05 August 2022
During a routine inspection
The Poundbury Cancer Centre opened in 2015 to provide quality analytical, interpretive, advisory and consultancy clinical cellular pathology.
The company provided a diagnostic service for histopathology specimens that included both surgically excised specimens and diagnostic biopsies. It provided standalone laboratory support for cellular pathology. This included a routine paraffin service, a comprehensive array of immunocytochemical and molecular tests with same day processing for
diagnostic tests and facilities for both onsite, and off-site reporting using digital pathology platforms.
The Centre focused particularly on the provision of tests for personalised oncology treatment, including companion diagnostics, to match a patient to a specific drug or therapy.
At the time of inspection, the service had achieved accreditation with the United Kingdom Accreditation Service and IS015189 for histopathological examination of human tissue for the purposes of clinical diagnosis.
The service employed one laboratory director, five in house pathologists and five pathologists who are contracted for remote working. One business development manager, reported as being externally contracted, one operations manager, two senior bio-medical scientist (BMS), six associated pathologists training for Institute of Biomedical Science (IBMS) registration portfolio, ten medical laboratory assistants and one administrator.
The service consists of two laboratory rooms and one administration room on a single floor. It did not offer a seven-day week service.
The service was regulated to provide Diagnostic and Screening procedures and there was a registered manager in post.
Following our inspection on 5 August 2022 we did not rate this service. This is because CQC does not apply a rating to independent laboratory services. We looked at four key questions: is the service safe, effective, responsive and well led. We did not inspect caring as the service does not have direct contact and interaction with patients.
We found that:
- The risk register of the service did not reflect the current risk to the service.
- Not all employment checks were carried out prior to the staff commencing employment.
- Damage had been caused to the fabric of the building and no remedial work had been completed.
- No infection control audit had been undertaken and no infection control policy is in place.
- No fire risk assessment had been completed following the damage to the building.
- No risk assessment had been carried out for those staff employed as a remote worker.
- Information was not readily available or accessible for staff in the absence of the quality manager.
However
- The service had enough staff to provide the right level of service.
- Staff had training in key skills and showed evidence of continuing professional development.
- The service was planned to meet the needs of local people, took account of people’s individual needs, and made it easy for people to give feedback.
- Managers monitored the effectiveness of the service, including the safe management of patient tissue samples staff completed risk assessments for each test performed to ensure these were in line with best practice standards. The service ensured quality was monitored through participating in external and internal quality assurance programs. Services provided were based on national guidance and evidence-based practice. Managers were visible and supportive of staff.