The Care Quality Commission
  • Hospital
  • Independent hospital

Archived: Blue Sky Orthopaedic

Syston Health Centre, Melton Road, Syston, Leicester, Leicestershire, LE7 2EQ 07841 783098

Provided and run by:
Blue Sky Orthopaedic Limited

All Inspections

29 November 2017

During an inspection looking at part of the service

Blue Sky Orthopaedic Limited is an independent orthopaedic clinic specialising in hand day surgery. It has no overnight beds. The company rents the facilities from a local GP practice in Syston, Leicestershire. Facilities include an operating theatre, a consulting room, office, utility and store rooms. The service provides hand surgery to adults, specialising in carpal tunnel decompression, trigger finger and thumb and Dupuytren’s disease surgery.

We inspected this service using our comprehensive inspection methodology on 28 and 29 June 2017. As a result of our findings we issued a warning notice served under Section 29 of the Health and Social Care Act 2008.

The full report of this inspection can be found on the CQC website: http://www.cqc.org.uk/location/1-2860593165

In order to follow up on progress against this warning notice we carried out a short notice announced focused inspection on 29 November 2017.

As this inspection was a focused inspection, we looked at the well-led domain only.

Services we do not rate

We regulate single speciality surgery services but we do not currently have a legal duty to rate them. We highlight good practice and issues that service providers need to improve and take regulatory action as necessary.

We found the provider had partially met the requirements of the warning notice. There were still some areas that required further improvement:

  • Continuing to embed the new governance framework and understanding of the new protocols and policies
  • Agreeing an internal and external audit plan which informs the service about areas to celebrate or improve, including a proposed NICE guidance audit.
  • Reviewing management capacity and cover for the registered manager.

However we also found the following areas of good practice:

  • Blue Sky Orthopaedic had developed a governance and policy framework, which included a strengthened approach to clinical governance.
  • Leadership meetings were formatted so that important aspects of governance could be regularly monitored.
  • Blue Sky Orthopaedic started to monitor their own dashboard of safety and quality measures, monthly. This included patient feedback, infection rates, process complaints and audit outcomes and management.
  • Policies and procedures to support medicines management and stock control were in place.
  • Processes for incident reporting, investigating and sharing learning had been developed and were well understood.
  • The service had arrangements in place for identifying, recording, managing and mitigating risk and monitored these at their leadership meeting.
  • Clinicians systematically used the World Health Organisation Five Steps to Safer Surgery checklist.
  • Safeguarding policy guidance was in place and staff had received safeguarding training
  • The service had its own appraisal forms and carried out appraisals in line with its own objectives.Training and appraisal files we reviewed were complete.
  • There were new policies for consent, duty of candour and the Mental Capacity Act 2005 and Deprivation of Liberty safeguards and staff understood and had received training on these topics.
  • The provider had audits in place for patient outcomes and the quality of sutures (stitches).

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve.

Heidi Smoult

​

Deputy Chief Inspector of Hospitals (Central), on behalf of the Chief Inspector of Hospitals

28 to 29 June 2017

During a routine inspection

Surgery was the main activity of the hospital. Where our findings on surgery also apply to other services, we do not repeat the information but cross-refer to the surgery section.

The service had a limited definition of incident reporting, and did not use trends in incidents to improve safety or quality or for problems solving. There was no detailed procedure on incident procedure to promote a shared understanding.

The service did not systematically use the World Health Organisation Five Steps to Safer Surgery, which have been proven to minimise harm to patients in the operating theatre.

There was no quality dashboard or comparison with other services, so the service did not know how it compared to others, or if it was getting better or worse at patient safety or quality.

The service did not formally review infection control in theatre or conduct hand hygiene audits to give them information about how consistently staff were washing their hands

The service had not carried out any recent clinical audits.

There was an incomplete picture of clinical outcomes due to a lack of post-operative audit and patient feedback mechanisms. This included a lack of information on levels of post-operative pain.

The service lacked a governance framework including a clinical governance group or programme of internal clinical audit.

The service lacked a strategy to continuously improve quality, safety or infection control.

Systems and measures to monitor, analyse or take action on safety, quality, performance were underdeveloped

Risks to service planning were not formally identified, logged, reviewed or mitigated

The service had a limited policy and procedural framework, and some important policies had not been written

However;

The operating theatre was visibly clean and there were effective segregation arrangements for clean and dirty materials and different kinds of waste. Sharps were disposed of separately.

Patient records were written in such a way to ensure patient safety and kept securely locked away

Clinicians took time to fully check patient’s readiness to leave after the operation.

Based on limited feedback, complication rates were nil and patients could use their hand and return to work very soon after the operation.

Clinicians took time to ensure patients understood the alternatives and risks to surgery, and what to expect during and after the treatment.

The service had good initial feedback from patients and recorded 100% satisfaction rates on feedback cards. We spoke to four patients who were very pleased with their operation and care.

Staff were kind and compassionate and took time to explain the treatment to patients. They communicated well with patients and relatives.

Blue Sky Orthopaedic offered a choice of clinics and times in accessible locations around Leicester

Blue Sky Orthopaedic treated patients within six weeks of referral.

The service was easy to access and gave patients a range of appointment options

Hand surgery at Blue Sky Orthopaedic was available to a wide range of patients including those with heart problems, cancer or diabetes. The service made adjustments for wheelchair users and patients with guide dogs.

The service had a strong team spirit and a patient centred culture.