The Care Quality Commission
  • Doctor
  • Independent doctor

Archived: Pacific House

Pacific House, 1 Easter Island Place, Eastbourne, East Sussex, BN23 6FA (01323) 470370

Provided and run by:
East Sussex Out Patient Services Limited

All Inspections

13 May 2021

During an inspection looking at part of the service

We carried out a focused inspection of Pacific House (East Sussex Outpatient Services Ltd) on 12 February 2021 in response to concerns about the safe care and treatment of patients and governance arrangements within the service. We found breaches of regulations and took enforcement action. We issued warning notices against Regulation 12 (Safe care and treatment) Regulation 17 (Good governance) and Regulation 18 (Staffing), of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We carried out this inspection of Pacific House to confirm that the service now met the legal requirements in relation to those breaches of regulations and to ensure sufficient improvement had been made. This report only covers findings in relation to those requirements. The service was not rated as a consequence of this inspection.

Throughout the COVID-19 pandemic CQC has continued to regulate and respond to risk. However, taking into account 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.

This included:

  • Conducting remote and face-to-face interviews with staff.
  • Reviewing patient records and patient tracking processes to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • A short site visit.

We conducted a remote review of patient records on 11 May 2021 and carried out an announced site visit on 13 May 2021. Prior to our site visit on 13 May 2021 we requested supporting evidence and documents from the provider which we reviewed remotely.

Pacific House is the administrative and management base for services provided by East Sussex Outpatient Services Ltd. East Sussex Outpatient Services (ESOPS) is an independent provider of consultant-led NHS commissioned outpatient services. Clinical outpatient services are provided from a neighbouring host location at Harbour Medical Centre, 1 Pacific Drive, Eastbourne BN23 6DW. This location is not a registered location under ESOPS’s registration with the Care Quality Commission (CQC).

The service is registered with CQC to provide the following regulated activities: Treatment of disease, disorder or injury; Diagnostic and screening services.

The medical director is the registered manager. A registered manager is a person who is registered with CQC 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 processes for reviewing patients who may be subject to delays in treatment. However, these required further embedding, review and audit to ensure their efficacy.
  • Systems for the reporting, review and recording of significant events had been improved.
  • Staff had received updated guidance to ensure their awareness of the safeguarding lead and procedures they would follow if they had a safeguarding concern.
  • Infection prevention and control auditing processes had been introduced. However, an action plan/log of findings was still required. Cleaning logs had been established in clinical rooms.
  • There were clear processes in place to minimise risks associated with Covid-19 with regard to screening patients attending for appointments. However individual staff risk assessments and support arrangements associated with Covid-19 had not been documented.
  • Processes for cleaning and decontamination of devices were more clearly defined. There were improved systems to ensure decontamination of devices was adequately documented. These processes required further embedding, review and auditing.
  • There were improvements in the management of training for administrative staff. Staff had received training in key areas. Processes introduced to monitor training undertaken by clinical staff employed on a sessional basis were incomplete.
  • Systems had been introduced to establish monitoring and oversight of clinical staff employed on a sessional basis. Consultants had been given access to organisational policies.
  • There were improved processes for responding to verbal complaints which ensured these were recorded to assist with review, audit and learning.
  • A structure of formal team meetings and improved processes for sharing information, guidance and learning with staff had been introduced.
  • Staff found leaders approachable and supportive and were keen to contribute to individual and organisational improvements.
  • Review of organisational policies was still underway and some required further revision. Staff had access to multiple versions of the same policy in some instances.
  • Monitoring processes, to provide assurance to leaders that premises they were leasing were safe and suitable for use, were not clearly defined.

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

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

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

The areas where the provider should make improvements are:

  • Continue to review and develop organisational policies to ensure staff have access to up-to-date guidance.
  • Develop an action plan and log to monitor outcomes of infection prevention and control audit findings.
  • Establish review of training and development needs of staff as part of annual review processes.
  • Review and update staff COVID-19 risk assessments as individual needs and guidance change.
  • Establish data sharing agreements with referring GP practices.
  • Establish arrangements to share and review actions and learning from complaints and significant events as a whole staff team.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

12 February 2021

During an inspection looking at part of the service

We carried out this announced, focused inspection of Pacific House (East Sussex Outpatient Services Ltd) in response to concerns about the safe care and treatment of patients and governance arrangements within the service. This report covers our findings in relation to those concerns. The service had not previously been inspected.

In the light of the COVID-19 pandemic, we undertook some of our inspection processes remotely and spent more focused time on site. We conducted staff interviews and our review of information remotely between 8 February and 18 February 2021 and conducted an on-site visit on 12 February 2021. The service was not rated as a result of this inspection.

Pacific House is the administrative and management base for services provided by East Sussex Outpatient Services Ltd. East Sussex Outpatient Services (ESOPS) is an independent provider of consultant-led NHS commissioned outpatient services. Clinical outpatient services are provided from a neighbouring host location at Harbour Medical Centre, 1 Pacific Drive, Eastbourne BN23 6DW. This location is not a registered location under ESOPS’s registration with the Care Quality Commission (CQC).

At the time of announcement of our inspection the provider was registered to provide outpatient services from a second location, Anchor Healthcare Centre, Meridian Way, Peacehaven BN10 8NF. The provider told us that this location was no longer in use and immediately submitted an application to remove the location from their registration.

The service is registered with CQC to provide the following regulated activities: Treatment of disease, disorder or injury; Diagnostic and screening services. At the time of announcement of our inspection the provider told us they provided vasectomy services from the Anchor Healthcare Centre location. This service was temporarily closed in conjunction with cessation of services provided from Anchor Healthcare Centre. However, the provider was advised that they were required to be registered to provide the regulated activity surgical procedures, in order to provide vasectomy services.

The medical director is the registered manager. A registered manager is a person who is registered with CQC 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 was a lack of clear, established processes for reviewing patients who may be subject to delays in treatment.
  • Systems for reporting and recording significant events had not been clearly established.
  • Staff were not always clear who the safeguarding lead was and what procedures they would follow if they had a safeguarding concern.
  • There was no audit of infection control processes and no oversight of an audit carried out by the host provider. The lead for infection prevention and control had not completed training to support the role.
  • There were clear processes in place to minimise risks associated with Covid-19 with regard to screening patients attending for appointments. However, individual staff risk assessments and support arrangements associated with Covid-19 had not been documented.
  • Processes for cleaning and decontamination of some devices were not adequately documented.
  • There was a lack of training for administrative staff. Staff had not received training in many key areas. There was no verifiable monitoring of training undertaken by clinical staff employed on a sessional basis.
  • There was a lack of performance review, clinical supervision and oversight of clinical staff employed on a sessional basis.
  • There was a lack of clear processes for responding to verbal complaints which did not ensure these were recorded to assist with review, audit and learning.
  • There was a lack of formal team meetings and a lack of clear processes for sharing information, guidance and learning with staff.
  • Staff found leaders approachable and supportive and were keen to contribute to individual and organisational improvements.
  • Newly developed policies were comprehensive and formed a good basis for future organisational improvement. However, their sharing with staff was premature due to inaccuracies and required revisions.
  • There was a lack of governance and monitoring processes to provide assurance to leaders that premises they were leasing were safe and suitable for use.

We took enforcement action and issued warning notices against the provider in relation to Regulation 12(1) Safe care and treatment, Regulation 17(1)(2) Good governance and Regulation 18(1)(2) Staffing.

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

We are mindful of the impact of the Covid-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care