Pall Mall Medical Diagnostic Treatment Centre

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Staff discussed people's needs with them, and they were involved in how care and treatment was planned. Staff gave people clear information about their care and treatment needed to support their health. Staff used the service's policies to follow the latest guidance and evidence-based practices. However, the ward staff did not have as frequent team meetings. The service had an audit schedule matrix in place however audits were not always effective. Staff did not always document consent accurately in line with legislation and guidance.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff discussed people’s needs with them, and they were involved in how care and treatment was planned. They were confident they had been listened to and understood. Patients told us staff asked them for any updates, such as any additional needs.

Staff used effective tools to support good clinical practice with people who had difficulties with communication. The service had an SLA in place for translation. Staff assessed and acted on risks to patients of avoidable harm. Staff worked with other specially trained professionals to support people with additional needs.

Records were up to date and showed that the assessments undertaken to review patients’ needs and had taken appropriate risk assessments on admission.

Staff used the service’s policies to follow the latest guidance and evidence-based practices. However, there were copies of old policies and guidance in the department that did not correspond with the most up to date national guidelines. Up to date policies were available electronically and staff knew how to access them.

Staff gave people clear information about their care and treatment needed to support their health. Staff made sure patients had enough to eat and drink including those with specialist nutrition and hydration needs. We observed that patients were offered several choices to eat from a menu. Meal options included vegetarian, vegan, and gluten free choices. Religious needs were catered for patients. Patients told us they were given a variety of food options and said staff were very attentive. Food was stored in fridges where temperature checks had not taken place.

The ward staff did not have as frequent team meetings. We did not see any minutes of any ward staff meetings. Ward staff told us meetings were more ad hoc rather than on a regular basis. Staff told us they would normally find out about updates via emails or messages from other members of the team.

Staff felt sometimes the communication between the theatre and ward team could be improved, for instance patients referred by third parties would sometimes not return to Pall Mall for aftercare and were referred to the third party, staff felt this information was not always clearly communicated or documented. Staff stated in a recent survey that they felt communication between teams could be improved, including regarding changes to theatre lists.

The service had quarterly Medical Advisory Committee (MAC) meetings.

Theatre staff worked well as a team, there were frequent team meetings and huddles. We saw evidence of multidisciplinary team meetings.

We did not look at Supporting people to live healthier lives during this assessment. There is no previous rating for the Effective key question so we cannot yet publish a score for this area.

The service had an audit schedule matrix in place however audits were not always effective. We identified concerns in the quality and safety of the environment, and processes to manage complaints and infection control.

The service undertook quarterly staff surveys and monitored progress. Staff survey themes included staff wellbeing and communication amongst teams.

Service leaders told us they regularly reviewed key metrics such as patient satisfaction, complication rates and complaints and incidents. Service leaders told us the “metrics allow us to benchmark our outcomes per surgeon and over time”. Service leaders told us they regularly reviewed each metric for trends. The service metric data was supplied quarterly to clinical governance and MAC committee where it was discussed.

Patient surveys however were on a more regular monthly basis, and we saw evidence of more in-depth analysis of themes and trends. The service had action plans for areas they hoped to improve on such as “communication, follow up and operational disruptions”.

The service had policies and procedures in relation to the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). The service did not consider DoLS training to be mandatory, therefore less than half of staff members had completed it. The service had undertaken a risk assessment to support their decision regarding DoLS training, but it was based on all staff having level 3 safeguarding training, at the time of our inspection compliance for level 3 safeguarding was 87%.

87% of staff were up to date with their consent training, this training covered the importance of guidance in Mental Health Legislation such as the Mental Capacity Act 2005.

Staff we spoke with understood how and when to assess whether a patient had the capacity to make decisions about their care.

Staff made sure patients consented to treatment based on all the information available and the 14-day cooling off period was adhered to in all patient records we reviewed. Staff understood the relevant consent and decision-making requirements of legislation and guidance, including the Mental Health Act and Mental Capacity Act 2005 and they knew who to contact for advice. Staff could describe and knew how to access the policy and get accurate advice on Mental Capacity Act.

Staff did not always document consent accurately in line with legislation and guidance. We reviewed 10 patients records and found 2 where the Consultant’s and patient’s name had not been printed.