Athena Surgical Centre

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Leaders did not operate effective processes for governance, information management and the management of risk, issues and performance. Leaders had not understood all the issues the service faced in terms of safety and quality. Policies, guidelines, and protocols did not always provide clear guidance for staff, were not always reflective of the service provided, were not always evidence based and did not always adhere to national guidance and legislation. Patient records were not always signed, dated and fully complete. The audit process of the service was not always robust enough to determine if the service was doing well and what improvements could be made. We were not assured that robust records were being kept relating to persons employed in the carrying on of the regulated activity or the management of the regulated activity. Leaders had experienced challenges in ensuring that all relevant information was shared between external partners during the provision of patient care. During our assessment, we found concerns which resulted in a breach of regulations 17 and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can find more details of our concerns in the evidence category findings.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff and leaders described a positive and compassionate culture. Staff felt supported, respected and valued. Staff felt positive and proud to work in the organisation. Staff said that leaders promoted staff empowerment to drive improvement. Staff said that raising concerns was encouraged and valued. Staff were aware of the service’s future plans for expansion of the service but said that they had not been involved in the development of the strategy. Staff were supportive of the service’s vision and strategic goal. Staff understood their role in helping to achieve the strategy. Leaders’ description of the service’s future plans did not always align with the service’s strategy document. For example, leaders described a significant focus on the development of the use of technology within the service but this had not been included in the strategy document.

The service had a documented strategy which set out the service’s future plans and ambitions. The strategy was focused on the provision of high-quality care and the expansion of the service. The strategy did not include timescales or information about how progress against the strategy would be measured and monitored. The strategy did not include details of any risks to delivering the strategy, including relevant local factors, or any action plan to address them. The strategy document stated that staff had been involved in the development of the strategy. However, staff spoken with during our inspection stated that they had not been involved with the development of the strategy. In addition, there was no evidence that people who used the service or external partners had been involved in the development of the strategy. There was no evidence that progress against delivery of the strategy was being monitored and reviewed. However, the service had only been operational for approximately 6 months at the time of our inspection.

Staff said that leaders were visible and approachable. Staff and leaders described an ‘open door policy’. Deputy managers spoke positively about the support that they had received in developing management and leadership skills. We received some feedback that the leadership team had not always worked as a cohesive team, where each voice was given equal weight. However, we were informed that after this issue had been raised, improvements had been made. The registered manager took on a range of responsibilities, in addition to quality and operational management of the service. This included working as theatre manager, which could include working clinically. The registered manager was also responsible for stock replenishment. This impacted on the registered manager’s capacity to manage and oversee the service. We received feedback that the service’s clinical consultant took a lead role in engaging with external organisations, in the registered manager’s place. The registered manager spoke positively about the support provided by the clinical consultant and noted that they had learnt a great deal from them.

The service was led by a registered manager, who was an operating department practitioner by background, and had nearly a decade of experience working as a theatre manager at another independent hospital. They had not previously undertaken the registered manager position. The service was also led by a medical director, who undertook the nominated individual role and was also a director of the company. The medical director had over a decade of experience working at consultant level in NHS trusts and also had experience of working in a leadership position within the NHS. They had not previously undertaken the nominated individual position. The service had one other director, who had a background in technology and management. The registered manager was supported by a clinical consultant, who worked for the service 1 day per week. The registered manager was also supported by 2 deputy managers. Leaders had not understood all the issues the service faced in terms of safety and quality. For example, our inspection identified concerns regarding medicines management, record keeping and recruitment processes which had not been identified and addressed by leaders. Leaders could not always demonstrate that they had appropriate knowledge of applicable national guidance, legislation and regulations, to ensure that these were appropriately implemented within the service. For example, leaders had not ensured that all staff were trained in how to interact appropriately with people who had a learning disability and autistic people, in line with requirements which came into force in July 2022. The safeguarding lead had not completed level 4 safeguarding training, in line with national guidance. The service was able to demonstrate a focus on succession planning and development of leaders, although there was not yet a formal leadership strategy or development programme in place.

Staff and leaders recognised the importance of acting with openness, honesty and transparency. Staff spoken with during our inspection said that leaders encouraged them to raise concerns and promoted the value of doing so. Staff said they felt confident that their voices would be heard, that they would be supported, without fear of detriment. Staff were aware of the service’s freedom to speak up processes. Staff spoken with during our inspection could provide examples of times where they had raised concerns. Staff said that their concerns had been taken seriously and responded to appropriately. However, whistleblowers had contacted the Care Quality Commission (CQC) prior to our inspection, to raise concerns about medicines management and hand hygiene practices. This indicated that staff did not always feel confident to raise concerns through internal processes.

Leaders had implemented freedom to speak up processes to ensure that staff could raise concerns internally. The service had implemented a whistleblowing policy which supported staff to raise any concerns. A daily huddle took place at the start of the day and staff said that this provided an opportunity for them to raise any safety concerns. In theatres, a member of staff undertook a ‘list safety officer’ role, which provided staff with another opportunity to raise any concerns. Leaders had also set processes up to allow staff to raise concerns anonymously if they wished. This included an email account, to which all staff were given login details, from which concerns could be raised anonymously with leaders. Leaders had also introduced an anonymous staff suggestions box. When CQC contacted the service prior to our inspection to raise the concerns received from whistle blowers, leaders took appropriate action to investigate and respond to the concerns raised.

All staff spoken with during our inspection felt that they were treated equitably. Leaders described a commitment to ensuring that the service was inclusive. Staff demonstrated an understanding of equality, diversity and human rights. Staff felt empowered and were confident that their concerns and ideas resulted in positive change to shape services.

There was evidence that equality and diversity were promoted in the organisation. The service had implemented an equality and diversity policy. All staff completed equality and diversity training. Equality, diversity and inclusion was also built into the recruitment process. For example, staff were asked about reasonable adjustments as part of the application process. Questions about equality and diversity were also included at interview stage. Our review of meeting minutes showed that staff and leaders had discussed topics relating to equality, diversity and inclusion. Actions had been implemented to bring about improvements as a result. However, the service had not yet begun to formally monitor data on equality, diversity and inclusion through meetings or performance reports. Equality , diversity and inclusion was not a standing agenda item at meetings. It was not yet clear that leaders had taken active steps to ensure that staff were representative of the population of people using the service. Equality Impact Assessments were not included in the policies that we reviewed as part of our assessment. This was not in line with the provider’s equality and diversity policy. Leaders had not yet carried out any staff surveys to engage with and involve staff, with a focus on hearing the voices of staff with protected equality characteristics and those who are excluded or marginalised. However, the service had only been operational for approximately 6 months at the time of our inspection.

Leaders acknowledged that they were in the early stages of implementing and embedding governance processes in the service. Following our inspection, leaders acknowledged that staff did not always have access to all relevant information regarding patients' care and treatment. Leaders also acknowledged that internal audits had identified ‘intermittent compliance issues pertaining to comprehensive record keeping.’ There was not always an alignment between the recorded risks and what leaders said was ‘on their worry list’. For example, a leader described risks relating to ensuring that staff followed standard operating procedures and ensuring that robust systems were in place to share information with external partners, particularly as the service expanded. These risks were not included in the risk register that we reviewed as part of our inspection. We received feedback that when leaders were considering developments to services or efficiency changes, they had not always allowed sufficient time for the impact on quality and safety to be assessed and mitigated. A risk had been included on the risk register regarding ‘lack of notice for new services/specialities’, stating that ‘potential harm if sufficient time not allocated to provide all provisions for surgery and after care. Planning required min 6 weeks per new service directors informed’. We were informed that after this risk had been raised, improvements had been made. Staff at all levels were clear about their roles and they understood what they are accountable for, and to whom.

Governance processes had only recently been established at the time of our inspection and the processes were not yet embedded. We were not yet assured that all levels of governance functioned effectively. For example, weekly management meeting minutes did not include details of which staff had been in attendance or an action log. Where issues or areas of concern were raised during these meetings, actions were not always identified in response. We were not assured that all relevant topics were being discussed and monitored through governance meetings. For example, meeting minutes did not include discussions regarding risks or monitoring of staffing data such as sickness, turnover, and vacancy rates. Policies, guidelines, and protocols did not always provide clear guidance for staff, were not always reflective of the service provided, were not always evidence based and did not always adhere to national guidance and legislation. Patient records were not always signed, dated and fully complete. Consultants retained their own notes. Staff did not always have access to information regarding pre-operative assessment and discharge of patients. The arrangements for identifying, recording and managing risks were not always effective. For example, the risk register provided during our inspection did not include risk owners, review dates, or updates to risk mitigations. The audit process of the service was not always robust enough to determine if the service was doing well and what improvements could be made. For example, we identified concerns regarding record keeping, medicines management and equipment as part of our inspection, what had not been identified and addressed through the service’s audit programme. We were not assured that robust records were always being kept relating to persons employed in the carrying on of the regulated activity or the management of the regulated activity.

People said that the service provided joined-up care with the other services in their care pathway.

Leaders said that they had positive relationships with external partners. Leaders said that they met regularly with external partners, to review performance and address any concerns. Staff and leaders said that they recognised the importance of being open and transparent with external stakeholders and agencies. They were able to provide examples of concerns that had been shared with external partners. Leaders acknowledged that they had experienced challenges in ensuring that staff had access to all relevant information when providing care for patients referred by external partners. Leaders had attempted to raise this issue with the NHS hospital trust prior to our inspection without resolution. Following our inspection, leaders had engaged in discussions with the NHS hospital trust to request that they transmit all patient data so that it could be incorporated into the patient file.

Partners said that leaders were mostly open and transparent. Partners could provide examples of occasions where Athena Surgical Centre leaders had shared concerns with them. However, partners also felt that some leaders could be more willing to hold candid discussions when concerns were identified, in order to bring about improvement. Partners confirmed that they met regularly with leaders at Athena Surgical Centre to review performance. Partners said that they had experienced some challenges with communication to support care provision and joined-up care. This has been reported on further within the safe domain of our report.

The service held contracts with 2 NHS hospital trusts for the provision of patient care. The service held regular meetings with external partners to review and monitor performance. We were only provided with evidence of meeting minutes and performance reports for 1 of the 2 contracts held with NHS trusts. We therefore could not review how regularly meetings were held, the content of discussions held at meetings, or the information that was shared with external organisations. The meeting minutes that we reviewed showed that staff shared learning with partners, for example from incidents and patient feedback. Staff did not always have access to information regarding pre-operative assessment and discharge of patients as there had not been agreement for this information to be shared by the NHS hospital trust. Following our inspection, leaders had engaged in discussions with the NHS hospital trust to request that they transmit all patient data so that it could be incorporated into the patient file. Staff engaged with people who used the service by asking them to provide feedback about their experiences of care. Leaders had not yet developed other methods of engaging with people and communities. For example, to get their input during service development or strategic decision making.

Staff told us they were committed to learning and improving services. Staff said that leaders promoted staff empowerment to drive improvement, and raising concerns was encouraged and valued. Staff were able to provide examples of improvement suggestions that they had made, which had subsequently been implemented within the service. Leaders said that they encouraged staff to speak up with ideas for improvement and innovation. Staff and leaders had primarily been focused on establishing and embedding hospital processes, as the service had only been operating for approximately 6 months at the time of our inspection. Staff and leaders were therefore not yet able to provide significant evidence of innovative practice within the service. Leaders had not always ensured that action was taken to bring about improvement when concerns were identified through external reviews. One of the service’s external partners told us that they had carried out a quality visit several months prior to our assessment, where they had identified concerns regarding equipment availability on the airway trolley. They had raised the concerns with staff during the quality visit. However, during our assessment, we also identified concerns regarding equipment availability on the airway trolley. This indicated that the concerns identified during the quality visit had not been rectified.

Staff took time together in meetings to review the service’s performance and objectives. The service used patient feedback, complaints, incidents and audit results to help identify any necessary improvements and ensure they provided an effective service. This was confirmed through a review of meeting minutes during our inspection. There was scope for the service to further develop systems to support improvement and innovation work, including objectives and rewards for staff, data systems, and processes for evaluating and sharing the results of improvement work. Staff had not yet begun to use standardised improvement tools and methods. People using the service, their families and carers had not yet been involved in improvement and innovation initiatives.

The service had only been operating for approximately 6 months at the time of our inspection. Staff and leaders had therefore primarily been focused on establishing and embedding hospital processes. The service was therefore not yet able to demonstrate outcome data relating to learning, improvement and innovation.