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Midlands Community Services Ltd Good

Inspection Summary

Overall summary & rating


Updated 21 May 2019

This service is rated as Good overall. (Previous inspection March 2018 – which was an unrated inspection in line with our inspection programme).

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 Midlands Community Services Ltd. This was to rate the service as part of our inspection programme.

Midlands Community Services Limited (MCS) is based in Brewood, Staffordshire and provides a vasectomy and carpel tunnel decompression service through the NHS for patients living in Staffordshire and Stoke on Trent.

This service is registered with the Care Quality Commission (CQC) under the Health and Social Care Act 2008 for treatment of disease, disorder or injury; surgical procedures; diagnostic and screening procedures and is registered as an Independent Healthcare Company. As a provider of Independent Healthcare the practice is able to offer its surgical services to patients from a much wider area than the NHS practice list at the same site. MCS is managed from Brewood Medical Practice and the directors of the company are also the GP partners at the practice.

Dr Alexander Houlder 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 service is run.

In preparation for the inspection, the practice had been sent blank comment cards and a small collection box from CQC. The team had taken these cards and boxes with them to their surgical sites in preparation for our inspection on the 2 April 2019. We received a total of 23 completed comment cards which included patients who had undergone either vasectomy and carpel tunnel care and treatment. All 23 of the cards were very positive about the service and care received.

Feedback obtained clearly demonstrated positive outcomes for patients. Patients spoke highly of the care and treatment they had received from the clinic. They described staff as friendly, efficient, helpful and caring. They also commented that staff put them at their ease during the procedure. Staff we spoke with told us they were well supported in their work and were proud to be part of a team which provided a high-quality service.

Our key findings were:

  • Patients received detailed and clear information about their proposed treatment which enabled them to make an informed decision.
  • Patients were offered convenient, timely and flexible appointments at a location of their choice.
  • Staff helped patients to be involved in decisions about their care. Patients were provided with patient information packs containing written pre and post treatment literature.
  • There was a transparent approach to safety with demonstrably effective systems in place for reporting and recording adverse incidents.
  • There were effective procedures in place for monitoring and managing risks to patient and staff safety. For example, there were arrangements to prevent the spread of infection.
  • The service had a structured programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided.
  • There was effective leadership, management and governance arrangements in place that assured the delivery of high-quality care and treatment.

The areas where the provider should make improvements are:

  • Seek assurances that appropriate risk assessments are in place at the sites managed by other providers.
  • Obtain information about any relevant physical or mental health conditions for all newly appointed members of staff.
  • Maintain a log of significant events and complaints from all data sources to monitor events over time for any trends.

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

Inspection areas



Updated 21 May 2019

We rated safe as Good because:

We found that this service was providing safe care in accordance with the relevant regulations.

Safety systems and processes

  • The service had clear systems to keep patients safe and safeguarded from abuse. Staff had received training in safeguarding and equality and diversity. Staff understood their responsibilities, had access to a safeguarding policy and the registered manager was the designated safeguarding lead.
  • All referrals were received from other NHS providers. This enabled the provider to check the identity and details of patients on the NHS electronic data base. Staff confirmed these details when they contacted patients to arrange appointments.
  • The provider carried out staff checks on recruitment and on an ongoing basis, including checks of professional registration where relevant. Disclosure and Barring Service (DBS) checks were undertaken for all staff employed. (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). We reviewed the recruitment records held for staff, one of whom had been employed since the provider had been registered with the Care Quality Commission. We found all of the required documentation had been obtained with exception of information about any physical or mental health conditions. The business manager had been made aware that this information needed to be obtained during the last inspection of the GP practice in March 2018. The practice had not collected this information retrospectively but assured us this information would be obtained when new staff were recruited.
  • Information in the minor surgery room informed patients that staff were available to act as chaperones. However, two members of staff were always present when procedures were being carried out. Designated 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. The lead nurse was the designated infection prevention and control lead and was responsible for staff training. Suitable risk assessments for the prevention and control of infection were in place. Staff had access to an infection control policy and had received training. External cleaners were contracted to maintain the cleanliness within the building and cleaning schedules were in place. The service was in the process of changing their contract cleaner as they had found mops inappropriately stored wet by their outgoing contact cleaner. The practice had suitable risk assessments and processes in place to reduce the risk of water borne infections such as Legionella.
  • Clinics were carried out in a number of buildings that were not owned or managed by MCS. Staff told us that they checked the cleanliness of each room used before commencing the clinic and no issues around cleanliness had been noted. Although there was no formal agreement in place for risk assessments and access to emergency medicines; the service did complete a clinic room check before they set up for surgery at each site. These records were completed by the service team and were kept by the staff. The service advised us they would be formalising this process and storing all of these documents centrally in the near future.
  • The provider ensured that their facilities and equipment were safe and that equipment was maintained according to manufacturers’ instructions. There were systems for safely managing healthcare waste.

  • The provider had undertaken risk assessments for the Brewood site. These included a health and safety, fire and legionella risk assessments. All electrical equipment was checked to ensure that equipment was safe to use, and clinical equipment was checked to ensure it was working properly. Fire checks and drills were carried out.

Risks to patients

  • The provider had arrangements in place to respond to emergencies. Clinical staff and health care assistants had completed training in emergency resuscitation and life support to ensure they were able to respond appropriately to any changing risks to patients’ health and wellbeing during their treatment.

  • Emergency medicines and equipment were easily accessible to staff during clinic times and stored in a secure area. All staff we spoke with knew of their location. The clinic had emergency resuscitation equipment available including an automatic external defibrillator (AED) and oxygen. The clinic also had medicines for use in the event of an emergency. Records completed showed regular checks were carried out to ensure the equipment and emergency medicine was safe to use.

  • Staff told us they knew the location of the emergency medicines and equipment at each of the sites used for clinics. This information was documented and available to staff at all times.

  • Staffing levels and the skill mix of staff were planned and reviewed to ensure patients received safe care and treatment. Each clinic had two members of clinical staff present, a doctor and health care assistant, specifically trained for the role. Arrangements were in place to cover holidays.

  • The service had professional indemnity arrangements in place for the GPs who conducted vasectomies and carpel tunnel decompression. The provider had group professional indemnity in place with covered the role of the health care assistant. All clinical staff were up to date with their professional registration and revalidation.

Information to deliver safe care and treatment

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

  • The service received completed referral forms for each patient from other health care professionals.
  • Individual care records were written and managed in a way that kept patients safe. The service maintained electronic records for patients. All paper records where scanned onto the electronic system.
  • The surgical assistant told us they recorded the batch number and expiry date for all medicines administered to patients. Any medicine administered was only done with an accompanying prescription by a doctor.
  • The service shared information with the patient’s GP by receiving referral letters detailing the patient’s condition and personal circumstances and always communicating with them after a procedure had been carried out. The service recorded information electronically on a shared system with the GPs.

Track record on safety

The practice had a good safety record.

  • There were comprehensive risk assessments in relation to safety issues, with the exception of documented assurances from host practice sites that appropriate risk assessments were in place.
  • The practice monitored and reviewed activity. This helped leaders 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 and procedure for recording and acting on significant events and incidents. We saw staff had access to a policy and standard form to record and report adverse incidents and events. The service had two significant events had been recorded in the previous 12 months. We looked at these in detail and found that appropriate action had been taken.
  • Significant events were often identified through feedback from patients. We saw that significant events were discussed at the bi-monthly clinical governance meetings, which were attended by all MCS staff.

  • The practice did not maintain a log of significant events, which would enable to practise to apply learning from events and to monitor events over time for any trends.
  • 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 service gave affected people reasonable support, truthful information and a verbal and written apology.
  • The provider had an effective system for receiving and dealing with safety alerts.



Updated 21 May 2019

We rated effective as



Effective needs assessment, care and treatment

  • The service had systems to keep clinicians up to date with current evidence-based practice. We saw that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance supported by clear clinical pathways and protocols.

  • Patients referred to the service had already been assessed as suitable for the procedure by the referring clinician. However, patients were offered further counselling if they felt they needed this. Both of the community surgeons were members of the Association of Surgeons in Primary Care (ASPC). The service used information and guidance provided by ASPC to inform their practice.

Monitoring care and treatment

  • The provider reviewed the effectiveness and appropriateness of the care provided. All staff were actively engaged in monitoring and improving quality and outcomes. Audits were carried out to demonstrate quality improvement. The provider shared their results on an annual basis with the ASPC and used the national data provided by the ASPC as a baseline for comparisons. The service had audited post vasectomy sterility rates and infection rates annually since commencement of service.
  • The service had monitored and compared their infection rates against the national average provided by the ASPC since April 2013. There had been slight fluctuations year on year in infection rates. However, these were always within the average range and lower than most respondents. The post-operative booklet given to patients had also been updated and included information about wound care and infections. The service was in the process of repeating both audits.

Effective staffing

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

  • The community surgeons had undertaken additional training to enable them to carry out their role.
  • The service had developed a specific training programme for the surgical healthcare assistants. Staff who worked in this role had been assessed as competent before they undertook the role and supported the community surgeons in clinic.
  • The service understood the learning needs of staff and provided protected time and training to meet them. Staff were encouraged and given opportunities to develop.

Consent to care and treatment

  • Staff sought patients consent to care and treatment in line with legislation and guidance. Staff understood the relevant consent and decision-making requirements of legislation and guidance, including the Mental Capacity Act (MCA) 2005. The service was aware of guidance issued by the ASPC and Medical Protection Society and had reviewed the consent forms on receipt of that guidance.

  • Separate consent forms were used for carpal tunnel decompression and vasectomies. All completed forms were scanned into the electronic patient notes. Both consent forms contained details of the potential complications that may result from the procedure.
  • Patients’ immediate and ongoing needs were fully assessed. Where appropriate this included their clinical needs and their mental and physical wellbeing.

  • Clinicians had enough information to make or confirm a diagnosis
  • We saw no evidence of discrimination when making care and treatment decisions.
  • Arrangements were in place to deal with repeat patients. (For example a patient who required carpel decompression to both wrists).
  • Staff assessed and managed patients’ pain where appropriate.

Coordinating patient care and information sharing

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

  • Patients received coordinated and person-centred care. Staff routinely shared information with the patients’ GP. The provider notified the patient’s GP as to whether the patient had attended and received treatment or if the patient had not attended. Patient information was stored electronically on a shared system with the GPs.
  • 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.
  • All patients were asked for consent to share details of their consultation and any medicines prescribed with their registered GP on each occasion they used the service.
  • Care and treatment for patients in vulnerable circumstances was coordinated with other services. For example patients with learning difficulties were encouraged to have an advocate with them during the counselling appointment, and extra time given to ensure that the surgery would be in the patients best interest.



Updated 21 May 2019

We rated caring as



Kindness, respect and compassion

  • The practice gave patients timely support and information.
  • All of the 23 patient Care Quality Commission comment cards we received were very positive about the service experienced.

All patients were asked to complete a satisfaction survey on the day of their operation. Patients who had attended for carpel tunnel decompression where contacted two weeks post-operatively by the lead nurse and asked about their experience. Patients who attended for a vasectomy were contacted by email/letter and asked to complete an electronic questionnaire five months post-operatively. The administrative staff reviewed these results each month and passed on any negative comments or issues to the relevant doctor, who would then contact the patient. The service collated the results for both services into an annual report.

We viewed the report dated April 16 – March 17. Both positive and negative comments were recorded in the report.

Involvement in decisions about care and treatment

Staff helped patients be involved in decisions about their care and were aware of the Accessible Information Standard (a requirement to make sure that patients and their carers can access and understand the information they are given):

  • Patients were provided with patient information packs containing written pre and post treatment literature. A different format could be made available upon request.

  • Interpretation services were available for patients who did not have English as a first language.

Staff told us that patients were encouraged to ask questions about any treatment and were listened to. Patients were offered either a one-stop appointment or a counselling appointment if they wished to discuss any concerns that they may have.

Privacy and Dignity

The practice respected and promoted patients’ privacy and dignity.

  • Staff recognised the importance of patients’ dignity and respect.
  • The practice complied with the General Data Protection Regulation 2018. All confidential information was stored securely.
  • The minor surgery room at Brewood was located away from the main waiting area. Staff told us that patient privacy and dignity was maintained at all times.



Updated 21 May 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 provider understood the needs of their patients and improved services in response to those needs. The service had been set up to meet patient need and reduce waiting times for both vasectomy and carpel tunnel decompression within the county of Stafforshire. Procedures were carried out at number of sites around the county, including two health centres in Stoke on Trent and local hospitals in Stafford, Tamworth and Lichfield.
  • The facilities and premises at Brewood Health Centre were appropriate for the services delivered. The service had a lift to provide access to the first floor. The provider had introduced a clinic check list on which they documented that they assessed each site prior to running the clinics. However, there was no formal agreement in place between the provider and each location owner to ensure the facilities and premises were appropriate.

Timely access to the service

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

  • Clinics were provided at least weekly at the main site dependent upon demand. Some sites had weekly or monthly clinics built around the number of patients from that area who required surgery.
  • The locations of the clinics were varied depending on the demand in each location. A monthly clinic was provided in Lichfield on a Monday. Patients referred for carpel tunnel decompression were treated within four weeks of receipt of their referral. Patients referred for vasectomies had a two week cooling off period and then were treated within four weeks (six weeks from receipt of referral). Patients could request an appointment outside of these timescales to meet their personal needs, for example due to work commitments or holidays. The service had a system in place to monitor that patients were seen within the specified timescales.
  • The service was committed to reducing the number of patients who did not attend for appointments. The service had started to contact patients by telephone to remind them of their appointment. Patients who did not attend received a letter after a month asking them to contact to re-arrange an appointment. If the patient did not respond, they were referred back to their GP.

Listening and learning from concerns and complaints

The service took complaints and concerns seriously and responded to 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 had not received any complaints during the pervious 12 months.
  • Although the service had not received any complaints, they reviewed all the comments received from patients via the surveys and verbal feedback. Any issues or concerns were passed to the relevant clinician, who usually contacted the patient for further decision. However, concerns picked up via this route were not always logged as a complaint which prevented the practice from sharing learning.



Updated 21 May 2019

We rated well-led as

Good because:

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.

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.
  • The service developed its vision, values and strategy jointly with staff.
  • Staff were aware of and understood the vision, values and strategy and their role in achieving them
  • The service monitored progress against delivery of the strategy.


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. Clinical staff, including nurses, were considered valued members of the team. They were given protected time for professional development and evaluation of their clinical work.
  • 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.

Managing risks, issues and performance

There were clear and effective clarity around 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. Clinical staff performance 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, 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.
  • Immediately after the operation and up to five months post-operatively patients were invited to complete a satisfaction survey asking for their feedback about the service they had received. The comments were reviewed on a monthly basis and any issues discussed at the bi monthly governance meeting. The community surgeons contacted individual patients to further discuss comments as required. The survey results were collated into an annual report. The majority of comments were complementary about the service received but the report also included negative comments.
  • The clinic had also gathered feedback from staff during staff meetings, appraisals and general discussion
  • 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.

Continuous improvement and innovation

There was evidence of 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.

There were systems to support improvement and innovation work. Both surgical procedures and both GP surgeons received annual review and support from dedicated consultants from a local hosipital. We saw that the registered manager had sought support following a concern raised by a patient that the local anaestheic had not been long lasting. This resulted in the surgeons learning a new injection technique and changing the local anaesthetic used.