Archived: Centre for Surgery - Watford

Updated 10 September 2020

MS Watford is operated by M Sarwar Limited. The service originally opened in 2015 under the former provider Acuitus Medical Ltd. In 2019 the service was taken over by a new provider and was registered with the CQC as MS Watford in April 2020. The service provides day case cosmetic surgery to self-funding patients aged 18 years and over. It is located in Watford, Hertfordshire and primarily serves the communities of Hertfordshire and Greater London. It also accepts patient referrals from outside this area.

The clinic has had a registered manager in post since it was registered with the CQC in April 2020.

We have not previously inspected this service. However, we had inspected the former provider four times. The most recent inspection took place in June 2019, where we found two key questions (safe and well-led) were inadequate, so the service was placed in special measures. We told the former provider that it must take some actions to comply with the Health and Social Care Act 2008 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 former provider with two requirement notices for breaches of Regulation 12 (safe care and treatment) and Regulation 17 (good governance). This inspection focused on aspects of the service that previously fell short of the good standard. We found the new provider had made significant improvements to the service.

Updated 10 September 2020

MS Watford is operated by M Sarwar Limited. The service provides day case cosmetic surgery to self-funding patients aged 18 years and over. Facilities include a dedicated surgical suite with admission room, operating theatre and recovery room. There is also one consultation room, waiting room, offices, toilet and shower facilities.

We carried out a focused inspection because the service was taken over by a new provider in April 2020. We wanted to see if the new provider had made significant improvements to the service since our last inspection of the former provider, Acuitus Medical Ltd, in June 2019. We carried out a short-notice announced focused inspection on 22 July 2020. We gave staff one days’ notice that we were coming to ensure the staff we needed to talk to were available.

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? However, because this was a focused inspection, we did not look at all five key questions. Instead, we focused on the areas of concern which we identified at the last comprehensive inspection of the service. We inspected the safe and well-led key questions and some parts of the effective and responsive key questions.

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 only provides cosmetic day surgery.

Services we rate

We have not rated this service.

This inspection looked specifically at the concerns we identified at the last inspection. Where there is a change of ownership, any ratings awarded to a previous provider cannot be aggregated with any new ratings awarded to the new provider to produce a new overall rating. Therefore, we were unable to rate the service because we did not inspect all five key questions.

We found significant improvements to the service had been made:

• The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Managers collected safety information and used it to improve the service.

• Staff provided good care and treatment, based on national guidance and best practice. Managers monitored the effectiveness of the service and made sure staff were competent. Staff supported patients to make informed decisions about their care and treatment and followed national guidance to gain patients’ consent.

• It was easy for people to give feedback and raise concerns. Concerns and complaints were taken seriously and investigated, and improvements were made in response to feedback where possible.

• Leaders ran the service well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities and were committed to improving services.

However, at this inspection we found the following issues that the service provider needs to improve:

• The infection prevention and control audit lacked sufficient detail.

• Staff did not report complications of treatment unless it was a ‘significant or unexpected complication of a clinical procedure/treatment’. This meant there was potentially a missed opportunity to identify trends and/or themes relating to complications. Managers took action to address this following our inspection.

• Response rates to patient surveys was low. The service was taking action to address this.

Following this inspection, we told the provider that it should make other improvements, even though a regulation had not been breached, to help the service improve. Details are at the end of the report.

Heidi Smoult

Deputy Chief Inspector of Hospitals (Central)

Updated 10 September 2020

Cosmetic surgery is the sole core service provided at this location.

We carried out a focused inspection to review concerns we found at our last inspection of the former provider in June 2019. We inspected the safe and well-led key questions and some parts of the effective and responsive key questions. We did not rate the service but found significant improvements to the service had been made.