Qualified Circumcision Clinic

Updated 23 July 2021

Mr Altaf Mangera operates as an independent circumcision provider as the Qualified Circumcision Clinic (QCC) and delivers services from registered locations in Sheffield and Coventry. The service based in Coventry operates from rented clinic space within the City of Coventry Health Centre, 2 Stoney Stanton Road, Coventry, West Midlands CV1 4FS. The service provides circumcision to children and adults for therapeutic and non-therapeutic reasons under local anesthetic. Many circumcisions carried out by the clinic are on children under one year of age, although older children and adults also use the service.

The service is registered with the Care Quality Commission for the provision of surgical procedures and the treatment of disease, disorder or injury regulated activities.

The City of Coventry Health Centre where the service is located is a newly converted and modernised multi-use health facility just outside the city centre. It is easily accessible for those bringing children or young people to the clinic, or for those with mobility issues. The centre has level floor surfaces, automatic doors and parking is available along with good public transport links. The Qualified Circumcision Clinic utilises three clinical rooms on the ground floor of the building for the delivery of its services, one for surgical procedures and another two for waiting and recovery areas.

The service is operated by an individual who is the named provider, and procedures are undertaken by the provider who is a qualified and registered adult urologist. Other staff working at the clinic includes a clinical support worker and a receptionist.

The Coventry-based service provides appointments monthly on Saturdays and occasional Sundays, dependent on patient demand.

Updated 23 July 2021

This service is rated as Good overall. (The service was last inspected on 11 & 12 October 2020 but was not rated at this time. The service was rated Good following an inspection in February 2020. The February 2020 rating still applied to the service following the October 2020 inspection.)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services well-led? – Good

We carried out an announced inspection at the Qualified Circumcision Clinic to follow up on breaches of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014. At our inspection in October 2020, we issued the provider requirement notices under Regulation 11: Need for Consent and Regulation 17: Good Governance due to the areas of non-compliance we found. At this inspection, we looked across the three key questions above in order to assess the improvements which were required in these areas following our last inspection.

The service provides circumcision to children and adults for therapeutic and non-therapeutic reasons. The service is offered on a private, fee paying basis only and is accessible to people who choose to use it.

The provider is the sole clinician for this service and carries out all of the circumcision procedures at the clinic.

At the last inspection we found that consent was not being obtained in line with the legal requirements as parental identity was not being consistently established and recorded. We also found that information about treatment was not always provided in a way that people could understand. At this inspection we found that improvements had been made to ensure parental consent was fully obtained and that parents had information about treatment in a way they could understand.

At the last inspection we also found that the provider was not recording the batch numbers and expiry dates of anesthetic administered to patients. At this inspection we found that improvements had been made in the recording of anesthetic administered and that clinical records were now improved. However, the quantity of anesthetic was not being recorded.

During our inspection in October 2020, we also found that there were not adequate systems in place to ensure that infection control and environmental risks were assessed and planned for. At this inspection., we found that this had been addressed by the provider. However, further improvement was needed in relation to clinical outcomes and how these were assessed and monitored on an on-going basis.

How we inspected this service

Throughout the pandemic CQC has continued to regulate and respond to risk. However, considering the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

As part of this inspection we spoke with three parents who had brought their children to the clinic for a circumcision. We also spoke with one adult who had attended the clinic for the procedure on the day of our inspection.

During our inspection we:

• Looked at the systems in place relating to safety and governance of the service
• Viewed a number of key policies and procedures
• Reviewed clinical records
• Explored clinical oversight and how decisions were made
• Spoke with staff
• Spoke with families of people who used the service and one person who had used the service themselves & who were able to speak with us

To get to the heart of patients’ experiences of care and treatment, we asked the following questions:

• Is it safe?
• Is it effective?
• Is it well-led?

These questions formed the framework for the areas we looked at during the inspection.

Our key findings were:

• Circumcision surgical procedures were safely managed and there were effective levels of patient support and aftercare.
• The service had commenced recording batch and expiry numbers of anesthetic administered. However, the volumes of anesthetic being administered was not being recorded.
• The provider was following up with each patient’s parents on the evening following the procedure.
• The practice had implemented a communication system with the patient’s own GP practice following the circumcision procedure.
• Consent had been consistently sought from both parents and identification documents checked. This was fully recorded to document that these had been seen.
• There was limited evidence of how patient outcomes were evaluated, analysed and reviewed as part of quality improvement processes.
• The service did not always adequately identify, investigate and learn from incidents relating to the safety of patients and staff members.
• There were systems, processes and practices in place to safeguard patients from abuse, and staff knew how and when to report any concerns.
• Policies and procedures were in place, however, none of these were readily available to staff whilst the clinics were running.
• The service provided information to parents/patients which explained the procedure and outlined the recovery process.
• Whilst the service had not received any complaints at the time of our inspection, we saw evidence that processes were in place to ensure these were investigated thoroughly.
• Health and safety risk assessments had been undertaken for the service.
• Staff personnel files were kept, and recruitment checks were completed on staff as required by law.
• Staff received on-going support from the provider and had regular appraisals. Training was monitored and kept up-to-date.
• The service sought feedback from patients and their parents.

The areas where the provider should make improvements are:

• Implement a system to assess clinical outcomes for patients.
• Improve the system for identifying, recording and acting on incidents and significant events in order for the service to recognise and learn from these to continuously improve the service.
• Improve the system for recording the quantities of anesthetic administered to patients.
• Review the accessibility of policies and procedures to ensure they are readily available for staff when the clinic is running to reduce risks to patients and their families.

Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care