Athena Surgical Centre

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We remained concerned about the service’s learning culture. The management of risks to people across their care journey was not always effective. There was not always immediate access to a member of staff who had completed Advanced Life Support (ALS) training in the recovery area. We remained concerned regarding the provider’s recruitment procedures and the provider’s pre-operative assessment policy and processes. However, leaders had made improvements to the service’s safeguarding and medicines management policies and procedures since our last assessment.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People told us they felt safe and that they felt confident to raise any concerns. None of the people spoken to as part of our assessment had experience of raising concerns with the service.

Prior to our assessment, anonymous whistleblowers stated that when staff raised concerns about safety, they were not always listened to. Whistleblowers stated that staff were blamed or treated negatively for raising concerns. This was not supported by the feedback received from staff during our assessment. Staff could provide examples of times where they had raised concerns internally, which had been taken seriously and responded to appropriately. This was supported by incident reports reviewed during our assessment. However, management board meeting minutes from August 2024 stated, “Recent team conversations had highlighted the need for all in the clinical team to feel listened to and heard in all conversations about patient Safety.” Leaders stated that they had taken action in response to the concerns raised, by agreeing to use a new admission criteria risk assessment process, to ensure that any concerns raised by staff regarding whether a patient was appropriate for admission were reviewed, discussed and documented. We also identified an example in a patient record where staff had repeatedly raised safety concerns with a clinical leader about a patient’s discharge plan and had attempted to make alternative arrangements. The clinical leader made the decision for the discharge to go ahead as originally planned. Staff knew what incidents to report and how to report them. Staff said that they met to discuss learning from incidents and look at improvements to patient care. Staff were able to describe recent incidents and changes to practice as a result. Leaders did not benchmark safety performance with other similar services. Leaders said that this was because there was a lack of similar services which they could compare themselves against. Leaders said that their outcome data showed that the service had very low complication rates, and very high levels of patient satisfaction. Leaders said that this gave them assurance regarding the service’s safety performance.

Incidents were not always being appropriately graded. For example, staff had not always indicated whether an incident was a ‘near miss’, ‘actual harm’, or ‘serious untoward incident’. In other cases, staff had graded incidents as a ‘near miss’ when they would be more appropriately graded as ‘actual harm’. For example, when a patient required extra observations and treatment. This meant that the service would not always have an accurate description of the event and its impact on the patient. We continued to have concerns that the service’s incident policy lacked the detailed guidance that staff needed when reporting and investigating incidents. For example, the service’s incident policy did not define the terms ‘near miss’ or ‘actual harm’, to assist staff when reporting incidents. This meant that the concerns raised at our last assessment had not yet been addressed. However, leaders had made improvements to the service’s duty of candour policy and this addressed the concerns raised during our last assessment. The meeting minutes reviewed during our assessment demonstrated that staff discussed incidents and shared learning. The service had received no complaints since our last assessment and we were therefore unable to review whether complaints were appropriately investigated, reported and learnt from.

People said that when they moved between different areas of the service, there was a plan for what would happen next and who would do what, and all the practical arrangements were in place.

Since our last assessment, staff had continued to experience challenges in ensuring that they had access to all relevant information when providing care for patients referred by external partners. Leaders said that they had successfully resolved the concerns identified during our last assessment. However, a new issue regarding access to consultant notes had arisen with a different external partner. Leaders had been working to address this issue, when the contract had ended. Leaders stated that they would ensure that any new contract arrangements would include a requirement for Athena Surgical Centre to hold a comprehensive set of medical records for each patient.

During our last assessment, external partners said that they had experienced some challenges with communication to support care provision and joined-up care. External partners had ended their contracts with Athena Surgical Centre for the provision of patient care since our last assessment. We were therefore unable to gather feedback from external partners during this assessment.

The approach to identifying and managing risks to people across their care journeys was not always effective. We remained concerned about the provider’s pre-operative assessment policy. For example, the inclusion and exclusion criteria within the policy lacked clarity and was contradictory in places. Leaders made improvements to the pre-operative assessment policy following our on-site visit. We remained concerned about the provider’s pre-operative assessment processes. During our review of 10 patient records, we identified that 2 patients had not been offered a multifactorial falls risk assessment, despite having a history of falls. In 1 of these cases, there was no evidence that any falls prevention measures had been implemented. Staff confirmed during our on-site visit that they did not have access to guidance on falls prevention interventions and a falls risk assessment had only recently been introduced. Following feedback provided during our on-site assessment, leaders updated the falls assessment guidance available for staff. The management of risks to people across their care journey was not always effective. In one of the patient records reviewed during our assessment, a patient had been discharged alone to a hotel following their procedure. The procedure would have impacted the patient’s vision and the patient had a condition which affected their mobility. We were concerned that the discharge arrangements were not in line with the provider’s policies and placed the patient at risk of harm. The service no longer held contracts with external providers for the provision of patient care. We were therefore unable to review the way that the service worked with partners to establish and maintain safe systems of care. The provider had processes in place for communicating with patients’ GPs following the provision of care and treatment. Patient records showed evidence of liaison with GPs.

People told us they felt safe and supported to understand and manage any risks.

Staff demonstrated a commitment to taking immediate action to keep people safe from abuse and neglect. Staff demonstrated an understanding of safeguarding and how to take appropriate action. Staff had not had experience of making any safeguarding referrals whilst working for the service. However, staff were able to provide examples of the types of concerns that would warrant a referral being made. Staff were aware of the safeguarding lead and said that they would go to them to make a referral, or for any advice or support.

The provider had appointed a new safeguarding lead since our last assessment. The safeguarding lead was trained to level 4 safeguarding, in line with national guidance. This addressed one of the concerns raised during our last assessment. All other staff had received training specific for their role on how to recognise and report abuse. Clinical staff were trained to level 3 in safeguarding and this was in line with national guidance. Overall compliance with level 3 safeguarding training was 100% at the time of our inspection. The provider had made improvements to their safeguarding policy in 2024 and this had addressed the concerns raised during our last inspection. Staff now had detailed guidance to refer to and had access to relevant contact details to make a safeguarding referral. Staff had not made any safeguarding referrals since registration and this meant that we were not able to review any action taken to keep people safe from abuse and neglect.

People said that they had been provided with information about who to contact if they realised that things might be at risk of going wrong or their health condition may be worsening.

Prior to our assessment, anonymous whistleblowers raised concerns that the service did not always have a balanced and proportionate approach to risk. For example, by accepting patients for treatment who were inappropriate for the service based on the service’s inclusion and exclusion criteria. We found some evidence to support these concerns during our assessment. For example, 2 of the 10 patient records reviewed during our assessment showed that patients classed as ASA3 (patients with severe systemic disease) had been accepted for treatment. The service’s Admission, Transfer and Discharge Policy stated that ‘all patients are classed as ASA1 or ASA 2 patients’. Following our on-site visit, leaders updated their pre-assessment process to state that ASA3 patients ‘Must be discussed with anaesthetist for suitability’. There was a lack of clarity amongst staff about the service’s inclusion and exclusion criteria. However, staff could provide examples of times where they had raised concerns regarding whether a patient was appropriate for the service, and this had been taken seriously and responded to appropriately. Leaders told us that they had introduced an admission criteria risk assessment process, to ensure that any concerns raised by staff regarding whether a patient was appropriate for admission were reviewed, discussed and documented. Staff were able to describe the process that they would follow in the event of patient deterioration. Staff described occasions where this process had been successfully put into practice. Leaders confirmed that there was no specific training for staff on recognising the symptoms and signs of local anaesthetic toxicity. Leaders stated that staff completed basic and immediate life support training.

Although some improvements had been made, we remained concerned regarding the provider’s policies for patient deterioration and when assessing patient risk. Policies did not always provide clear guidance for staff. We remained concerned about the provider’s pre-operative risk assessment processes. The pre-operative risk assessment template, which was included in patient records, signposted staff to use a ‘six item Cognitive Impairment Questionnaire’ and falls prevention interventions. However, these were not available for staff to use. Following feedback provided during our on-site visit, the provider updated their pre-assessment policy and processes. Within recovery, there was not always immediate access to a member of staff who had completed Advanced Life Support (ALS) training. The anaesthetist working in theatres was ALS trained but would not always be immediately available in the event of patient deterioration. Staff did not complete sepsis training as part of the service’s mandatory training programme. National Institute for Health and Care Excellence guidance (NG51) states that staff should be given regular training in identifying, assessing and managing suspected sepsis. The service carried out audits to monitor the processes in place to identify and manage risks. This included a ‘pre-assessment and specific day case requirements’ audit and a ‘post-anaesthetic care’ audit. These audits showed high levels of compliance in the 3 months prior to our assessment. However, the audits had not been effective in identifying the concerns regarding pre-operative assessment or ALS training in recovery, which were identified as part of our September 2024 assessment. The provider had processes in place to respond to patient deterioration. This included the use of the National Early Warning Score, a sepsis care bundle, and on-call arrangements. Managers had processes to ensure that the World Health Organisation (WHO) Five Steps to Safer Surgery Standards were being met.

People said that they were cared for in safe environments that were designed to meet their needs.

Prior to our assessment, anonymous whistleblowers had raised concerns about the service’s environment and equipment. The concerns raised were mostly not supported by the feedback that we received from staff during our assessment. Staff did not raise concerns regarding the quality of equipment. However, some staff noted that there was only one 12-lead electrocardiogram (ECG) available in the service. Staff raised concerns about the potential impact of only having one 12-lead ECG. For example, if the machine were to develop a fault or the potential for delays in the event of an emergency. Staff were aware of the process to follow in the event of equipment faults or other environmental concerns and said that action was taken when concerns were identified. Some staff said that repairs would be prioritised based on urgency, and this meant that some repairs could be delayed if they were classed as a low priority. Staff and leaders told us that the service’s inventory controller had resigned shortly before our assessment. This member of staff was responsible for consumable stock checks, ordering consumable equipment, arranging equipment servicing and repairs, and arranging environmental safety checks. The inventory controller post remained vacant at the time of our assessment and leaders were actively recruiting to this post. Leaders had recognised the risk that was posed by this post remaining vacant.

Equipment was mostly available in accordance with national guidance and best practice. This was an improvement from our previous assessment. However, there was no size 10 bougie on the difficult airway trolley. A bougie is a thin, flexible surgical instrument for exploring or opening a passage of the body. Leaders addressed this concern following our on-site visit. Most consumables checked during our on-site visit were within their expiry date. However, we identified 3 expired consumables in a consultation room. The expired consumables were removed from use during our on-site visit. We observed a ripped mattress within theatres. The mattress was replaced following our on-site visit. All equipment checked during our on-site visit was up-to-date for servicing. Our observations showed that the service had appropriate arrangements in place for the use of ionising radiation. We also saw that the service had appropriate arrangements in place for the storage and use of cleaning products which were subject to the Control of Substances Hazardous to Health (COSHH) regulations. Since our last assessment, staff had increased the frequency that anaesthetic breathing systems were being changed. This addressed one of the concerns identified during our last assessment. The service had also begun using intermittent pneumatic compression equipment for venous thromboembolism (VTE) prevention since our last assessment.

The hospital operated from a stand-alone unit which was newly built in 2023. The facility included 3 theatres and 3 multi-purpose clinical consultation rooms. The design of the environment followed national guidance. The service had contracts in place with external organisations for equipment servicing and repairs. Equipment was up to date for servicing at the time of our assessment. Staff carried out daily and weekly safety checks of specialist equipment. This was confirmed through a review of checklists during our inspection. Staff had received training on all the equipment that they would be expected to operate as part of their role. This was an improvement from our previous assessment. A back-up emergency generator was in place in the event of power failure. The generator had been tested by an external organisation in 2024. Staff had carried out a range of environmental risk assessments, including for fire, Legionella, substances which met the COSHH regulations, and radiation risk. High levels of compliance were shown in a range of audits relating to the environment and equipment.

People told us they felt there were enough staff to meet their needs. People told us that staff appeared to be skilled and experienced.

Prior to our assessment, anonymous whistleblowers had raised concerns about the service’s recruitment processes and regarding members of staff working as surgical first assistant without appropriate qualifications. We found some evidence to support the concerns raised. During our on-site visit, staff told us that a particular member of staff undertook the surgical first assistant (SFA) role. Following our assessment, leaders told us that this member of staff had not undertaken the SFA role as they were not qualified to do so. Leaders stated that “We acknowledge there may have been some confusion among a few staff members…for any surgical assistance requiring more than superficial retraction and the cutting of superficial sutures, we always assign a qualified SFA.” Leaders acknowledged that there was not always immediate access to a member of staff trained in Advanced Life Support (ALS) within recovery. They stated that they had already identified this concern and they had plans to increase the number of staff trained to ALS level. Leaders also acknowledged that staff, other than the radiation protection supervisors, had not completed general radiation awareness training since imaging equipment had been introduced into theatres. This was not in line with the Ionising Radiation (Medical Exposure) Regulations 2017. During our on-site visit, staff and leaders confirmed that no dual role policy was in place, in line with national guidance. However, following our on-site visit, leaders provided a dual role policy dated April 2024. However, each staff member reported an induction. Staff provided positive feedback about the training that they had received, and they felt that this had prepared them for their role. Staff said that they were encouraged to develop their skills. All staff said that they had attended team meetings, where they had reviewed and discussed the service’s processes and performance.

The service mostly had enough staff to keep patients safe. However, within recovery there was not always immediate access to a member of staff who had completed Advanced Life Support (ALS) training. Although the anaesthetist working in theatres had completed ALS training, they would not always be immediately available in the event of patient deterioration in recovery. The Association of Anaesthetists of Great Britain and Ireland’s Immediate post-anaesthesia recovery (2013) states “At all times, at least one member of staff present (in recovery) should be a certified Acute Life Support (ALS) provider”. Since our last assessment, staffing levels in recovery had increased to a minimum of 2 members of staff. This was in line with national guidance and addressed one of the concerns identified during our last assessment.

Although we identified areas of improvement, we remained concerned that recruitment procedures and practicing privileges procedures were not always operating effectively or fully established. For example, leaders had allowed some staff to work in the service before they had received their enhanced Disclosure and Barring Service (DBS) certificate. Leaders had not followed the processes set out in national guidance and legislation for allowing staff to begin work before their enhanced certificate had been received. The service’s DBS procedure lacked detailed guidance. 2 consultants had been allowed to start working in the service without a signed practicing privileges agreement. Practicing privileges agreements did not always include reference to on-call arrangements. The provider’s practicing privileges policy stated that an annual review would be carried out to monitor medical practitioner’s performance. This was not being carried out at the time of our assessment. However, leaders had begun work to implement monitoring processes. We identified concerns during our assessment that staff were undertaking the surgical first assistant (SFA) role without the necessary qualifications. This was identified through documentation within patient records, within the theatre register, and within the staffing rota. Leaders stated that this documentation was an error due to confusion amongst staff about the SFA role. Leaders reviewed the relevant patient records and confirmed that the procedures were undertaken by a surgeon and scrub staff without the need for an SFA. The SFA role was not included in the job descriptions of relevant members of staff, in line with national guidance. The service had high turnover rates. The turnover rate was 40.9% since our last assessment. There were high rates of agency and bank staff usage in some areas of the service. The recovery area had 41.7% agency or bank staff usage between July and September 2024.

Service users provided positive feedback about the cleanliness of the service. People told us that they had observed staff washing their hands and using personal protective equipment when required.

Staff demonstrated an understanding of infection prevention and control principles. Staff provided positive feedback about the infection prevention and control processes in place at the service. Staff acknowledged that cleaning schedules did not provide sufficient space to record the cleaning which occurred in-between patients. Staff said that cleaning schedules would be reviewed and amended following our assessment.

Staff labelled equipment to show when it was last cleaned by using ‘I am clean’ stickers. Disposable curtains had been changed at the frequency set out in the provider policy. Staff had access to bins in patient rooms to safely dispose of clinical waste. This addressed concerns identified during our last assessment. All patient areas were visibly clean. Staff were observed thoroughly cleaning equipment between patients. Clean and dirty equipment was managed well within the theatre and there was no cross contamination of equipment. Staff followed infection control principles including the use of personal protective equipment (PPE). Staff adhered to ‘bare below the elbows’ principles. We observed consistently good hand hygiene by staff. Personal protective equipment was readily available for staff to use. Staff mostly ensured that sharps bins were correctly assembled, labelled appropriately and below the fill line. However, we observed a ripped mattress within theatres, which posed an infection prevention and control risk. Staff said that the rip in the mattress had occurred on the day of our inspection. Staff were able to provide evidence to support this, through daily checklists and the equipment fault log. Staff replaced the mattress following our site visit.

Since our last assessment, the service had moved from employing in-house cleaning staff to using an external cleaning company. Leaders now also had access to an external infection prevention and control (IPC) advisor. The advisor had reviewed the service’s IPC policy and carried out an audit of IPC processes. The external IPC audit had identified areas for improvement and leaders had implemented an action plan in response. The service had a contract with an external organisation for the decontamination of reusable equipment. The service mostly performed well for cleanliness. Managers carried out bi-monthly internal IPC audits. However, some areas of concern had been identified during 1 IPC audit in July 2024, and it was not clear what action had been taken in response. Staff completed training in infection control and hand hygiene. Staff were 100% compliant with infection control training at the time of our assessment. Staff also completed training on Aseptic Non-Touch Technique. Staff were only 57% compliant with this training at the time of our assessment. Leaders stated that this training was in progress at the time of our assessment. The service had a cleaning schedule which set out how frequently cleaning should take place. This included some areas which needed to be cleaned between each patient. However, the cleaning schedule did not provide sufficient space for staff to record cleaning in-between patients. This meant that staff were not able to record all cleaning that had taken place. Leaders could therefore not provide assurance that cleaning had been completed in-between patients. This concern had been identified during our last assessment but had not yet been addressed.

Staff worked effectively to prevent, identify and treat surgical site infections. There had been one incident of healthcare acquired infection since registration.

People told us that they were given information about their medicines in a way they could understand.

Staff told us they could access relevant local medicines policies, procedures, and guidelines. Staff told us that any relevant safety alerts were shared with them by the provider. Leaders told us they could access pharmacy support from their local community pharmacy. Staff received medicines training at induction and were assessed as competent to provide medicines support to people.

During our last assessment, the provider could not assure us that oxygen was stored in line with national guidance. During this assessment, we found that full and empty oxygen cylinders were kept separate, and staff were aware of their locations in case of an emergency. Medicines used for medical emergencies were available, accessible for immediate use, and tamperproof. We saw that the service completed daily and weekly checks of emergency medicines and equipment across the service. People were treated with dignity and respect and given their medicines safely and at the right time. They were informed about what medicine was being administered. We observed staff check if people were in pain and administered pain relief when requested. We saw staff check patient allergies and ask for patient consent. Medicines, including Controlled Drugs (CDs, medicines requiring additional controls due to their risk of misuse and diversion), were securely stored at an acceptable temperature and within their expiry date. The frequency of temperature monitoring had been risk assessed.

The provider’s role in relation to people’s medicines was clearly defined and described in relevant policies, procedures, and training. Current and relevant professional guidance about the management of medicines was followed. During our last assessment, staff did not follow the provider’s medicines management policy for CDs. During this assessment we saw CDs were ordered, received, administered and disposed of in line with legislation, best practice and local policies. Records of handling CDs were accurate and made in line with legislation, best practice and local policies. During our last assessment, the service could not demonstrate that prescription stationary was stored securely. During this inspection we saw there were systems and processes in place to manage blank prescriptions in line with national guidance. Venous Thromboembolism (VTE) risk assessment, weight and allergy statuses were appropriately documented. The outcome of the VTE assessments were acted on. The service audited medicines management on a quarterly basis and we saw improvements were implemented because of audits. Medicines and medical devices safety alerts were brought to the attention of relevant staff and acted upon.