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The Surrey Park Clinic Requires improvement

The provider of this service changed - see old profile

Inspection Summary


Overall summary & rating

Requires improvement

Updated 3 February 2017

The Surrey Park Clinic is operated by The Surrey Park Clinic (IHG) Ltd. Facilities include one treatment room for minor outpatient surgical procedures , a pre and post surgical rest room, three consulting rooms and a pharmacy for outpatient dispensing.

The service provides outpatient services including minor outpatient surgical procedures and ultrasound scans, mostly for adults but including 40 children and young people aged 13 - 18 (July 2015 – June 2016). We inspected outpatient services and include services for children and young people within this core service report because of the very low number of children and young people attending as patients.

We inspected this service using our comprehensive inspection methodology. We carried out the inspection on 17 October 2016. We rated the service overall as requires improvement. However, caring was good, and leadership was inadequate because of the lack of formal governance structures and clinical oversight.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

The main service provided by this service was outpatients. We rated this service as requires improvement overall.

We found areas of practice that require improvement:

  • Senior staff who investigated incidents and complaints had not been trained in root cause analysis which meant that investigations were not always sufficiently robust.
  • Measures taken to prevent incidents recurring were not always successful, indicating that the reason for the incident occurring had not been adequately understood.
  • Staff did not understand their responsibilities under the duty of candour and we saw examples where the service had failed to discharge their responsibilities under this duty.
  • There were limited audits within the service to assure managers that staff were following the correct pathways and policies which kept patients safe, for example there were no regular hand hygiene audits.
  • Although patient records were mostly stored securely, complete contemporaneous records were not available as consultant notes were not stored on site.
  • Staff did not all have the required level of safeguarding training for both adults and children and young people.
  • The service had levels of bank staffing which were consistently worse than the average rate for other independent services.
  • The clinic’s policies and procedures were nearly all outside of their review date, which meant that staff might not have worked to the relevant and current evidence-based guidance, standards, best practice and legislation.

We found areas of practice that were inadequate:

  • The service did not have a formal clinical governance committee or medical advisory committee to review clinical practice and address clinical issues, and there was no clinical risk register to log and monitor risks.
  • The clinic owner and general manager, who were both non-clinical staff, took responsibility for the granting and reviewing of practicing privileges. The absence of a consultant or doctor to advise on these processes meant it might have been difficult for the senior management team to assess the competencies and suitability of doctors applying for practicing privileges.
  • There had been repeated incidents where a patient had been informed of another patient’s test results which was a breach of the Data Protection Act and indicated that the service had failed to understand why this had happened.
  • The service did not have access to interpreters and used family members instead. This meant the clinic might not have had assurance all patients who did not speak English understood, or felt involved in, all aspects of their care. Staff, including members of the senior management team, did not appear to understand that using family members to interpret was not best practice.
  • There was no registered manager at the time of the inspection and the service had failed to take any action to remedy this. However, the general manager responded promptly immediately after the inspection and submitted an application.

We found areas of good practice in relation to outpatient care:

  • Equipment was correctly labelled with details of service dates and we saw evidence of daily checklists for the resuscitation trolley.
  • We saw documentation of patient allergies and evidence of antibiotic cover in the patient records we examined.
  • The service had an on-call rota to enable them to see patients out of hours should they have any complications following labiaplasty.
  • There were multi-disciplinary team meetings each month demonstrating a coordinated approach to patient care.
  • Patient feedback on the service received at the clinic was consistently positive, with many commenting on the degree to which staff gave them privacy and time to make decisions.

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. We also issued the provider with three requirement notices that affected outpatients. Details are at the end of the report.

Professor Edward Baker

Deputy Chief Inspector of Hospitals 

Inspection areas

Safe

Requires improvement

Updated 3 February 2017

We rated safe as requires improvement because:

  • The proportion of incidents rated as moderate harm was worse than the rate for other independent acute hospitals.
  • Staff who investigated incidents had not been trained in root cause analysis, which meant the investigation may not fully identify the reason for the incident, or correctly identify how to prevent any recurrence.
  • Staff did not fully understand the duty of candour and did not always discharge their responsibilities under this to patients when things went wrong. This was a breach of a regulation. You can read more about it at the end of this report.
  • There was no regular hand hygiene audit so managers could not be assured that all staff were compliant with the policy.
  • Patient records were incomplete as consultant records were held by the consultant without a copy in the patient record.
  • Staff did not have the correct level of safeguarding adults and safeguarding children training. This meant that staff did not all have the appropriate level and frequency of training to be able to identify and act upon safeguarding concerns.
  • Staffing levels were heavily reliant on bank staff and there was only one permanent full time nurse to monitor compliance with clinical governance and patient safety.

However,

  • Adverse events were a standard agenda item in team meetings and we saw evidence of discussions in minutes.
  • All areas were visibly clean and tidy, with cleaning charts and stickers providing evidence of appropriate cleaning.
  • All electrical devices were labelled with the date of their most recent safety test and service, so staff could be assured they were safe to use.
  • Patient records included individual care pathways and documented history of allergies.

Effective

Not sufficient evidence to rate

Updated 3 February 2017

Are services effective?

We inspected, but did not rate, effective.

  • Almost all of the clinic’s policies were outside their review date, some by over two years. This meant staff might not have worked to the relevant and current evidence-based guidance, standards, best practice and legislation.
  • The service used patient satisfaction audits to measure outcomes. Patient satisfaction results can be very subjective and may not always provide a robust tool for measuring outcomes.
  • Consultant files showed gaps in the documentation required to support practising privileges at the service, which meant the clinic might not have had assurances all medical staff at the clinic were competent and fit to carry out their role.

However,

  • Patients who attended for labiaplasty and participated in their audit reported that their pain was well controlled during the procedure.
  • We saw evidence of a good induction process for a bank healthcare assistant, with all areas signed and dated and evidence of continuing professional development.
  • There was a coordinated approach to patient care with monthly multi-disciplinary team meetings.
  • There was an on call rota to provide out of hours cover for patient who experienced problems following labiaplasty, and appointments were available at a range of times to meet the needs of the patient.

Caring

Good

Updated 3 February 2017

We rated caring as good because:

  • Staff took care to protect a patient’s confidentiality when speaking to them at reception and on the telephone.
  • Patient feedback was consistently positive about the kind and respectful treatment they had received.
  • Patients commented that they felt staff looked after them “as a whole person” and addressed their needs quickly and effectively.

Responsive

Requires improvement

Updated 3 February 2017

We rated responsive as requires improvement because:

  • In the absence of the lead nurse, laboratory results were checked and followed up either by a health care assistant or a member of the administration team. Non-clinical staff may not have had appropriate knowledge or training to be able to action results appropriately.
  • The service did not have access to interpreters and used family members instead.It was not possible to have assurance that all information had been correctly communicated to the patient.

However,

  • Patients could access appointments quickly and at a time to suit them.
  • There was clear information available on how to make a complaint, and all complaints were responded to within 28 days.
  • The service actively sought feedback from patients and changed practice in response to this.

Well-led

Inadequate

Updated 3 February 2017

We rated well-led as inadequate because:

  • There had been no registered manager since the previous owner changed roles over a year before the inspection. This was a breach of a regulation. You can read more about this at the end of this report.
  • There was no up to date statement of purpose for the service nor a specific set of values. Information that was available referred to the previous owner and registered manager who had left the role over a year ago.
  • There was no formal clinical governance structure and no minuted meetings to review governance.
  • There was no medical advisory committee to oversee clinical practice and ensure that clinical care met the highest standards of safety and quality.
  • Practicing privileges were granted and reviewed by staff who were not clinical.
  • There was no formal risk register to identify and monitor risks.
  • These governance isses were a breach of regulation. You can read more about this at the end of this report.
  • There were tensions within the service relating to consultant behaviour which the management team were working to change.

However,

  • The general manager submitted an application to be registered manager shortly after the inspection.
  • There were plans to establish a MAC by the end of 2016 and they had started the process of recruiting a lead clinician to chair this.
  • The management team was making progress in several key areas, and was working to update policies and patient pathways.
  • The service took steps to get patient feedback and made service improvements as a result of this.
Checks on specific services

Outpatients and diagnostic imaging

Requires improvement

Updated 3 February 2017

Do not include in report ☐

Outpatients was the main activity of the service.

We rated this service as requires improvement because although it was caring, it required improvement for safety and responsiveness to people’s needs and was inadequate for well-led.

  • Investigations into incidents were not sufficiently thorough which meant that there was no assurance that any changes in practice would prevent recurrence.
  • Staff did not understand their responsibilities under the duty of candour and this meant there were no assurances that the service would be open and transparent with patients if things went wrong.
  • Patient records were incomplete as consultants brought their own records and did not always leave a copy in the service.
  • There was no formal clinical governance structure and no medical advisory committee to oversee clinical practice.
  • Although there were no nursing vacancies, there was a high reliance on bank nurses and health care assistants, with only one full time permanent nursing post with overall clinical responsibility.
  • The service relied on patient satisfaction questionnaires to assess patient outcomes rather than clinical audit.

However,

  • all the areas we visited were visibly clean and tidy and all reusable equipment was labelled to indicate that it was clean.
  • Clinical and non-clinical waste was correctly separated, and sharps bins were managed appropriately to minimise risk of harm to patients and staff.
  • Documentation was clear, legible and correctly signed with patient care pathways and documentation of allergies in all notes.
  • Patient feedback was consistently positive about the care they received from staff.