Probus Surgical Centre

• The inspection was an announced comprehensive inspection for Probus Surgery Limited at the centre in Probus. We visited the Probus Surgical Centre on 13 and 14 September 2016. We did not carry out an unannounced inspection. We did not visit any of the satellite locations as there was no surgery taking place at this time.
• We spoke with patients who used the service, nursing and medical staff, including the general practitioners, executive and non-executive managers and visiting consultants, administrative staff, the deputy surgical manager and practice manager. We observed clinical procedures and spoke with patients before and after these. We requested written feedback from people who had used the service.
• We reviewed information provided by Probus Surgery Limited, prior to, during and following the inspection. We also requested information from stakeholders, including the clinical commissioning group. We reviewed information we hold on our electronic systems
• We visited the operating theatres, pre and post-operative rooms and other clinical and administrative rooms at the Probus Surgery.

Our key findings were as follows:

Overall we rated Probus Surgical Centre surgery services as good because:

• Staff were aware of their responsibilities to report incidents and there was a good incident reporting culture amongst staff.
• Equipment was maintained and serviced regularly and staff took prompt action if a piece of equipment became unserviceable.
• There were systems in place to ensure patient safety for example the World Health Organisation (WHO) surgical safety checklist was used.
• Staffing levels and skill mix were planned, reviewed and consistently met so that people received safe care and treatment.
• There were systems in place to give patients information about what to do if they felt unwell or had questions about their care and treatment.
• There was an effective system for gaining patients consent prior to their procedure.
• We saw staff being kind and caring to patients. They had time to spend with them to explain any procedures and allay anxieties they have had.
• Patients told us they were treated with dignity and respect and their confidentiality was upheld. There was a comprehensive chaperone policy in place.
• Patients were involved when arranging appointments that suited their needs and circumstances. The service gave patient’s detailed information about the procedure they were to have and invited questions so that they could make an informed choice about their treatment.
• There was access to interpretation and translation services for patients whose first language was not English. Any leaflets or patient information could be offered in alternative formats such as large print.
• Referral to treatment time was better than the targets and meant the centre saw and treated 100% of patients within 18 weeks of referral.
• The centre had a complaint policy and handled complaints in a timely manner according to their policy. There was evidence the service made changes because of lessons learnt from complaints.
• The service had a vision and strategy that staff knew about and felt included in.
• There was a clinical governance plan and evidence of shared learning from incidents. There was a risk register and evidence of actions to mitigate risks.
• The service collected patient outcome data to evaluate the effectiveness of care and treatment delivered.

However:

• When we reviewed consultants’ practising privileges records the required evidence was not easily accessible or identifiable. The filing system needed to be reviewed to provide assurance to the clinical director and others, that those who carried out consultation and surgical procedures were fit to do so. We raised the concerns and the provider immediately put in place an action plan and a timetable to review all records.
• Not all surgical and nursing staff were up-to-date with their annual performance appraisals, and mandatory training.
• Actions identified to mitigate some of the risks on the risk register did not have specific dates identified for review or completion.
• There was no hand wash basin in the recovery lounge area which meant staff had to leave the room regularly to wash their hands.

We saw several areas of outstanding practice including:

• The centre was linked with the Peninsular Medical School in Truro and had provided one three week supervised elective placement from 15 November 2015 that covered all of the procedures at the centre.
• The cataract service was delivered by a team of three specialist ophthalmologists. The Centre ran a one-stop clinic, whereby patients were treated on the same day if deemed suitable for surgery. This had proved to be popular as patients did not usually wish to travel long distances unnecessarily, given the rurality of Cornwall.

However, there were also areas of where the provider needs to make improvements.

Importantly, the provider must:

• Ensure all practising privileges records required by the provider for surgeons carrying out procedures are available, up-to-date and recorded.
• Ensure mandatory training for surgical staff meets the hospital’s target for compliance at all times.
• Ensure Disclosure and Barring Service checks for medical staff are carried out as required and available for review.

In addition the provider should:

• Consider improving the availability of all paper and electronic records for theatre procedures.
• Update the risk register to include potential risks, mitigating factors and deadlines.
• Review the adult and children’s safeguarding policy to reflect current guidance on reference to female genital mutilation.
• Introduce an effective audit programme that addresses the quality of patient records in both paper and electronic form.
• Consider conducting a risk assessment with regard to the need for a sink in recovery lounge to support infection prevention control.
• consider how to respect privacy and dignity in areas where a number of patients are receiving care at the same time

Professor Sir Mike Richards

Chief Inspector of Hospitals