Archived: Sussex Downs Fertility Centre

This service is rated as Requires improvement overall.

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Requires improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires improvement

We carried out this announced comprehensive inspection of Sussex Downs Fertility Centre on 4 October 2022 under Section 60 of the Health and Social Care Act 2008. This inspection was planned to check whether the service was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008. This was the provider’s first inspection of the service since it registered with the Care Quality Commission (CQC).

How we carried out the inspection:

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

This included:

• Speaking with staff in person, on the telephone and using video conferencing.
• Requesting documentary evidence from the provider.
• A site visit.

We carried out an announced site visit to the service on 4 October 2022. Prior to our visit we requested documentary evidence electronically from the provider. We spoke to staff on the telephone and using video conferencing prior to our site visit.

Sussex Downs Fertility Centre is an independent provider of fertility services, located in Eastbourne. This service is registered with CQC under the Health and Social Care Act 2008 in respect of some, but not all, of the services it provides. These include pregnancy scans (post 12 weeks) and a range of women’s health and gynaecological consultations and procedures, such as hysteroscopy. (A hysteroscopy is a procedure used to examine the inside of the uterine cavity).

There are some exemptions from regulation by CQC which relate to particular types of regulated activities and services and these are set out in Schedule 1 and Schedule 2 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Sussex Downs Fertility Centre provides a full range of fertility services for NHS and private patients and holds a licence with the Human Fertilisation and Embryology Authority (HFEA) to enable them to carry out this work. Fertility services provided are not within CQC scope of registration. Therefore, we did not inspect or report on those services.

Sussex Downs Fertility Centre is registered with the Care Quality Commission to provide the following regulated activities: Treatment of disease, disorder or injury; Diagnostic and screening procedures; Surgical procedures.

The service’s managing director 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.

Our key findings were:

• There were some safeguarding systems and processes to keep people safe. However, there was no documented policy for the safeguarding of children.
• There were some comprehensive processes in place for the induction of staff and monitoring of role-specific competencies. However, some staff had not completed training in key areas.
• There was a lack of records to demonstrate that recruitment checks had been carried out in accordance with regulations for some staff.
• The monitoring and storage of staff documentation was not well managed and did not ensure leaders had clear oversight of their status.
• Arrangements for chaperoning were effectively managed.
• There were some processes to assess the risk of, and prevent, detect and control the spread of infection. However, staff immunisations were not monitored in line with current guidance.
• Cleaning and disinfection of intracavity ultrasound probes were not carried out in line with best practice guidance.
• There had been insufficient action taken to address and manage identified risks associated with Legionella bacteria.
• There were appropriate arrangements to manage medical emergencies and suitable emergency medicines and equipment were in place.
• Clinical record keeping was clear, comprehensive and complete, and in line with best practice guidance.
• There was evidence of clinical audit and auditing of clinical record keeping processes.
• There were effective governance, incident reporting and risk assessment processes in some areas. However, some identified risks were not always included in action planning or followed up in a timely manner.
• Leaders were focused upon staffing levels and stabilising the staff team following a period of high staff turnover.
• There was effective and open communication and information sharing amongst the staff team. There were regular team meetings and staff felt motivated to contribute to driving improvement within the service.
• Patients were asked to provide feedback on the service they had received, and the service acted promptly to respond to feedback. Complaints were managed appropriately.

The areas where the provider must make improvements as they are in breach of regulations are:

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out their duties.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

• Review the complaints policy to provide information to support patients should their complaint remain unresolved.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services