Pall Mall Medical Diagnostic Treatment Centre

Updated 4 March 2021

Pall Mall Medical Diagnostic Treatment Centre is an independent health care facility under the management of Pall Mall Medical (Manchester) Limited. The service provides elective day case cosmetic surgery and the option of overnight stays with nursing care for those who chose this. They also provide diagnostic procedures such as endoscopy and magnetic resonance imaging.

The centre has had a registered manager in post since 2013. The service is registered for the following regulated activities;

• Treatment of disease, disorder or injury

• Diagnostic and screening procedures

• Surgical procedures

• Family planning

We inspected this service as a follow up to the issue of a warning notice for a breach in Regulation 17 ‘Good Governance’ which was issued on 15 July 2020 following an inspection conducted on 05 June 2020.

We raised concern regarding poor systems to ensure the quality of the care and service provided was regularly monitored, assessed and steps taken to improve the quality and safety of the services provided in the carrying on of regulated activity. In that;

• There was no annual audit programme in place and the audits completed did not have a meaningful outcome or action plan to identify how issues uncovered would be improved, nor how these would be followed up and repeated to assess improvement.
• Clinical governance meetings were not regular enough nor did they effectively enable the understanding of performance or record on safety.

The Medical Advisory Committee did not adequately assess, monitor and mitigate the risks to patients. They were not frequent enough and did not demonstrate an effective approach to risk management and it did not discuss and examine the issues necessary in order to understand risk, safety and competency of staff. The Medical Advisory Committee process did not employ a stringent procedure to provide assurance around the skills and competency of those holding practising privileges at the hospital and they did not engage in the revalidation and appraisal process for doctors.

• The ‘Serious Incidents and Never Events’ policy was not consistent with expected practice around serious incident reporting and provided inconsistent and unclear advice on the recognition, recording and notifying of serious incidents. It lacked clarification on what constituted a serious incident and may result in the failure to identify an incident and therefore fail to reduce the chances of reoccurrence. It was unclear on the definition and recognition of never events. It may lead the service to fail to report serious incidents to the Care Quality Commission appropriately.
• The risk register included clinical and other risks. Four clinical risks were on the risk register from November 2019 and were graded as high, however two of them had no actions attached to mitigate the risks and there were no review dates in place.
• Other policies such as the ‘Practising Privileges’, ‘Medical Advisory Committee’, complaints, and consent, were not in keeping with national guidance standards and did not support staff to follow effective and safe systems of work.
• There was no policy in place around theatre staffing requirements and perioperative practice to ensure safe systems of working and following national guidance.

We continued to engage regularly with the provider to assess their progress against the requirements from both the inspection and notice.

We inspected the service to further assess compliance against the requirements of the warning notice.

We carried out an unannounced focussed inspection on 07 January 2021, which was during a national lockdown due to the COVID-19 pandemic. We looked at specific areas including records, incidents, consent, leadership, governance, Fit and Proper Persons Regulation, managing risks, issues and performance, engagement and learning and continuous improvement and innovation.

Updated 4 March 2021

We inspected this service as a follow up to the issue of a warning notice for a breach in Regulation 17 ‘Good Governance’ which was issued on 15 July 2020 following an inspection conducted on 05 June 2020. During our inspection we found there had been some improvements since the last inspection. We saw that;

• There had been improvements in the audit processes used by the service to assess, monitor and improve the quality and safety of the services provided. The service had introduced an improved system of audit, however there remained further areas where audit would support assurance.
• We saw that there were systems in place to monitor progress against plans to improve the quality and safety of services. Although, we found that the pace of change was not as per the notice due to the challenges of the pandemic, there remains room for further improvement.
• Whilst there were positive improvements in the governance processes, there was limited evidence of improvement in the medical advisory committee processes and its ability to oversee the safe and appropriate clinical performance of the service.
• There had been improvements in the consent process, we saw that cooling off periods were observed. However, we found omissions in the documentation of consent in two of the 16 records we checked.
• The management of incidents had improved, but the process of sharing learning still needed to be embedded.
• There had been improvements in record keeping and documentation, although we identified some gaps in one record we reviewed.

However, we also found some additional areas that required improvement:

• The service had a system to maintain staff records but we found gaps within the records we reviewed for example, continuing professional medical and nursing registration.
• The service did not have evidence that they had carried out checks and continued to meet the criteria to ensure that people who hold director level responsibility for the quality and safety of care, and for meeting the fundamental standards of care, were fit and proper to carry out this important role.
• Audits did not always review quality as part of the process, for example, records and consent audits reviewed the presence of key documentation but not the quality of the recording.
• Although the provider had a system to monitor registration with a professional body, there was no audit, review or reporting to provide assurance to leaders.
• Although the provider had a system for the granting and maintaining of practising privileges, there was no effective system to regularly provide scrutiny to these decisions.

Updated 4 March 2021

We inspected this service as a follow up to the issue of a warning notice for a breach in Regulation 17 ‘Good Governance’ which was issued on 15 July 2020 following an inspection conducted on 05 June 2020. During our inspection we found there had been some improvements since the last inspection. We saw that;

• There had been improvements in the audit processes used by the service to assess, monitor and improve the quality and safety of the services provided. The service had introduced an improved system of audit, however there remained further areas where audit would support assurance.
• We saw that there were systems in place to monitor progress against plans to improve the quality and safety of services. Although, we found that the pace of change was not as per the notice due to the challenges of the pandemic, there remains room for further improvement.
• Whilst there were positive improvements in the governance processes, there was limited evidence of improvement in the medical advisory committee processes and its ability to oversee the safe and appropriate clinical performance of the service.
• There had been improvements in the consent process, we saw that cooling off periods were observed. However, we found omissions in the documentation of consent in two of the 16 records we checked.
• The management of incidents had improved, but the process of sharing learning still needed to be embedded.
• There had been improvements in record keeping and documentation, although we identified some gaps in one record we reviewed.

However, we also found some additional areas that required improvement:

• The service had a system to maintain staff records but we found gaps within the records we reviewed for example, continuing professional medical and nursing registration.
• The service did not have evidence that they had carried out checks and continued to meet the criteria to ensure that people who hold director level responsibility for the quality and safety of care, and for meeting the fundamental standards of care, were fit and proper to carry out this important role.
• Audits did not always review quality as part of the process, for example, records and consent audits reviewed the presence of key documentation but not the quality of the recording.
• Although the provider had a system to monitor registration with a professional body, there was no audit, review or reporting to provide assurance to leaders.
• Although the provider had a system for the granting and maintaining of practising privileges, there was no effective system to regularly provide scrutiny to these decisions.