Pall Mall Medical Diagnostic Treatment Centre

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Managers investigated incidents but did not always share lessons or themes with the whole team and the wider service. Staff did not always complete all risk assessments for patients. The equipment and facilities were not always clean and well-maintained. The service did not always control infection risk well. Staff did not always store or manage medicines safely. However, appropriate recruitment processes were in place to ensure staff were fit and proper for their roles. Managers monitored mandatory training and alerted staff when they needed to update their training.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told us they knew how to report safety incidents, they felt there was an open and honest culture. Managers investigated incidents but did not always share lessons or themes with the whole team and the wider service. The ward team did not have regular meeting where incidents or learning could be discussed. However, the theatre team did have regular huddles which included discussion of incidents. Staff would normally find out about changes via email or social media messages. There were daily operations meetings, but staff could not always attend these due to in-patient demand. The theatre team had daily staff huddles where updates could be shared.

At the time of inspection, mandatory training compliance showed:

• 70% completed within 12-month period (Dec 2023 - Dec 2024)
• 80% completed within a 13-month period (Nov 2023 - Dec 2024)
• 90% completed within a 14-month period (Oct 2023 - Dec 2024)
• 100% completed within an 18-month period (June 2023 – Dec 2024)

However not all staff had up-to-date sepsis awareness training. The provider told us that some staff who were overdue did not have direct contact with post-operative patients or had received alternative sepsis training.

Managers monitored mandatory training and alerted staff when they needed to update their training. We saw evidence that training was monitored in clinical governance reports.

Incident policies were regularly reviewed and up to date. Complaints and incidents were investigated in line with policy. The service conducted an annual review for complaints and received 56 between January to December 2023, 90.1% of complaints were acknowledged within 3 days, this was in line with the service’s policy. We saw evidence of clinical governance reports which reviewed incidents and identified themes for learning, however it was not clear how this was shared with staff and clinical teams.

The service displayed a copy of their certificate and subscription to the Independent Sector Complaints Adjudication Service (ISCAS). The certificate had expired on the 31 March 2024. The provider confirmed that the subscription had been renewed and the certificate needed replacing.

The service did not always share information with patients' GP's. We reviewed 10 patient medical records, 3 did not contain any GP records, despite patients providing consent for the service to obtain them.

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Staff gave patients all the relevant information regarding associated risks with specific procedures during the consent process, this allowed patients to make informed decisions about their own care and treatment. The 14-day cooling off period was adhered to in all the 10 patient records we reviewed. Patients told us they had been given enough time to make decisions. Patients received information about the cost associated with their procedures at their first consultation.

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Patients felt that the communication from the provider could be improved, they received appointment information from different staff members through inconsistent communication channels such as email, text and other social media messaging services. Patients told us this could be confusing, repetitive and convoluted. The service was planning on launching a bespoke patient portal which consisted of a centralised platform to manage appointments, medical records, and communication. Service leaders hoped the portal would resolve the current communication issues and aimed to launch it sometime in 2025.

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The service conducted infrequent audits to monitor World Health Organisation Five Steps to Safer Surgery Standards compliance, which meant compliance was not routinely checked. We witnessed a theatre case whereby the Five Steps were not adhered to, there was "no sign in" and music played during the "time out".

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All admissions and operations were planned. Staff told us that a resident medical officer (RMO) provided 24-hour cover for the service. The provider had a service level agreement (SLA) with a local NHS trust to provide smooth handover of care in the event of an urgent transfer. The service's transfer of critical patients standard operating service policy was up to date. There had been 1 occasion in the last 12 months where a patient required transfer to an NHS trust, but there had been no serious harm, and the staff members involved followed the service's policy appropriately.

The service had a blood transfusion policy that was up to date and an active SLA with a local NHS trust to provide blood products in the event of an emergency. The service was in the process of negotiating a new SLA with the trust to continue providing this service.

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Staff received specific training relevant to their role on how to recognise and report abuse. Clinical staff had level 2 safeguarding training in both adults and children, managers had completed level 3. Staff could identify the safeguarding lead and knew how to access the safeguarding policy. However, we did not see any evidence that the named safeguarding lead had completed their level 4 training, and this is not in line with national intercollegiate guidance.

Safeguarding children training compliance rates were 91% for levels 2 and 3. Staff knew how to identify adults and children at risk of, or suffering, significant harm and who to inform if they had concerns. The provider displayed local authority information for safeguarding referrals in clinical areas. The safeguarding adult’s policy was up to date, but we found an outdated version that had been printed and kept on the ward.

The service had a child protection and looked after children policies; however, both were under review and had not been updated since 2016 and 2018. Leaders told us the service did not carry out surgery on anyone under the age of 18, but did have an agreement with some third-party providers to use their premises to carry out paediatric cases.

Staff did not always complete all risk assessments for patients. Of the 10 medical records we reviewed we found 8 records where the surgeon had not completed the venous thromboembolism (VTE) risk assessment. An audit completed by the provider in March 2023 identified issues with completion of records although a subsequent audit in May 2024 found improvements. The audit stated there would be a reaudit of compliance on an annual basis.

Service leaders told us it was the responsibility of the consultants to consider whether patients were suffering from conditions such as body dysmorphia. The provider had in house psychological support. We did not see any evidence that staff members had undergone awareness training on topics such as body dysmorphia. Service leaders told us they were in the process of introducing a policy to support staff in identifying and managing anxiety and depression.

Patients felt staff fully explained the risks associated with their procedures and felt they had been given enough time to make their decision. They felt involved in decisions about their care and felt the service offered a patient centred approach. Patients felt they were given enough information about aftercare and the clinic organised follow up appointments.

Staff completed risk assessments for patients on admission. Risk assessments included consideration of mental health risks. The service also had admission criteria which staff used to screen patients and to determine if they were high risk and suitable for surgery.

The provider had a pre-operative assessment form and a separate form for patients to indicate their consent to share information with their GP.

The premises and equipment were visibly unclean and dusty. The service had two wards; both were wheelchair accessible. Rooms were made up of individual side rooms and had en-suite bathrooms. Ward 1 en-suites included shower rooms. Ward 2 rooms had access to a shared shower. The service had 2 operating theatres which were in good state of repair. Call bells and emergency cord pulls were in appropriate areas so patients could reach them. We fed back our concerns to service leaders on day one of the inspection but found similar issues the following day.

We found doors were not always locked, including to storage rooms containing medicines, tea rooms, the plant room and other rooms containing cleaning substances that would be deemed hazardous under the Control of Substances Hazardous to Health (COSHH) regulations.

The clinical waste was overfilled and left unlocked. The medical gas storage door was left unlocked, meaning it was accessible to members of the public walking past the building.

Fire exits were blocked by items such as cages and storage boxes. Other fire risks included, the unsafe storage of two helium cylinders, boxes piled up in unsuitable areas blocking the air conditioning unit.

The service had an up-to-date Fire Safety Policy but had an older 2021 version on display in the staff room.

We found out of date equipment such as a biohazard spill kit, and first aid kit. We reported this to service leaders during our assessment who took appropriate action to remove the out-of-date items.

Staff did not always carry out regular safety checks of specialist equipment. We noticed that there were gaps in resuscitation trolley checklist records and found a number of items that were out of date.

Liability insurance certificates had expired, after we pointed this out service leaders rectified this issue and printed out an updated copy.

All fire extinguishers had been serviced and we saw evidence that PAT testing had been undertaken.

We found gaps in audit schedules for nurse call bells.

Colour coded bins and bags were used for different types of waste and sharps bins were correctly labelled. We observed staff safely disposing of sharps. However, we found items of normal domestic waste found in some sharp bins.

There was an issue with the air conditioning in theatre 2, the temperature was known to increase at times, this was risk assessed by the provider and had been kept on the risk register since January 2024.

We escalated our concerns at the end of our visit and asked the provider to take immediate action. The provider submitted evidence following our inspection showing action had been taken to improve.

Appropriate recruitment processes were in place to ensure staff were fit and proper for their roles. The provider had processes to assess whether staff required disclosure and barring service (DBS) checks. We found one gap in DBS records however following the inspection the provider evidenced that an appropriate DBS check had been completed.

The service used a checklist for vetting new staff which included DBS checks on a 3-year basis.

Staff worked together well to provide safe care that met people’s individual needs. Staff did not feel rushed and felt they had enough time with patients. Patients told us staff were responsive to their needs.

Staff working out of hours told us they felt supported by the RMO.

Leaders made sure staff had a full induction of the service.

The service did not always control infection risk well. Staff did not always use equipment and control measures to protect patients, themselves, and others from infection.

Ward areas were not always clean and did not always have suitable furnishings well-maintained. “I am clean stickers” had been placed on equipment that was visibly dirty.

We found hand gel dispensers that had not been filled and some had expired in May 2021. We found a cleaning record sheet from a previous domestic company that had not been updated since 2022. The provider clarified that this was no longer used by the service. We found gaps in cleaning schedules; domestic staff had inconsistent ways of recording what had been cleaned.

We observed staff were not always bare below the elbows in clinical areas. The provider told us that staff acted in line with their local hand hygiene policy.

The service had a process in place to identify patients requiring pre-operative screening for MRSA to prevent surgical site infection. Managers monitored how well the service prevented infections.

We saw evidence of infection control audits that showed 100% compliance for the ward environment. Theatres were visibly clean and the most recent December audit showed 100% compliance.

The surgical site infection rates for the period of January 2024 to March 2024, indicated an average infection rate of 3.16%. National data for average infection rates in cosmetic surgery is not available.

Staff did not always store or manage medicines safely. Medicines were not always stored in line with the provider's own policy, the policy recommended intravenous (IV) and oral medicines to be stored separately, yet we found them stored together.

We found medicines stored in rooms and cupboards that were left unlocked and accessible to patients. We found medicines in storage rooms without any temperature checks. The provider told us the rooms had air conditioning and so could not exceed temperatures likely to impact on the safety of medicines.

We found that management, storage and administration of controlled drugs were in line with the service's medicines policy.

Service leaders told us they had SLAs in place with local pharmacies for supplies.

The service had a Pharmaceutical Adviser that undertook audits. The October 2024 announced audit found the service to be compliant, with some recommendations regarding fridge temperatures. Audit results did not correspond with the concerns we identified during our inspection.

We found concerns with the Ward 1 resus trolley including out of date adrenaline. The provider told us that replacement adrenaline had been ordered.

Medical gases were not always stored in line with regulations, we found helium cylinders left on a windowsill.

We saw evidence of antimicrobial audits and the most recent audit reviewing the prescriptions of antibiotics saw a 100% compliance.

We escalated our concerns at the end of our visit and asked the provider to take immediate action. The provider submitted evidence following our inspection showing action had been taken to improve.