The Care Quality Commission
  • Hospital
  • Independent hospital

Pall Mall Medical Diagnostic Treatment Centre

1 Belvedere Road, Newton Le Willows, Merseyside, WA12 0JJ 0330 058 4455

Provided and run by:
Pall Mall Medical (Manchester) Limited

All Inspections

07 January 2021

During an inspection looking at part of the service

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.

05 to 12 June 2020

During a routine inspection

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 surgery and the option of overnight stays with nursing care for those who chose this.

We inspected this service as a response to concerns raised about the provision of surgery at this location. We carried out an unannounced inspection on 05 June 2020, we interviewed managers on 12 June 2020.

In order to respond specifically to the concerns raised to us we only looked at some aspects of the safe, effective, responsive and well led domains. Specifically, we looked at the following key lines of enquiry;

In ‘Safe’ we looked at;

  • Mandatory training
  • Incident reporting
  • Cleanliness and Infection prevention and control
  • Environment and equipment
  • Records
  • Assessing and responding to risk
  • Theatres staffing
  • Incidents

In ‘Effective’ we looked at;

  • Competent staff
  • Consent

In ‘Responsive’ we looked at;

  • Learning from complaints and concerns

In ‘Well-led’ we looked at;

  • Governance
  • Managing risk and performance

During the inspection, we visited the operating theatres, the recovery areas, the ward and treatment areas. We spoke with eleven members of staff including registered nurses, health care assistants, medical staff and senior managers. We spoke with one patient. During our inspection, we reviewed six sets of patient records. We reviewed 11 sets of records following the site visit and reviewed policies and other documentation.

We did not rate this service.

During our inspection we found some good practice, we saw that;

  • Infection prevention and control practices enhanced as a result of the coronavirus situation appeared comprehensive and commensurate with public health guidance.
  • The environment appeared pleasant, well equipped, clean and hygienic.
  • Staff believed that there have been positive changes around safety and improvements in operational systems and practices, since the arrival of a new director of clinical services.

Managers appeared engaged and willing to make improvements. However, we found areas of practice that could be improved;

  • Governance systems did not support the identification, capture and management of risks and measures to improve safety and quality.
  • The consent processes did not enable informed consent to be sought and recorded in line with recommended guidance.
  • The complaints policy and procedures around complaints did not support people to complain, it also may have led to opportunities for learning to be missed.
  • Policies and procedures did not support safe systems of practice.
  • Record keeping did not always meet recommended minimum standards.

Following this inspection, we told the provider that it must take some actions to comply with the regulations. We issued the provider with a warning notice and requirement notices. Details are at the end of the report.

Ann Ford

Deputy Chief Inspector of Hospitals (North)

10 April 2014

During an inspection in response to concerns

This inspection took place because concerns had been raised about the way the service was being provided. We had been told that a crash team and resuscitation team were not in place and that controlled medicines were not being stored securely and properly managed. Controlled medicines are medicines that require extra checks and special arrangements because of their potential form misuse. Consequently a Home Office license is required for their use.

We found that appropriate equipment was in place for dealing with emergencies. Staff were trained to the appropriate level on how to deal with an emergency and a senior member of staff was always appointed to be in charge in these situations.

We found that controlled medicines were stored and handled correctly.

Staff received on going training and an annual appraisal of their work took place. This meant staff had an opportunity to discuss training needs and development in their role. Agency staff were used occasionally but generally if vacancies occurred, bank staff were used. The bank staff were familiar with the service and its practices which contributed to providing a consistent care to the people who used the service.