Practice Plus Group Surgical Centre Portsmouth

St Mary’s NHS Treatment Centre opened in December 2005, and provides services to people living in Portsmouth, Fareham, Gosport and South East Hampshire. NHS treatment centres are private-sector owned, but contracted to treat NHS patients free at the point of use. Care UK Clinical Services Ltd, the largest independent provider of NHS services in England, took over St Mary’s in 2008.

The treatment centre provides urgent and emergency (minor injuries and minor illness) care to the local population in a modern, purpose-built minor injuries unit (MIU), staffed by specialist practitioners. It also provides day case elective surgery to NHS patients within the following specialities: orthopaedics, general surgery, ophthalmology and endoscopy. (We have reported on endoscopy in the outpatients and diagnostic imaging report).

Admission to the treatment centre for surgery follows strict referral criteria for people aged 16 years and over who require routine -urgent surgery. There is an outpatient department within this building for routine pre and post-operative appointments.

The treatment centre has a day case ward with 15 bed spaces. There are three operating theatres, plus an endoscopy suite operating Monday to Friday.

We carried out a comprehensive announced inspection of St Mary’s NHS Treatment Centre on 29 and 30 September 2015, and an unannounced inspection on 8 October 2015.

We inspected the following three core services:

• urgent and emergency service /minor injuries unit
• surgery
• outpatients and diagnostic imaging.

The overall rating for this service was ‘Good’.

The services at this treatment centre were safe, effective, caring, responsive and well led. The centre took into account individual patient needs and preferences when designing the delivery of well-planned services to the local population. There were sufficient staff, and robust processes, ensuring the appropriate provision of timely and compassionate care.

Our key findings were as follows.

Are services safe?

By safe, we mean that people are protected from abuse and avoidable harm.

• The centre protected patients from the risk of abuse and avoidable harm. There were clear, open and transparent processes for reporting and learning from incidents. Staff reported incidents and managers shared learning locally and within the wider organisation.
• The departments were visibly clean and staff followed infection prevention and control practices. Post-operative infection rates were lower (better than) the national hospital average.
• Patients were risk assessed to ensure they were suitable for treatment at the centre and staff monitored them appropriately during their stay. Children under two years could attend the minor injuries unit, but the nurse practitioner would then seek advice from a senior doctor at the local trust.
• An audit programme set by Care UK reviewed clinical practice against local policies. This enabled benchmarking both locally and within the Care UK group. Audits completed in July 2015 showed compliance with policies regarding perioperative hypothermia, recording of fluid balance, completion of the five steps to safety checklists, VTE assessments and training for safeguarding children and adults was between 98% and 100%.
• The centre appropriately maintained and tested equipment.
• Medicines were stored securely and handled correctly.
• Staffing levels were sufficient to meet the needs of patients and there was good access to medical support at all times. Managers calculated nurse-staffing levels around the planned workload using an adapted recognised safer staffing tool. Staff said it was rare managers did not keep to planned staffing levels. Medical staff were available at all times when patients were present in the surgical department.
• The centre held patients’ records in paper format and electronically, and these were always available before a patient was seen. All medical records stayed on site and staff archived them after six months.
• Staff undertook appropriate mandatory training for their role, and managers supported them to keep this up-to-date. There were also training and developmental opportunities for all staff.
• All staff we spoke with knew where to access policies, procedures and guidance to follow in the event of a major incident. Senior staff were also aware of their individual responsibilities in the event of a serious or untoward incident on the premises.

Are services effective?

By effective, we mean that people’s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence.

• Minor injuries unit services were available seven days a week, with surgery taking place five days a week. In the outpatients department, the centre held clinics mainly in the week, with some on Saturdays. By working in multidisciplinary team and ‘one-stop’ clinics, the treatment centre reduced the number of appointments patients needed.
• Staff delivered evidence-based care in line with nationally agreed policies and practice, for example, guidance from the National Institute for Health and Care Excellence (NICE).
• Staff had attended training relating to the Mental Capacity Act best practice guidelines and Deprivation of Liberty Safeguards (DoLS). Staff we spoke with were aware of the DoLS policies and procedures.
• Staff had regular appraisals and supervision, and were encouraged and supported to take part in training and development.
• We spoke with patients after their visit to the unit and they told us clinical staff had sought their consent before any examination, care or treatment.

• The treatment centre was performing in line with other organisations providing the same surgery. Patient outcomes were monitored through national quality monitoring schemes, corporate audits and locally developed audits.

• Staff met patients’ pain needs and reviewed them appropriately during a procedure or investigation. In the minor injuries unit, staff assessed patients for their levels of pain during the triage process. However, at the inspection we raised concerns that the unit did not use any pain score tools. When we returned to the unit for an unannounced inspection, we found they had introduced pain scores for both children and adults which were being used effectively.

Are services caring?

By caring, we mean that staff involve and treat patients with compassion, dignity and respect.

• Staff treated patients with courtesy and respect, and patients were fully involved in decisions about their care.
• In all departments, patients and relatives commented positively about the care provided by all the staff, including those who were non-clinical.
• Staff on the main reception and the outpatient department reception were highly praised by patients and relatives for their welcoming attitude, discretion and attention to detail. Reception desks were a sufficient distance away from waiting areas so patients could speak to reception staff in confidence. There were signs behind reception desks giving the names of the receptionists. Receptionists in both the outpatient department and day surgery unit stated that they believed their role was to look after patients and observe them while in their area.
• Patients told us staff always treated them with discretion and ensured their privacy.

Are services responsive?

By responsive we mean that services are organised so they meet people’s needs.

• In MIU, the centre planned and delivered services in a way that met the needs of the local population. Services reflected the importance of flexibility, choice and continuity of care.

• Staff took into account the needs of different people, for example, patients living with dementia, learning, or other disability conditions. Not all staff had received training in such conditions, but there was a process in place to ensure staff saw these patients as quickly as possible.

• Surgical services were responsive to the needs of local people. Patients were able to influence the choice of date for their surgery during outpatient consultations.

• Patient admissions for surgery were staggered throughout the day so they did not have to wait a long time after their admission.

• The treatment centre met national waiting times and patients had surgery within 18 weeks of referral.

• St Mary’s planned outpatient services well, and the facilities were appropriate to support the running of the different specialist clinics.

• Before their first attendance, the centre sent patients appropriate information about, for example, the consultant or clinic they were to see, the length of appointment time, any treatment they might have at the first appointment.

• Waiting times for a first appointment were three weeks or less for all specialties. The national referral to treatment time (18 week target) was met for all specialities.
• The centre reminded patients about their appointment the day before, through a computer-generated text or a personal telephone message. Patients generally had additional tests performed on the day of their appointment.
• Complaints were responded to in line with Care UK’s complaints policy. The registered manager had responsibility for overseeing the management of complaints, with the individual department leads carrying out complaint investigations that were relevant to their area of work.
• The centre took comments from patients seriously, and this led to planned changes for waiting areas. The commissioners had supported a review of increased opening hours because of longer waits in the local hospital.

Are services well-led?

By well-led, we mean that the leadership, management and governance of the organisation, assure the delivery of high-quality person-centred care, supports learning and innovation, and promotes an open and fair culture.

• Senior managers were highly visible across the hospital. Staff described knowing them on first name terms, and said they were approachable at all times.
• Staff spoke highly about their departmental managers, about the support they provided to them and to patients. All staff said managers supported them to report concerns. Their managers would then act on them. They said their managers regularly updated them on issues that affected the unit and the whole hospital.
• Staff in MIU knew and understood the vision, values and strategic goals of their service and of their treatment centre. The information used in reporting, performance management and delivering the quality of care was accurate, valid and timely. There was a structured governance programme for the treatment centre, which included governance meetings locally at the treatment centre and regionally with other Care UK treatment centres.
• Governance processes at department level, treatment centre level and corporate level allowed for monitoring of the service and learning from incidents, complaints and results of audits across surgical services.
• Records from these governance meetings showed St Mary’s followed a structured process for monitoring outcomes, risks, effectiveness, staffing (including sickness rates), vacancies, and compliance with mandatory training.
• Information on people’s experience was reported and reviewed alongside other performance data. This enabled the translation of strategy into effective performance management.
• In outpatients and endoscopy, staff had a clear ambition for the service and were aware of the vision for the organisation. The unit displayed its vision and strategy plans on notice boards in the staff room. The department supported staff who wanted to be innovative. Patients could give feedback about their experiences and the centre used this to improve the service.
• We observed a newly formed patient forum. A group of patients came together to discuss the treatment centre and its services to the community.

We saw several areas of outstanding practice including:

• In endoscopy, the latest Joint Advisory Group [JAG] accreditation report gave overall feedback that the treatment centre was an ‘excellent’ facility. JAG praised the leadership, environment, high-quality service and well-trained workforce. The JAG report recommended considering completing the JAG accreditation for training.
• In outpatients, patients were able to talk in person with the appointment schedulers to arrange their next appointments before leaving the treatment centre. The schedulers were able to provide appointment options from which the patient selected a choice relevant to their life and preferences. This provided a very personalised service.

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

The provider should ensure:

• That appropriate arrangements for monitoring and auditing the management and use of controlled drugs are in place.

• That antibiotic liquid medicines given include an expiry date once reconstituted.
• That appropriate actions are taken when it is identified that medicines have been stored outside of their recommended temperature range
• Health visitors are informed of children attending MIU.
• All relevant staff working in the MIU receive training in dementia and learning disability.
• Written literature is available in different formats, such as large print or braille, and languages other than English, and provide directions on how to access patient information.
• All staff are aware of the risk and hazard register records that relate to their ward/department areas.
• All areas have their own risk register or a dedicated section within the central risk register.
• A review of the walk-in service for x-ray patients is undertaken to improve waiting times and flow.

• The Diagnostic target is added to the risk register.
• Consider screening lead coats, used within fluoroscopy, annually in line with best practice guidelines.

Professor Sir Mike Richards

Chief Inspector of Hospitals