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Inspection Summary


Overall summary & rating

Good

Updated 14 March 2019

The Surrey Park Clinic is operated by The Surrey Park Clinic (IHG). The service opened in 2005 to provide specialist women’s healthcare with a focus on the treatment of gynaecological issues, hormone treatment, fertility and pregnancy care. It is a private clinic in Guildford, Surrey. Facilities include one treatment room used for scanning, three consulting rooms, a phlebotomy room, a pharmacy for outpatient dispensing and a number of offices for administration purposes.

We previously completed a comprehensive inspection in October 2016 when we rated the service overall as required improvement. There were three regulatory breaches. The service provided an action plan to demonstrate how it would improve. In July 2017, we completed a follow up announced inspection where we focussed on the action plan and found the service had taken positive actions to improve and there were no breaches of regulation. We did not rerate the service following the 2017 inspection as we only reviewed actions taken to address the breaches of regulation.

We inspected this service using our comprehensive inspection methodology. We carried out an unannounced visit to the clinic on 9 January 2019.

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 service provides diagnostic and outpatient services including minor procedures and ultrasound scans, mostly for adults but included eight young people aged 16 to 17 years during the reporting period (August 2017 to July 2018). We inspected the outpatients and diagnostic imaging core services.

The main service provided by The Surrey Park Clinic was outpatients. Where our findings on outpatients for example, management arrangements – also apply to other core services, we do not repeat the information but cross-refer to the outpatient’s section of the report.

Services we rate

Our rating of this service improved. We rated it as Good overall.

We found areas of good practice in relation to outpatient care that had improved since the last comprehensive inspection.

  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. When things went wrong, staff apologised and gave patients honest information and suitable support.

  • The service provided care and treatment based on national guidance and a new audit plan was established to check effectiveness.

  • The service had suitable premises and equipment and looked after the general environment well, flooring and furnishings had improved and were easy to keep clean.

  • Staff kept detailed records of patients’ care and treatment using an electronic system with security safeguards. Records were clear, up-to-date and easily available to all staff providing care.

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.

  • The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.

  • The service systematically improved service quality and safeguarded high standards of care by creating an environment for excellent clinical care.

  • The service had a vision for what it wanted to achieve which it developed with staff.

  • Managers promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.

Other areas of good practice:

  • The service provided best practice when prescribing, dispensing, recording and storing medicines.

  • The service made sure staff were competent for their role and supported their staff with clinical supervision.

  • Staff cared for the patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.

  • The service planned and provided services in a way that met the needs of patients. The service took account of patient’s individual needs.

At this inspection, we found one breach of regulation as substances hazardous to health were not stored securely and in line with policy. We told the provider that it should make other improvements to help the service improve.

Nigel Acheson

Deputy Chief Inspector of Hospitals (South)

Inspection areas

Safe

Good

Updated 14 March 2019

Our rating of safe improved. We rated it as Good because:

  • The service provided training in key skills for all staff.

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.

  • The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection. The service had suitable premises and equipment and looked after the general environment well.

  • The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.

  • Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date and easily available to all staff providing care.

  • Staff completed risk assessments for each patient. They kept clear records and asked for support when necessary.

  • The service followed best practice when prescribing, dispensing, recording and storing medicines.

  • The service managed patient safety incidents well. Staff recognised incidents and reported them in line with policy. When things went wrong, staff apologised and gave patients honest information and suitable support.

However:

  • The storage of substances hazardous to health was not managed in line with risk assessments.

  • Not all staff had completed their mandatory training according to records seen.

  • Resuscitation equipment was not checked daily and in line with local policy.

  • Cleaning schedules were not consistently signed providing a complete record.

  • Recent review of the medicine management policy did not demonstrate input from the onsite pharmacist.

Effective

Not sufficient evidence to rate

Updated 14 March 2019

We do not currently rate the effective domain because there is not sufficient evidence to make a judgement.

  • The service provided care and treatment based on national guidance and a new audit plan was established to check effectiveness.
  • Staff monitored patients to see if they were in pain and offered pain relief if needed.
  • The service made sure staff were competent for their role and supported their staff with clinical supervision.
  • Staff of different kinds worked together as a team to benefit patients.
  • The service was available for patients six days a week and there were arrangements were to provide support out of hours.
  • Staff followed the service’s policy on obtaining and recording patient consent to examination and treatment.

However:

  • Not all clinical policies and standard operating procedures included version control information, including review dates.

Caring

Good

Updated 14 March 2019

Our rating of caring stayed the same. We rated it as Good because:

  • Staff cared for the patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.

  • Staff provided emotional support to patients to minimise their distress.

  • Staff involved patients and those close to them in decisions about their care and treatment.

Responsive

Good

Updated 14 March 2019

Our rating of responsive improved. We rated it as Good because:

  • The service planned and provided services in a way that met the needs of patients.
  • The service took account of patient’s individual needs.
  • Patients could access the service when they needed it, referral to treatment time was in line with good practice and patients were pleased with the flexible and prompt approach.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results and shared with staff.

However:

  • There was no process to implement a complaints escalation procedure that allowed external escalation for independent review if needed.

Well-led

Good

Updated 14 March 2019

Our rating of well-led improved. We rated it as Good because:

  • Managers in the service had the right skills and abilities to run a service providing high quality sustainable care.

  • The service had a vision for what it wanted to achieve which it developed with staff.

  • Managers promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.

  • The service systematically improved service quality and safeguarded high standards of care by creating an environment for excellent clinical care.

  • The service had good systems to identify risks, plan to eliminate or reduce them, and cope with both the expected and unexpected.

  • The service collected, managed and used information well to support its activities, using electronic systems with security safeguards.

  • The service engaged well with patients, staff and the public to plan and manage appropriate services, and collaborated with partner organisations effectively.

  • The service was committed to improving services by learning from when things went well or wrong, and promoting training and innovation.

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.

Diagnostic imaging

Good

Updated 14 March 2019

The clinic has one scanning machine and offers ultrasound scans, for diagnostic purposes.

Outpatients

Good

Updated 14 March 2019

The clinic offers consultations for women specialising in gynaecology, infertility, pregnancy and menopause.