enabled the service to schedule appointments appropriately such as allocating the last appointment for a patient with autism when the waiting area would be quieter.

Effective

Good

Updated 26 March 2020

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 who used the service had an initial consultation where a detailed medical history was taken from the patient or parents of the patient where the procedure was being performed on a child or infant.
  • Parents of patients who used the service were provided with detailed information regarding the process and the different procedures which were delivered by the clinic. This included advice on post-operative care. If the initial assessment showed the patient was unsuitable for the procedure this would be documented, and the patient referred to their own GP. After the procedure clinicians also discussed after care treatment with parents and sought to inform them of what to expect over the recovery period and pain management. This was both to allay concern and anxiety from the parents and to prevent them unnecessarily attending other primary or secondary care services. The clinic contacted all patients four weeks following the procedure to ensure there were no issues and provided open access to the clinic until the full recovery period was complete.
  • Feedback from parents collected by the providers in house survey showed (653 - 85% response rate)

    • Happy with the information after circumcision – 80% stated excellent
    • 99% stated they had enough information about the procedure
    • 83% rated child safety during the visit as excellent
    • 100% stated they were provided written aftercare and emergency contact details.

  • Alongside written and verbal aftercare information parents were also supplied with liquid paracetamol, antiseptic cream and sterile gauze.
  • The service offered post-operative support and was contactable 24 hours a day.

Monitoring care and treatment

The service was actively involved in quality improvement activity.

  • The service used information about care and treatment to make improvements. For example, the service examined significant events and complaints and used this to refine and improve services. In addition, the service also audited post circumcision bleeding and post circumcision infection.
  • In addition to the provision of the circumcision procedure, the clinic carried out reviews of patients, two weeks post procedure and parents were encouraged to contact the service following the procedure should they have any questions or concerns regarding their child’s treatment.

Effective staffing

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

  • All staff were appropriately qualified. The provider had an induction programme for all newly appointed staff.
  • Relevant professionals (medical and nursing) were registered with the General Medical Council (GMC) and were up to date with revalidation
  • The provider understood the learning needs of staff and provided protected time and training to meet them. Up to date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop.

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 service did so when this was necessary and appropriate. For example; the clinic sent a letter to the patient’s own GP following the procedure.

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 obtained and documented. Where the procedure was carried out on a child or infant, consent was required by both parents (unless it was proven that the parent had sole control and responsibility for the child).
  • In addition, the provider had a process in place to obtain consent from absent parents. For example; where a parent was overseas and unable to attend the clinic in person. As part of this process the absent parent was contacted by telephone and asked various questions about their child to verify their identity. Once the clinic was satisfied with the information provided, and consent was obtained, the procedure could be carried out.
  • Staff understood the relevant consent and decision-making requirements of legislation and guidance, including the Mental Capacity Act 2005.
  • When providing care and treatment for children and young people, staff carried out assessments of capacity to consent in line with relevant guidance.

Caring

Good

Updated 26 March 2020

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

During our inspection we observed that all staff including the doctor were courteous and helpful to both patients and parents and treated them with dignity and respect.

  • Doors were closed during consultations and conversations taking place in these rooms could not be overheard.
  • The clinic told us, and we observed, that they spent time with parents both pre and post procedure carefully explaining the circumcision and recovery process to reduce any anxieties they may have.
  • The clinic had produced a range of information and advice resources for parents that they could take away with them to refer to later.
  • Staff used a range of methods to create a calm and relaxed environment, with toys for children and played calming music within the treatment room. Health care assistants were on hand throughout the procedure to support parents and were skilled in the use of distraction techniques to help the children during the procedure and recovery.
  • Staff understood patients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all patients.

The clinic valued feedback as a measure to improve services. They used a survey tool and asked parents or children if they were old enough to complete a feedback form following the procedure. Additional feedback was also sought as part of the four week post surgery review. The results were analysed on a monthly basis and discussed during team meetings. Results obtained from (653 - 85% response rate) survey forms obtained by the clinic showed high overall satisfaction with the services provided.

We also received feedback from 17 parents. This feedback was positive about the care and treatment received and thanked staff for the time taken to explain the procedure and aftercare. They found staff helpful and would recommend the service to others.

Involvement in decisions about care and treatment

Staff helped parents and patients, where old enough, to be involved in decisions about care and treatment.

  • Staff had language skills which allowed them to communicate effectively with service users whose first spoken language was not English.
  • Pictorial information had been produced by the service and where appropriate these were used to help older patients and parents understand the procedure and what to expect post procedure.
  • The service told us that for patients with learning disabilities or complex social needs family, carers or social workers would be appropriately involved. They would for example make appointments at the end of clinics to ensure time was available and the waiting area would not be crowded.
  • Parents were encouraged to be present during the procedure as this was felt by the service to reduce anxiety both for the child and the parents. Parents could choose not to be present if they so wished and this was documented. It was standard procedure to document those present during the procedure including if any extend family were also present.
  • Patients told us through comment cards, that they felt listened to and supported by staff and had enough time during consultations to make an informed decision about the choice of treatment available to them.
  • Staff communicated with people in a way that they could understand.

Privacy and Dignity

The service respected patients’ privacy and dignity.

  • Staff recognised the importance of people’s dignity and respect.
  • Staff knew that if patients wanted to discuss sensitive issues or appeared distressed, they could offer them a private room to discuss their needs.

Responsive

Good

Updated 26 March 2020

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 demonstrated to us on the day of inspection it understood its service users and had used this understanding to meet their needs:

  • The clinic had developed a range of information and support resources which were available to service users.
  • The website for the service was very clear and easily understood. In addition, it contained valuable information regarding the procedure and aftercare.
  • The clinic operated an emergency 24-hour contact number, whereby one of the clinicians was available for contact by parents of patients who had post procedural concerns or wanted additional advice.
  • The facilities and premises were appropriate for the services delivered.
  • Reasonable adjustments had been made so that people in vulnerable circumstances could access and use services on an equal basis to others.

Timely access to the service

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

  • The service operated one session per clinic, and clinics were held on Sundays. Appointments could be made via a dedicated telephone booking line.
  • During peak times such as school holidays the service was able to accommodate additional appointments.

Listening and learning from concerns and complaints

The service took complaints and concerns seriously and responded them appropriately to improve the quality of care.

  • Information about how to make a complaint or raise concerns was available. Staff treated patients who made complaints compassionately.
  • The service informed patients of any further action that may be available to them should they not be satisfied with the response to their complaint.
  • The service had complaint policy and procedures in place. The service learned lessons from individual concerns, complaints and from analysis of trends. It acted as a result to improve the quality of care.

Well-led

Good

Updated 26 March 2020

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.
  • 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.
  • We saw evidence of meetings being held on a quarterly basis. These meetings discussed topics which included key operational developments, infection control and quality assurance.
  • The provider was aware of, and complied with, the requirements of the Duty of Candour. When unexpected or unintended safety incidents occurred, the service told us they would give affected patients reasonable support, truthful information and a verbal and written apology.

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.

Culture

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 service focused on the needs of patients.
  • Leaders and managers acted on behaviour and performance inconsistent with the vision and values.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.
  • Staff told us they could raise concerns and were encouraged to do so. They had confidence that these would be addressed.
  • There were processes for providing all staff with the development they need. This included appraisal and career development conversations. All staff received regular annual appraisals in the last year. Staff were supported to meet the requirements of professional revalidation where necessary.
  • There was a strong emphasis on the safety and well-being of all staff.
  • The service actively promoted equality and diversity. It identified and addressed the causes of any workforce inequality. Staff had received equality and diversity training. Staff felt they were treated equally.
  • 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. The governance and management of partnerships, joint working arrangements and shared services promoted interactive and co-ordinated person-centred care.
  • Staff were clear on their roles and accountabilities
  • Leaders had established proper policies, procedures and activities to ensure safety and assured themselves that they were operating as intended.
  • The service had a governance framework in place, which supported the delivery of quality care. This outlined the structures and procedures in place and ensured that:
  • There was a clear staffing structure. Staff, both clinical and non-clinical were aware of their own roles and responsibilities.
  • Service specific policies and protocols had been developed and implemented and were accessible to staff in paper or electronic formats. These included policies and protocols with regard to:
  • Safeguarding
  • Consent
  • Infection prevention and control
  • Complaints
  • All staff were engaged in the performance of the service.
  • Arrangements were in place for identifying, recording and managing risks and issues.

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.
  • The service had processes to manage current and future performance. Performance of clinical staff could be demonstrated through audit of their consultations, prescribing and referral decisions. Leaders had oversight of safety alerts, incidents, and complaints.
  • Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to change services to improve quality.
  • 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.
  • 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 plans to address any identified weaknesses.
  • The service submitted data or notifications to external organisations as required.
  • 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 service encouraged and heard views and concerns from the public, patients, staff and external partners and acted on them to shape services and culture.
  • Staff could describe to us the systems in place to give feedback. We saw evidence of feedback opportunities for staff and how the findings were fed back to staff. We also saw staff engagement in responding to these findings.
  • The service was transparent, collaborative and open with stakeholders about performance. They participated in the Greater Manchester infant male circumcision quality assurance process and had met all the requirement set out.

Continuous improvement and innovation

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

  • There was a focus on continuous learning and improvement.
  • The service made use of internal and external reviews of incidents and complaints. Learning was shared and used to make improvements.
  • Leaders and managers encouraged staff to take time out to review individual and team objectives, processes and performance.