The Care Quality Commission
  • Doctor
  • Independent doctor

Weston Surgical Centre

Overall: Good read more about inspection ratings

224 Weston Road, Meir, Stoke On Trent, Staffordshire, ST3 6EE 07795 970718

Provided and run by:
Childrens Surgical Consortium Limited

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Weston Surgical Centre on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Weston Surgical Centre, you can give feedback on this service.

19 March 2022

During a routine inspection

This service is rated as Good overall.

The location was last inspected in September 2017 and was not rated at that time.

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 Weston Surgical Centre as part of our inspection programme and to follow up on breaches of the Health and Social Care Act 2008 Regulated Activities Regulations 2014.

As a result of our inspection undertaken in September 2017, we issued the provider with requirement notices under:

  • Regulation 12: Safe care and treatment – for concerns in relation to the administration of controlled drugs.
  • Regulation 16: Receiving and acting on complaints – as the service did not have a formal and accessible system for identifying, receiving, handling and responding to complaints by service users and other persons.
  • Regulation 17: Good governance - as the service:
    • Did not have in place systems to assess, monitor and improve the quality and safety of services provided.
    • Did not have systems in place to assess, monitor and mitigate risks relating to the health, safety and welfare of service users and others.
    • Was not maintaining an accurate, complete and contemporaneous record in respect of each service user.
    • Was not maintaining securely records kept in relation to the services provided.

At this inspection we found that the practice had put measures in place for ongoing improvement. The practice is now rated Good overall.

Weston Surgical Centre provides male circumcision surgery to children and adults for predominantly religious and cultural purposes under local anaesthetic. The service also provides aftercare for patients.

The lead clinician 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.

How we inspected this service

Throughout the pandemic CQC has continued to regulate and respond to risk. However, considering the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend the minimum amount of time on site.

During our inspection we:

  • Looked at the systems in place relating to safety and governance of the service.
  • Viewed key policies and procedures.
  • Reviewed clinical records.
  • Interviewed the lead clinician both by telephone and face to face.
  • Interviewed other staff and persons associated with the service both by telephone and face to face
  • Received written feedback from staff.

To get to the heart of patients’ experiences of care and treatment, we asked the following questions:

  • Is it safe?
  • Is it effective?
  • Is it caring?
  • Is it responsive?
  • Is it well-led?

These questions formed the framework for the areas we looked at during the inspection.

Note: Within the report where we make reference to a parent or parents this also includes those who act as a legal guardian or legal guardians of an infant or child.

Our key findings were:

  • The clinic was clean and hygienic, and staff had received training on infection prevention and control.
  • The service had good systems to manage risk so that safety incidents were less likely to happen. When safety incidents did happen, the service learned from them and improved their processes.
  • Staff treated service users with kindness, respect and compassion and their privacy and confidentiality was upheld.
  • Feedback from patients was very positive in relation to the quality of service provided.
  • Patients could access the service in a timely way.
  • There was a complaints policy and procedure, both of which were accessible to patients.
  • Governance arrangements were in place and staff felt supported, respected and valued by the provider.

Although we saw no breaches of regulation, there are areas of improvement that the provider should consider:

  • Implement a system to ensure the appropriate water hygiene safeguards against legionella (Legionella is a term for a bacterium, which can contaminate water systems in buildings).
  • Record batch number and expiry dates of medicines used in patients’ notes.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

9 and 11 September 2017

During a routine inspection

We found the following areas of good practice:

  • We saw that when an incident was identified, the service conducted investigations to learn and improve. Outcomes from the investigation was discussed and shared at staff meetings.
  • We saw that clinical risks to patients were assessed and that staff acted appropriately when risks were identified.
  • The most recent results of an annual audit conducted showed that the centres rates of complications including infections were lower than other hospital providers it compared with.
  • We saw that the service followed recommendations outlined in National Institute of Health and Care Excellence (NICE) guidelines for sedation.
  • We spoke with parents who told us they had felt reassured by the information provided by staff, were all positive about their experience of the service and told us that there had been no concerns.
  • Staff gave examples of improvements to the service as a result of patient feedback.
  • There was a positive open working culture. We saw that there were staff meetings held every clinic day to debrief and discuss any concerns or good practice.

However, we also found the following issues that the service provider needs to improve:

  • We saw that there was no clear and effective governance framework to ensure that the service was running safely and delivering high quality care.
  • We saw that there was no risk register in place to record and monitor potential or actual risks of the service.
  • We found concerns over the supply, ordering, prescribing and disposal of controlled drugs.
  • We saw that controlled drugs were stored and used at the centre but that staff were not documenting the use of them in accordance with up to date legislation.
  • We saw that not all records of patient care was documented.
  • We saw that staff mandatory training completion was unclear due to the lack of clear documentation and that the service policy was overdue for review.
  • During the inspection we saw that some equipment was out of date and was stored with equipment that was fit for use.
  • We had concerns over the security and suitability of the environment for treating young children.
  • The service did not have standard operating procedures in place to ensure that the service was working to the most current and up to date recommendations.
  • We saw that audits were conducted however these did not reflect concerns we had during the inspection and therefore did not provide assurance of the monitoring of quality and safety.

15 August 2013

During a routine inspection

During our inspection we spoke with the parents of three children who used the service, one child who used the service, four members of staff and the provider. People told us they were happy with their care. One person told us, 'It's such a good idea to have a service like this. I'm really happy with it'. Another person told us, 'We were told there is a bit of a delay today, but it's not a problem as it's been explained to us'.

We found that systems were in place to ensure that consent to procedures was gained in accordance with legal requirements. Consideration was given as appropriate, to include children in the decision making process.

People received compassionate care and treatment that ensured their safety and welfare. Appropriate checks were in place to make sure people were fit for surgery and systems were in place to reduce the risks of infection. People received care and treatment that was based upon best practice recommendations, but an accurate record of the care and treatment provided was not always maintained.

Staff told us they felt supported and had received the training required to enable them to work at the service.

The provider had systems in place to monitor the quality and effectiveness of the treatments they provided.