Practice Plus Group Surgical Centre, Devizes

Updated 9 February 2017

Background to the Devizes NHS Treatment Centre

The Devizes NHS Treatment Centre opened in November 2009. This treatment centre operated in partnership with a Care UK inpatient facility situated 30 miles away in Bristol. Both sites shared the same senior management team and heads of department. The patient pathway utilised services at both sites giving patients the option of having appointments and surgery at either one.

The Devizes NHS Treatment centre houses four standardised consulting rooms to carry out consultations for new and follow up patients equipped to perform minor procedures: naso-endoscopies, ear suctioning, biometry and ‘Yag’ laser and haemorrhoid banding. Outpatient specialties included ophthalmology, oral surgery, ear, nose and throat, general surgery, orthopaedic, gynaecology and urology. The radiology services included x-ray, ultrasound and dental imaging.

There were four pre-operative/day case admission chairs separated by partitions with a single sex changing room and toilet. There were five recovery beds and three recovery chairs. There were two operating theatres. At the time of our inspection, the treatment centre had very recently completed building renovations to the endoscopy suite in order to comply with Joint Advisory Group recommendations and achieve accreditation. Surgical specialties included day case ophthalmology, oral surgery, ear, nose and throat, general surgery, orthopaedic (minor), gynaecology and urology.

All day patients, including endoscopy, are admitted, recovered and discharged from the post-anaesthetic recovery unit. The centre also had a dedicated endoscopy suite, which has its own self-contained endoscope washer disinfector for decontamination. Endoscopy included upper and lower gastrointestinal, rectal bleeds and cystoscopies. A number of services were provided to the treatment centre by another Care UK facility including decontamination of instruments, pharmacy and in-patient surgery. Other services were outsourced to other providers including pathology, MRI/CT scanning, audiology, hard and soft facilities management and musculoskeletal physiotherapy.

Patient referrals were taken from NHS acute trusts in Bath and Swindon. During the period April 2015 to March 2016 there were 57 outpatient attendances and 22 surgical procedures completed for young people aged 16-18 years. These included 14 dental extractions plus one gastroscopy, 1 arthroscopy, one septoplasty, one colonoscopy, one ligation of varicocele and one varicose vein operation.

During this inspection we looked at surgery and the outpatient and diagnostic imaging service.

We inspected the treatment centre as part of our routine comprehensive inspection programme for independent healthcare services. We carried out a comprehensive announced inspection on 13 and 14 September 2016 and an unannounced inspection on 21 September 2016.

The registered manager and accountable officer for controlled drugs for Devizes NHS Treatment Centre was the treatment centre director, who had been in the post since August 2011.

During this inspection we looked at surgery and the outpatient and diagnostic imaging service.

Updated 9 February 2017

Devizes NHS Treatment Centre is an independent treatment centre and part of Care UK Limited. At the time of our inspection it provided care and treatment to NHS patients, with no privately funded work undertaken.

The treatment centre provided surgery and outpatient and diagnostic services. The majority of services were provided to persons 18 years and over but also provided dental surgical services to persons aged between 16 and 17 years. Day case and inpatient surgery specialities included Ophthalmology, Oral surgery, ear, nose and throat (ENT), General surgery, Orthopaedic (minor), Gynaecology, and Urology. There were four pre-operative/day case admission chairs separated by partitions with a single sex changing room and toilet. There were five recovery beds and three recovery chairs. There were two operating theatres and a dedicated Endoscopy suite, which had its own self-contained Endoscope washer disinfector for decontamination. Endoscopic services included upper and lower gastrointestinal, rectal bleeding and cystoscopies

The outpatient department provided a service for patients before and after surgery. The radiology services included x-ray and ultrasound, and dental imaging. Outpatient specialties included ophthalmology, oral surgery, ear, nose and throat, general surgery, orthopaedic (major and minor), gynaecology, and urology.

A number of services were provided to the treatment centre by another Care UK facility including decontamination of instruments, pharmacy and in-patient surgery. Other services were outsourced to other providers including pathology, MRI/CT scanning, audiology, hard and soft facilities management and musculoskeletal physiotherapy.

All treatment was consultant led. Consultants were employed on either a substantive, bank or self-employed contracts. The senior leadership team included the treatment centre director, the medical director, the head of nursing and clinical services, operations manager and finance manager.

We carried out a comprehensive announced inspection of Devizes NHS Treatment Centre on 13 and 14 September 2016 and an unannounced inspection on 21 September 2016. We inspected and reported on two core services, the surgical services and the outpatient and diagnostic imaging service.

The overall rating for the Devizes NHS Treatment Centre was good. We rated both core services as being good for safe, caring, responsive and well led. We rated surgical services as good for effective but did not rate outpatient and diagnostic imaging for this domain. Our key findings were as follows:

Are services safe?

By safe, we mean people are protected from abuse and avoidable harm.

We rated safety overall as good because:

• The provider promoted a culture of openness and transparency. Staff understood and fulfilled their responsibilities to report incidents with learning and trends monitored and escalated through the governance system. Staff were aware of their responsibilities under the duty of candour.
• Staff ensured that the surgical and outpatient environment/equipment were kept clean. Procedures were in place to prevent the spread of infection. Infection control was regularly audited. All equipment at the centre was regularly serviced and prompt action was taken to rectify faulty equipment.
• The electronic patient record system in use at the centre allowed easy but secure access for all staff. Records contained all relevant information and comprehensive assessments of patient risk, which were clear and complete. Patients were followed up by telephone after their outpatient appointment and prior to their surgery.
• There were safe systems for the management of medicines. These were monitored closely by the pharmacy team and discrepancies were fed into the governance processes.
• Staffing at the centre was determined using a safe staffing tool which ensured adequate nursing and medical staff were in place when services were delivered.
• There were arrangements in place to safeguard adults and children from abuse. Concerns were reported by staff and were investigated by the safeguarding lead.

However,

• We found in storage rooms, where intravenous fluids were kept, there was no record of temperatures within those rooms being recorded. This meant that there was no assurance that the intravenous fluids in the rooms were kept safe for patient use.
• The location of the scrub sink in theatres, created a risk of the spread of infection as both clean and dirty instruments were transported past the sink before and after surgery. However, this was highlighted as a risk on the surgical department risk register, the rate of infection at the centre was very low and we were provided with evidence that a risk assessment had been carried out.
• We found fire exits were not always kept clear. We saw a supplies cage obstructing a fire exit on two separate occasions.

Are services effective?

By effective, we mean people’s care, treatment and support achieves good outcomes, promotes a good quality of life, and is based on the best-available evidence.

We rated services overall as good for effective because:

• Services at the centre provided treatment in line with national guidance and staff were aware of and followed the relevant National Institute for Health and Care Excellence (NICE) guidelines. Comprehensive policies and procedures were in place to support staff and compliance with them was monitored to ensure consistency of practice.
• Information about patient care, treatment and outcomes was collected and monitored. There was not always sufficient data to submit to national audits but local audits were undertaken. The treatment centre participated in national Patient Reported Outcome Measures (PROMS) for groin hernias and varicose veins and hip and knee arthroplasty operations. PROMS scores for groin hernias were similar to the England average but scores could not be calculated for varicose veins as there was not sufficient data. Performance of the treatment centre was benchmarked against other Care UK centres and local independent care providers.
• There were two unplanned readmissions within 28 days of discharge between April 2015 and March 2016. This was lower than average compared to other independent healthcare providers who have submitted data to the CQC.
• There were four unplanned transfers of day case patients to other treatment centres between April 2015 and March 2016. This was lower than average compared to other independent healthcare providers who have submitted data to the CQC.
• Staff followed evidence based integrated care pathways and worked together to provide coordinated care.
• Staff were trained to enable them to effectively carry out their roles with all having an up to date appraisal. Staff were encouraged and given opportunities to attend external training. The appointment process for medical staff was rigorous and assured.
• Consent to care and treatment was obtained in line with legislation and guidance. There were systems in place to ensure the consent process was thorough and patients with additional needs were supported to make decisions. Staff demonstrated understanding of the Mental Capacity Act 2005. Due to the enforcement of patient safety inclusion criteria, patients with impaired cognition were rarely treated at the treatment centre and this legislation was rarely applied. 

Are services caring?

By caring, we mean staff involve patients and treat patients with compassion, dignity and respect.

We rated services overall as good for caring because:

• There was a patient centred culture in all departments with staff showing care, kindness and compassion to all patients. Patients complimented the treatment and care they received, commenting that staff were courteous and respectful.
• Patients were involved in the decision making process regarding their treatment and staff kept them informed at all times.
• Scores from the friends and family test demonstrated that 99 to 100% of patients were likely to recommend the services at the centre to others.
• Staff demonstrated an encouraging, supportive and sensitive approach toward patients. Staff used communication skills to provide reassurance to patients who needed emotional support.
• All patients were chaperoned for all appointments.

However;

• There were instances where private patient conversations could be heard by staff and patients within the surgery and outpatient departments.

Are services responsive?

By responsive, we mean services are organised so they meet people’s needs.

We rated services overall as good because:

• The planning of services met patients’ individual needs and the access and flow of outpatient appointments, admissions and discharges was well organised. Patients were given choices of locations and times for their outpatient appointments and admission. Preparation of theatre schedules were completed three months in advance to allow time for outpatients to be given a date for their surgery at their initial appointment.
• Patients’ needs were considered in the planning and delivery of the service but the provider was aware further work was needed to develop dementia care. Multidisciplinary meetings could be called and were held to discuss patient requirements. Patients with additional needs, such as learning disabilities or those living with dementia were planned for and reasonable adjustments were put in place. For example, carers were encouraged to attend outpatient appointments, double appointment slots were offered and patients could be accompanied to theatre by family members or carers.
• Complaints received were responded to in a timely manner with learning used to develop future practice and improve services provided to patients.
• Patient safety acceptance criteria were used by triage nurses to ensure only patients whose needs could be safely met were accepted at the treatment centre.
• Referral to treatment times were within 12 weeks against a target of 18 weeks. From December 2015 to the date of our inspection, patients had waited no more than six weeks for their diagnostic investigation.

However;

• The percentage of patients who did not attend for their appointment was high for initial and follow-up dental appointments.
• Some aspects of the clinic environment were not well designed to meet the needs of patients with visual impairment.
• The average waiting time was 27 minutes and some patients waited longer than one hour.

Are services well led?

By well-led, we mean the leadership, management and governance of the organisation, assure the delivery of high-quality person-centred care, supports learning and innovation, and promotes and open and fair culture.

We rated services overall as good because:

• The vision and objectives for the service were evident and understood by most of the staff. There was a vision to work closely with the primary care services and local acute NHS treatment centres to expand the volume of referrals and procedures performed at the centre.

• Future plans included the introduction of a frailty screening system and a frailty lead nurse, working towards accreditation with the Imaging Services Accreditation scheme and inviting consultants from local acute treatment centres to perform procedures at the centre to provide learning opportunities.
• Within the centre there were a clear governance processes in place to monitor the service provided and reliable systems for staff to identify and escalate risks. Monthly governance meetings were held and attended by heads of department and senior management. Risks were discussed, managed effectively and reviewed regularly.
• A comprehensive audit programme was followed with results reviewed at regular meetings. Actions plans were created and implemented to improve results and performance.
• Leadership at each level was seen to be visible, approachable and responsive. Staff told us they had confidence at each level and felt supported by managers and their peers
• The centre was moving towards meeting the workforce race equality standards. In order to do this an electronic database had been created to record personal details volunteered by staff regarding ethnic background.
• The staff survey demonstrated the majority of staff felt proud of the work they did. Management had taken steps to improve integration of the staff at the Devizes site  and the Care UK inpatient location at Bristol as a direct response to staff survey results in 2015.
• Engagement with patients was good as there were various opportunities to provide feedback to the centre. Response rates for the friends and families test was high which allowed feedback to be reviewed by senior management with actions taken to improve services as a result.

However,

• The format of the risk register at the centre was not user friendly and included outdated risks. There were no specific risk registers for surgery, outpatient or diagnostic imaging. This meant that open department specific risks were harder to locate on the risk register.
• There were mixed results from the staff survey, regarding how staff felt about their managers effectiveness at managing change and satisfaction with immediate line management was lower than the average across Care UK locations.

Our key findings were as follows:

• Safety within the centre was of a high standard. Staff were encouraged to report incidents which were thoroughly investigated and learning was shared across the organisation.
• Responsibilities to identify and report safeguarding concerns were understood by staff and they had received appropriate training to do so.
• The treatment centre environment was clean and staff adhered to good infection control practice.
• Staff completed comprehensive risk assessments which were audited to ensure risk to patient harm was mitigated and avoided.
• Equipment was clean, well maintained and serviced.
• Records were accurate, complete and stored securely.
• Staffing within the centre was adequate and at a safe level, with all staff adequately trained.
• Multidisciplinary team meetings and work was appropriate and benefitted patients.
• Patient outcomes were monitored and data submitted demonstrated they were within expected ranges. The treatment centre submitted data to Patient Reported Outcome Measures (PROMs) and there were no inpatient deaths between April 2015 and March 2016.
• Evidence based guidelines were used to provide care and treatment to patients.
• All treatment was consultant led.
• Patient feedback was consistently positive in respect of their care and treatment.
• Patients were kept informed of their care and were actively involved in the decision making process.
• The treatment provided was patient centred and all staff was caring, kind and compassionate.
• Referral targets at the centre were being met consistently.
• Patients were given a choice of suitable appointments and treatment was cancelled or delayed only when necessary.
• The service provided to patients was responsive to their needs and reasonable adjustments made for patients living with dementia or learning disabilities.
• Patient feedback was actively sought and used to make improvements.
• Clear governance arrangements were in place and risks were identified and managed.
• Service quality was monitored and reviewed through an extensive audit programme.
• Staff feedback about leadership was generally positive.
• The senior management team were visible, approachable and supportive.

However:

• There were issues with the processes and practice for identifying and escalating risks.
• Intravenous fluids were not always stored appropriately which made them potentially unsafe for patient use.
• Private patient conversations were not always confidential.

• Fire exits were not always kept clear.

We saw areas of outstanding practice including:

• Utilisation of multidisciplinary meetings was good as it gave staff the opportunity to discuss patient requirements and put reasonable adjustments in place at the earliest opportunity.

However, there were also areas of where the provider should make improvements. The provider should:

• Take and record temperatures of all rooms containing intravenous fluids, to ensure intravenous fluids are safe for patient use.
• Ensure that confidentiality is maintained at all times, specifically when patients are using admission bays and consulting rooms.
• Ensure that the procedure for unloading trolleys of supplies is reviewed in relation to the requirement to maintain access to the fire exit at all times.
• Take action to reduce the percentage of patients who did not attend for their appointment in the dental surgery clinic.
• Consider ways to make the environment of the outpatient clinic more accessible for patients with visual impairment.
• Review the functionality of the risk register so that staff are able to clearly identify the measurable controls in place to mitigate risks as well as the gaps in controls. The risk register should clearly identify which core service(s) the risk applies to and contain all significant risks.
• Ensure that regular team meetings occur at the Devizes for outpatient department and that these meetings are attended by the outpatient department manager.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Updated 9 February 2017

We rated outpatients and diagnostic imaging as good overall because:

• Incidents were reported and thoroughly investigated, and learning was shared. Trends from incidents were monitored and reviewed.

• The outpatient department environment was clean and staff adhered to infection control protocols. There had been no incidents of treatment centre acquired infections during the twelve months preceding our inspection.

• There were safe systems for the management of medicines. These were monitored closely by the pharmacy team and discrepancies were fed into the governance processes.

• There was adequate nursing and medical staff as determined by the use of a safe staffing tool.

• Individual patient care records were comprehensive, legible and complete. Records were stored securely.

• There was good compliance with mandatory training including safeguarding adults and children. Safeguarding concerns were reported by staff and were investigated by the safeguarding lead.

• Staff assessed and responded to patient risks. The patient experience nurse followed up all patients by telephone after their outpatient appointment and prior to their surgery. This nurse ensured that all investigations and screenings were completed, and checked that patients understood and were compliant with pre-surgery guidance such as changes to medication routines.

• Outpatient department teams reviewed assessment and treatment protocols in line with guidance published by the National Institute for Health and Care Excellence.

• Staff in the diagnostics service followed best practice guidelines including use of local rules and diagnostic reference levels to aid optimisation in medical exposures.

• The outpatient service participated in a comprehensive audit programme and submitted patient reported outcome measures for groin hernia repair and varicose vein operations.

• All staff had an up to date appraisal. Staff were encouraged to attend external training. The appointment process for medical staff was rigorous and assured.

• There were good interdisciplinary relationships within the treatment centre. Clear referral criteria were available for referring health professionals.

• All relevant information needed for patient care was accessible to staff.

• Patients attending outpatients and diagnostics were extremely likely or likely to recommend the service to others.

• Staff showed an encouraging, supportive and sensitive approach toward patients and used communication skills to provide reassurance to patients who needed emotional support.

• Patients were given a choice of locations for their outpatient appointment. Theatre schedules were prepared three months in advance to allow outpatients a choice of date for their surgery.

• Referral to treatment times were within 12 weeks. Radiology images were reported on within 24 hours.

• Multidisciplinary meetings were held to discuss the requirements of patients with additional needs such as learning a disability. Reasonable adjustments were made such as encouraging carers to attend the outpatient appointment and booking double appointment slots.

• The registered sick children’s nurse ensured that the specific requirements of patients aged 16-18 years were identified and addressed prior to their surgery date.

• Complaints were investigated thoroughly and learning was shared across teams.

• Governance systems were in place to ensure safe care for patients. There were reliable systems for staff to identify and escalate risk

• In the monthly governance meeting, senior staff discussed and reviewed key performance data and updates to clinical protocols and guidelines.

• There was a comprehensive programme of audit. Actions were taken to make improvements as a result of audits.

• The treatment centre was moving towards meeting the workforce race equality standards. An electronic database had been set up to record personal details volunteered by staff regarding ethnic background.

• Staff told us they felt supported by managers and their peers

• There was good engagement with patients and with staff.

However

• Not all staff prioritised the requirement to keep fire exits clear. We saw a supplies cage obstructing a fire exit on two separate occasions.

• Staff turnover was high during April to July 2016.

• Not all staff took action to minimise risks to the privacy of patients during outpatient consultations.

• The percentage of patients who did not attend for their appointment was high for dental first appointments and for dental follow up appointments.

• Some aspects of the clinic environment were not well designed to meet the needs of patients with visual impairment.

• The 2016 staff survey identified areas for improvement.

• Details of the controls and gaps in controls on the risk register were not consistently well defined.

• The risk register was not specific to core services and contained both open and closed risks. This meant that open risks specific to the outpatient department were less easily located on the risk register.

Updated 9 February 2017

We rated surgery as good overall because:

• Staff understood and fulfilled their responsibility to report incidents. There was shared learning from incidents, both locally and throughout Care UK.

• Monitoring patient safety was a high priority and there were effective systems in place for doing so.

• Treatment was provided in line with national guidance and any updates were made known to all staff.

• Staff were supported by senior management and policies were in place which offered clear guidance on all relevant practice.

• Staff treated patients with dignity and their thoughts, feelings and wishes were considered when treatment was provided.

• Training was provided to staff which supported them to deliver care that was safe and of a high quality.

• Feedback from patients about the care they received was positive. Staff were seen to be kind and caring with a focus on individualised patient care.

• Patient’s needs were met through the use of effective planning. The admission and discharge of patients was well organised which enhanced the patient’s experience.

• The provider investigated complaints and responded to them in a timely manner. Learning was shared to improve and develop practice.

• Governance processes were clear and ensured quality, safety and care were monitored. Regular meetings and reporting ensured that performance and risks were understood by staff at all levels.

• Leadership within the service and at each level was seen to be visible, approachable and responsible. Staff were confident in the leadership and felt able to raise concerns.

However:

• The risk register in operation at the centre was not always updated regularly.

• The temperatures in some of the store rooms were not recorded which posed a safety risk in terms of intravenous fluids not being safe for patient use.

• Patient’s confidentiality was not always maintained when they were in admission bays being admitted for surgery