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

Policies, guidelines, and protocols did not always provide clear guidance for staff, were not always reflective of the service provided and were not always evidence based. The service did not always have effective governance structures, processes and systems of accountability. Leaders had not always ensured that concerns identified during our last assessment had been fully addressed. 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. The service did not always have clear and robust service performance measures, which were reported and monitored. Audits had not always been effective in identifying the areas of concern that were identified during our assessment. However, leaders had reflected on the findings of the last assessment and had worked to make improvements to the service’s governance framework. Leaders had made improvements to the service’s risk management processes since last assessment. Staff said that they felt supported, respected and valued.

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.

Prior to our assessment, anonymous whistleblowers had raised concerns about the service’s culture. The concerns raised by whistleblowers indicated that the service did not have a positive and compassionate culture. This was not supported by the feedback received from staff during our assessment. Staff said that they felt supported, respected and valued. Leaders stated that there had been no reported instances of bullying or harassment. Leaders stated that since our last assessment, they had been focused on “…rebuilding Athena Surgical Centre's reputation, securing new contracts and restoring our good name as a quality care provider”. Staff were aware of and supportive of the service’s strategic direction. Staff understood their role in helping to achieve the strategy. However, leaders stated that they had not updated the strategy since our last assessment, to ensure that the strategic priorities that they described to us were reflected in the strategy.

The service had a documented strategy which set out the service’s future plans and ambitions. The strategy had not been updated since our last assessment. 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 assessment 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. These concerns were included in our last assessment report (published June 2024) but had not yet been addressed by the time of our September 2024 site visit.

Prior to our assessment, we received concerns from anonymous whistleblowers regarding the behaviours of the service’s directors. We also received concerns regarding the departure of the majority of the service’s nursing leadership team. However, the concerns raised were not supported by the feedback that we received from staff during our assessment. Staff said that leaders were visible and approachable. Staff said that they had not observed any inappropriate behaviours by the service’s leaders. Staff described improvements in leadership since our last assessment. Leaders said that they had reflected on the concerns identified during our last assessment and had made changes to their leadership of the service as a result. Leaders stated that they had recognised the need for increased visibility, as well as the importance of staff empowerment and engagement. 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 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 was received.

There had been a significant turnover in the service’s nursing leadership since our last assessment. This included the departure of the service’s registered manager (who also worked as the service’s theatre manager), deputy managers, and clinical consultant. As a result, there was no registered manager in place at the time of our assessment. In the absence of a registered manager, the service was being supported by a clinical consultant, who was appointed in March 2024 and worked 3 days a week. One of the service’s directors had submitted an application to become the registered manager in September 2024. The director did not have a clinical background or previous experience of managing a healthcare service to draw upon whilst working in the registered manager position. However, leaders stated that a plan was in place for the director to be supported by a member of staff with a clinical background. 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. Leaders had not always ensured that concerns identified during our last assessment had been fully addressed. For example, we continued to find concerns regarding recruitment processes, the service’s policies, and pre-operative risk assessment processes. 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.

Prior to our assessment, anonymous whistleblowers contacted us to raise a range of concerns regarding safety and quality within the service. This indicated that staff did not always feel confident to raise concerns through internal processes. Whistleblowers had raised concerns about the service’s freedom to speak up processes and around a culture of retribution when concerns were raised internally. However, the concerns raised were not supported by the feedback that we received from staff during our assessment. Staff could provide examples of times where they had raised concerns internally. Staff said that their concerns 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. The discharge had gone ahead as planned.

Leaders had implemented processes to enable staff to raise concerns internally. This included a daily huddle, a ‘list safety officer’ role, an anonymous email account, and an anonymous staff suggestions box. The service also had a freedom to speak up guardian and a freedom to speak up policy. However, this policy did not always provide clear guidance for staff about how they could raise concerns internally or externally. For example, the policy referred to the anonymous email system but did not provide information about how staff could access this system. Leaders stated that information about how to access the anonymous email system was displayed in the staff room, and had been shared during team meetings. The freedom to speak up policy did not refer to external organisations that staff could contact for support when speaking up. During our assessment, we asked for a summary of any concerns raised internally by staff since our last assessment and actions that leaders had taken in response. Leaders stated that no specific concerns had been raised by staff, other than concerns for their job roles and responsibilities.

All staff spoken with during our inspection felt that they were treated equitably. Leaders described a commitment to ensuring that the service was inclusive. However, leaders were not able to provide evidence of action that had been taken to review and improve the culture of the organisation in the context of equality, diversity and inclusion.

There was some 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. 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. These concerns had been identified at our last assessment and had not yet been addressed.

Staff and leaders described the significant amount of work that had been undertaken since our last assessment to improve the service’s governance framework, as well as the management of risk, issues and performance. Leaders described how they were using external expertise to assist them in reviewing their policies and procedures. Leaders provided examples of how the impact on quality and sustainability had been assessed and monitored when considering developments to services or efficiency changes. There was mostly an alignment between recorded risks and what leaders said was on their ‘worry list’. Staff and leaders acknowledged that they had continued to experience challenges regarding comprehensive record keeping since our last assessment. Leaders continued to monitor compliance through a monthly audit of patient records. Leaders raised concerns regarding any areas of non-compliance with staff. Compliance rates had been on an improving trajectory since our last assessment. Staff said that concerns had been raised internally regarding the quality of record keeping within the theatre register. This related to nicknames being used when recording the name of the practitioners involved in procedures on the theatre register. This was confirmed through our review of the theatre register. However, improvements had been made since concerns had been raised internally.

Although some improvements had been made, we remained concerned that policies, guidelines, and protocols did not always provide clear guidance for staff, were not always reflective of the service provided and were not always evidence based. Leaders had been working to improve the quality of patient records since our last assessment and this had led to areas of improvement. However, the patient records reviewed during our assessment continued to contain areas of non-compliance. The service’s governance framework had been updated since our last assessment. However, we remained concerned that the service did not always have effective governance structures, processes and systems of accountability. For example, we were not assured that all relevant topics were being discussed and monitored through governance meetings. Meeting minutes did not include discussions regarding key staffing data or operational performance data. Leaders did not complete an action log to monitor the completion of any actions identified as part of governance and management meetings. The terms of reference for governance and management meetings did not always clearly set out the responsibilities, membership, and frequency of meetings. The service did not always have clear and robust service performance measures, which were reported and monitored. The service had a wide range of local audits within their audit programme. However, audits had not always been effective in identifying the areas of concern that were identified during our assessment. In addition, where areas of concern were identified during audits, it was not always clear that actions had been identified or implemented in response. We therefore remained concerned that the audit programme was not always robust enough to determine if the service was doing well and what improvements could be made. However, leaders had made improvements to the service’s risk management processes since last assessment.

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.

Leaders stated that their contracts with external partners for the provision of patient care had ended since our last assessment. Staff and leaders said that they recognised the importance of being open and transparent with external stakeholders and agencies. 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 provider had processes in place for liaising with GPs following the provision of care and treatment. Patient records showed evidence of liaison with GPs. 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 in partnership with external stakeholders to support care provision, service development and joined-up care. 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.

Prior to our assessment, anonymous whistleblowers had raised concerns that staff were not encouraged to speak up with ideas for improvement. However, the concerns raised were not supported by the feedback that we received from staff during our assessment. Staff said that they had been involved in the changes implemented since our last assessment and leaders had asked for their input. Leaders were able to provide examples of improvement and innovation initiatives. This included the introduction of an ordering book for theatres and recovery, the introduction of a software system for hospital wide use, and the introduction of rapid infusers. However, leaders had not always ensured that concerns identified during our last assessment had been fully addressed. For example, we continued to find concerns regarding recruitment processes, the service’s policies, learning from incidents, and pre-operative risk assessment processes. In addition, we were not always assured that all necessary improvements were made following the investigation of incidents. This raised concerns that the service did not have effective processes to ensure that learning happened when things went wrong.

Staff took time together in meetings to review the service’s performance and objectives, in order to identify any necessary improvements and ensure they provided an effective service. This was confirmed through a review of meeting minutes during our inspection. However, 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.

Leaders provided evidence of improved outcomes because of improvement or innovation initiatives. Leaders stated that the introduction of an ordering book for theatres and recovery had led to reduced delays due to unavailable equipment, improved readiness for surgery and a reduction in lost or misfiled orders. Leaders stated that the introduction of a hospital-wide software system had led to a reduction in administrative delays. Leaders provided data which showed that turnaround times between procedures had reduced from 42.4 minutes in January 2024 to 28.6 minutes in July 2024.