Prem House Clinic is an independent hospital, based in Liverpool which provides surgical cosmetic services and is part of Prem House Clinic Limited. The majority of surgical procedures are day case breast augmentations but also blepharoplasty and abdominoplasty to patients over the age of 18 years of age are provided.
The hospital’s senior management team consists of a director and the registered manager. Clinical advice is provided from the chair of the medical advisory committee (MAC).
We inspected Prem House Clinic as part of our comprehensive inspection programme and we carried out an announced inspection on 13 July 2016. At the time of our initial visit there was no surgery planned for the day. We also carried out an unannounced inspection on 18 July 2016, which was the first day surgery was planned following our announced inspection. We have not rated this service because we do not currently have a legal duty to rate this type of service or the regulated activities which it provides. A warning notice has been issued to the provider setting out improvements that need to be made.
Are services safe at this hospital
- The majority of staff we spoke to were unaware what constituted an incident and issues such as, surgical site infections, which would be considered incidents, were not being reported. We were not assured that learning from incidents was being cascaded to staff to improve standards.
- The adverse incident management policy did not reflect the duty of candour requirements. There was a theatre standards policy but this was not always being implemented and the World Health Organization (WHO) five steps to safer surgery were not being followed in full.
- The processes and procedures for the safe management of medicines was not robust. We found that the prescribing of medication was not clear and there were occasions when medication had been given to patients more often than was recommended. There was also medication which did not have the expiry date on and medication that was dispensed for a specific individual was being used as medicine for other patients
- It was unclear if essential equipment had been regularly checked and there was suction tubing, two interlock connectors and yellow blood bottles in the resuscitation trolley that would be used in an emergency which were out of date. There were times when patient records were left unattended and the integrated care pathway documentation was not always being fully completed.
- There was a lack of guidance for staff on what to do following the completion of risk assessments.
- The out of hours service was not being monitored to measure its effectiveness and to improve standards in care. The majority of staff we spoke to were unaware how this service operated and a patient said they had been unable to access the service.
- Staffing levels and skill mix were planned and reviewed to ensure there was sufficient numbers of staff to provide safe care.
- There were good hand hygiene practices were observed and posters available for the public outlining how to wash their hands to help control infections. Environmental risk assessments were completed on an annual basis on all areas such as the ward and theatre.
Are services effective at this hospital
- Best practice guidance, such as those from the National Institute for Health and Care Excellence (NICE), was not always being clearly documented, especially in relation to undertaking routine pregnancy testing or asking patients if they may be pregnant, before procedures.
- Whilst food and drink was available for patients at the hospital the malnutrition screening tool, which was completed during consultation, did not outline the score correctly for staff to refer to for nutritional assessments.
- The hospital was not monitoring patient outcomes effectively. There was not a review system in place to ensure that surgeons undertaking procedures were competent. Not all doctors were fully engaged with the annual appraisal process.
- The hospital were not routinely collecting and reporting on cosmetic patient reported outcomes( Q-PROMs) data which is a recognised tool to collect patient satisfaction with their operation.
- Patient pain was managed effectively and staff worked well together. Consent processes were based on national guidance. The hospital had a local audit programme in place.
- The Private Healthcare Market Investigation Order (2014) requires every private healthcare facility to collect a defined set of performance measures and to supply that data to the Private Healthcare Information Network (PHIN). Hospitals were required to collect this data from January 2016, ready for submission in September 2016. The hospital had a process in place to record this information and was aware of the requirement.
Are services caring at this hospital
- Patients were treated with dignity and respect and were fully involved in their care.
- Staff explained procedures to them in a way they understood.
- Patients spoke positively about the care they had received and had been given all the information they required.
Are services responsive at this hospital
- The facilities and premises were appropriate for the services that were planned and delivered. However, the anaesthetic room was not used and patients were anaesthetised in theatre. This meant they had to pass the recovery area and there were times when they saw other patients who were being recovered from surgery. One such patient was in distress and this caused anxiety in a patient awaiting surgery.
- Discharge arrangements were not always robust and the theatre standards policy was not always being implemented.
- There was a lack of policies for some key areas such as female genital mutilation and some policies contained inaccurate information.
- The hospital did not use the Independent Sector Complaints Adjudication Service which meant that the only process of appeal was for the complaint to be dealt with internally by the director.
- Consultation clinics were regularly monitored to make sure they were running on time. On rare occasions when clinics ran late, staff would ensure patients were kept informed. The hospital arranged appointment and surgery times to meet the needs of the individual patient.
- Information leaflets were available for patients and staff could access interpreter services if required.
Are services well led at this hospital
- There was a governance reporting structure with meetings being held on a monthly or quarterly basis. However, there was limited assurance that learning from incidents or complaints were discussed or disseminated to staff to help improve standards of care.
- There was no formal risk register in place to highlights risks to the service or outline how they would be mitigated in an effective and timely way.
- The hospital sought feedback from patients about the care received through their own surveys.
- Staff were positive about the leadership of the service and enjoyed working at the hospital.
Our key findings were as follows:
Incidents
- The hospital had an adverse incident management policy and procedure. However, the majority of staff were unaware what constituted an incident. What would be considered incidents were not being reported. For example, patients returning to theatre or surgical site infections. We were not assured that learning from incidents was being cascaded to staff to improve standards. The adverse incident management policy did not reflect the duty of candour requirements.
Assessing and responding to risk
- The five steps to safer surgery were not being fully followed.
- It was unclear if the anaesthetic equipment and breathing circuits had been regularly checked and there were a number of consumable items in the resuscitation trolley that were out of date. There was suction tubing, two interlock connectors and yellow blood bottles
- Following discharge, patients could call the hospital for advice or reassurance. However, the calls to this service were not being monitored to look for trends to help improve standards of care. The majority of staff we spoke to were unaware how this service operated and a patient said they had been unable to access this service.
- Discharge arrangements were not robust.
Medicines
- The processes and procedures for the safe management of medicines were not robust. We found that the prescribing of medication was not clear and there were occasions when medication had been given to patients more often than was recommended. There was also medication which did not have the expiry date on.
- We found medicines that had been dispensed for a specific individual were being used as medicine for other patients and quarterly audits of controlled drugs had not highlighted issues with controlled drugs.
Records
- Patient records were left unattended at times which increased the risk of them being accessed by unauthorised personnel.
- The integrated care pathway documentation was not always being fully completed and there was a lack of guidance for staff following the completion of risk assessments.
Evidenced based care and treatment
- National Institute for Health and Care Excellence (NICE) guidance was not always being followed.
Competent staff
- There was a lack of monitoring of staff competencies.
- All doctors were not fully engaged with the appraisal process and mandatory training levels were low, especially in life support.
Access and Flow
- The patient journey through the hospital was not always as person centred as it could have been. As the anaesthetic room was not being used, patients had to pass the recovery area where patients who had just had their operation were recovering.
Complaints
- The hospital did not use the Independent Sector Complaints Adjudication Service which meant that the only process of appeal was for the complaint to be dealt with internally by the director.
- The complaints policy contained inaccurate information.
Governance and risk management
- There was a governance reporting structure and the main governance committee was held on a monthly basis. However, learning from incidents or complaints or trends were not discussed to help improve standards.
- We saw no evidence that other doctors working at the hospital under practicing privileges attended the medical advisory committee to help give clear clinical oversight of the clinic.
- There was no formal risk register to identify potential risks to the organisation or to patients. This offered no assurance that risks were being mitigated in an effective and timely manner.
- Policies were not always being fully implemented, for example, the complaints policy contained inaccurate information. Policies were not available for some key areas, such as female genital mutilation.
There were areas where the provider needs to make improvements. A warning notice has been issued to the provider. Importantly, the provider must:
- Ensure there are effective systems and processes in place to assess, record and mitigate risks.
- Ensure processes are in place and followed to guarantee equipment for resuscitation are in date.
- Ensure there is a safe process in place for the management of medicines.
- Ensure safe storage of patients’ records.
- Ensure staff adhere to all policies and ensure the theatre standards policy is fully implemented.
- Ensure the integrated care pathway documentation is completed accurately and the paperwork is correct, especially the malnutrition screening tool.
- Ensure that risk assessments include relevant guidance for staff.
- Ensure that relevant best practice guidance is implemented and ensure routine pregnancy testing or recording of patients last menstrual period is recorded in all cases.
- Ensure full compliance with the use of the early warning scoring (EWS) system and that staff are fully competent in the use of the system.
- Ensure that policies are reviewed to ensure they contain accurate and up to date information. Especially the complaints policy, discharge policy, admission policy and adverse incident policy together with developing a female genital mutilation policy.
- Ensure the service is meeting the recommendations from the Review of the Regulation of Cosmetic Interventions in relation to collecting QPROMS and SNOMED coding information.
- Ensure that all doctors have up to date appraisals.
- Ensure that all staff receive regular supervision meetings
- Ensure that all staff are up to date with mandatory training, especially in basic, intermediate and advanced life support as well as safeguarding training.
- Ensure that patient outcomes are fully monitored.
- Ensure that there are robust systems in place to ensure competencies of doctors performing surgery are regularly monitored.
- Ensure that incident processes and procedures are reviewed and that staff understand what constitutes an incident and that learning is identified and cascaded to staff to improve services.
- Ensure that the out of hours on call service is fully monitored to inform improvements in standards of care.
- Ensure that the patient journey is reviewed, especially from being anaesthetised to discharge.
- Ensure there are robust systems in place for the safe management of medicines.
- Ensure that a copy of the discharge information is sent directly to the patient’s general practitioner.
In addition the provider should:
- Consider how doctors engage with the medical advisory committee.
- Consider how the responsible officer engages with governance meetings.
Professor Sir Mike Richards
Chief Inspector of Hospitals