Probus Surgical Centre

Updated 9 February 2017

• Probus Surgery Limited is an independent health care provider who provide planned surgical procedures under local anaesthetic to NHS patients in Cornwall. Patients were seen for pre assessment at Probus Surgical Centre. The procedures are undertaken in the Probus Surgical Centre attached to the GP surgery. This arrangement has been in place since 1995. Probus Surgery is located in the village of Probus, approximately six miles east of Truro, Cornwall.
• A new building was established in 2008, consisting of two theatres, a nursing station, a clean area, two pre and post-operative rooms and a discharge lounge. The centre was registered with the CQC in 2011.
• The aim of the centre is to provide care in a primary care setting where patients can be treated closer to their home.
• The Centre has a number of satellite clinics throughout the county, where occasional surgical lists are provided, aiming to deliver care as close to patients homes as possible, Probus Surgery Limited had a contract with the local clinical commissioning group to provide these services at the following:

- Meneage Surgery, Helston.

-The Morrab Surgery, Penzance.

-Stratton Surgery, Stratton, near Bude.

-Stratton Community Hospital

-Liskeard Community Hospital, Liskeard.

-The Rame Practice, Torpoint.

• We did not inspect these satellite surgeries as part of this inspection.

• The most common surgical procedures undertaken between April 2015 and March 2016 were:

• Cataract extractions and Intra Ocular Lens eye implants (953)
• Hernia Repairs (374)
• Vasectomy (339)
• Carpal Tunnel Decompressions (314)

• At the time of our inspection the centre employed 14 doctors under practising privileges (including two GPs at Probus Surgery), one theatre sister, five registered nurses, and three health care assistants. There was an administration and booking team managed by the deputy surgical manager.
• The centre was open Monday to Friday from 8 am until 6 pm.

• Out of hours contact details were in the information leaflets and letter given to the patient when discharged.
• Dr Gaetan Lin Sin Cho is the nominated individual for Probus Surgery Limited centre and a registered manager for Probus General Practice. Registered in 29 June 2011, he had been in post five years, three months. The previous registered manager had been absent and following appropriate notification to Care Quality Commission, Dr Simon Purchas became the new registered manager.

The centre (including its satellite surgeries) did not treat any patients under the age of 18 years.

Updated 9 February 2017

• The inspection was an announced comprehensive inspection for Probus Surgery Limited at the centre in Probus. We visited the Probus Surgical Centre on 13 and 14 September 2016. We did not carry out an unannounced inspection. We did not visit any of the satellite locations as there was no surgery taking place at this time.
• We spoke with patients who used the service, nursing and medical staff, including the general practitioners, executive and non-executive managers and visiting consultants, administrative staff, the deputy surgical manager and practice manager. We observed clinical procedures and spoke with patients before and after these. We requested written feedback from people who had used the service.
• We reviewed information provided by Probus Surgery Limited, prior to, during and following the inspection. We also requested information from stakeholders, including the clinical commissioning group. We reviewed information we hold on our electronic systems
• We visited the operating theatres, pre and post-operative rooms and other clinical and administrative rooms at the Probus Surgery.

Our key findings were as follows:

Overall we rated Probus Surgical Centre surgery services as good because:

• Staff were aware of their responsibilities to report incidents and there was a good incident reporting culture amongst staff.
• Equipment was maintained and serviced regularly and staff took prompt action if a piece of equipment became unserviceable.
• There were systems in place to ensure patient safety for example the World Health Organisation (WHO) surgical safety checklist was used.
• Staffing levels and skill mix were planned, reviewed and consistently met so that people received safe care and treatment.
• There were systems in place to give patients information about what to do if they felt unwell or had questions about their care and treatment.
• There was an effective system for gaining patients consent prior to their procedure.
• We saw staff being kind and caring to patients. They had time to spend with them to explain any procedures and allay anxieties they have had.
• Patients told us they were treated with dignity and respect and their confidentiality was upheld. There was a comprehensive chaperone policy in place.
• Patients were involved when arranging appointments that suited their needs and circumstances. The service gave patient’s detailed information about the procedure they were to have and invited questions so that they could make an informed choice about their treatment.
• There was access to interpretation and translation services for patients whose first language was not English. Any leaflets or patient information could be offered in alternative formats such as large print.
• Referral to treatment time was better than the targets and meant the centre saw and treated 100% of patients within 18 weeks of referral.
• The centre had a complaint policy and handled complaints in a timely manner according to their policy. There was evidence the service made changes because of lessons learnt from complaints.
• The service had a vision and strategy that staff knew about and felt included in.
• There was a clinical governance plan and evidence of shared learning from incidents. There was a risk register and evidence of actions to mitigate risks.
• The service collected patient outcome data to evaluate the effectiveness of care and treatment delivered.

However:

• When we reviewed consultants’ practising privileges records the required evidence was not easily accessible or identifiable. The filing system needed to be reviewed to provide assurance to the clinical director and others, that those who carried out consultation and surgical procedures were fit to do so. We raised the concerns and the provider immediately put in place an action plan and a timetable to review all records.
• Not all surgical and nursing staff were up-to-date with their annual performance appraisals, and mandatory training.
• Actions identified to mitigate some of the risks on the risk register did not have specific dates identified for review or completion.
• There was no hand wash basin in the recovery lounge area which meant staff had to leave the room regularly to wash their hands.

We saw several areas of outstanding practice including:

• The centre was linked with the Peninsular Medical School in Truro and had provided one three week supervised elective placement from 15 November 2015 that covered all of the procedures at the centre.
• The cataract service was delivered by a team of three specialist ophthalmologists. The Centre ran a one-stop clinic, whereby patients were treated on the same day if deemed suitable for surgery. This had proved to be popular as patients did not usually wish to travel long distances unnecessarily, given the rurality of Cornwall.

However, there were also areas of where the provider needs to make improvements.

Importantly, the provider must:

• Ensure all practising privileges records required by the provider for surgeons carrying out procedures are available, up-to-date and recorded.
• Ensure mandatory training for surgical staff meets the hospital’s target for compliance at all times.
• Ensure Disclosure and Barring Service checks for medical staff are carried out as required and available for review.

In addition the provider should:

• Consider improving the availability of all paper and electronic records for theatre procedures.
• Update the risk register to include potential risks, mitigating factors and deadlines.
• Review the adult and children’s safeguarding policy to reflect current guidance on reference to female genital mutilation.
• Introduce an effective audit programme that addresses the quality of patient records in both paper and electronic form.
• Consider conducting a risk assessment with regard to the need for a sink in recovery lounge to support infection prevention control.
• consider how to respect privacy and dignity in areas where a number of patients are receiving care at the same time

Professor Sir Mike Richards

Chief Inspector of Hospitals

Updated 9 February 2017

Overall we rated Probus Surgery Limited surgery services as good because:

We rated safe for surgery services as good because:

• Lessons were learned and improvements were made when things went wrong. Staff understood their responsibilities to raise concerns, safety incidents and near misses, and to report them.
• Patients’ immediate individual care records were written and managed in a way that kept people safe.
• There were systems to prevent and protect people from a healthcare-associated infection.
• There were arrangements for managing medicines which kept people safe.
• We saw that there were systems and processes in place to safeguard people from abuse. Staff understood their responsibilities to report concerns about, or suspicions of, abuse.
• The organisation followed best practice by use of the NHS Five Steps to Safer Surgery, and the World Health Organisation surgery checklists in all operating procedures.
• Staff obtained patients’ informed consent, in accordance with legislation and good practice.
• Staffing levels and skill mix were planned, reviewed and consistently met so that people received safe care and treatment.
• There was a comprehensive policy supporting business continuity. including instructions on what staff should do in the event of emergency events, including adverse weather.

However:

• Not all surgical and nursing staff were up-to-date with their annual performance appraisals, and mandatory training.
• There were no curtains for privacy between patients in pre and post operative areas
• Neither the adult nor the children’s safeguarding policy made reference to female genital mutilation
• There was no hand wash basin in the lounge area which meant staff had to leave the room regularly to wash their hands.

We rated effective for surgery as requires improvement because:

• When we reviewed consultants’ practising privileges records the required evidence was not easily accessible or identifiable. We raised concerns about this and the provider immediately put in place an action plan and a timetable to review all records.
• Patient’s pain was monitored but patients’ pain was not consistently recorded.

However,

• Short and medium term treatment outcomes were audited and showed that procedures were effective. Patients were satisfied with outcomes.
• The provider undertook clinical audits on a regular basis which examined clinical outcomes.
• All surgical procedures were carried out using a local anaesthetic. Patient’s pain was well managed.
• The provider monitored performance and quality and reported findings to the local clinical commissioning group (CCG) each month in an overall activity report.
• The provider ensured that relevant information regarding patients’ care and treatment was shared with GPs in order to ensure appropriate after care where necessary.
• Staff had access in a timely way to patient information, including risk assessments, care plans, case notes and test results.
• Medical staff obtained patients’ consent to care and treatment in line with legislation and guidance.

We rated caring for surgery as good because:

• Patients, and those who accompanied them were treated with kindness, dignity, respect and compassion while they received care and treatment.
• Staff ensured patients’ privacy and dignity were respected, including during procedures that required physical or intimate contact.
• Patients told us and we saw that confidentiality was maintained.
• Patient survey results recorded in July 2016 described patient experiences as overwhelmingly positive.
• NHS Friends and Family Test results were consistently positive. Most NHS patients who attended the centre October 2015 and March 2016, said they would recommend the service.
• Staff at the centre worked with patients, and those close to them, as partners in their care. When a history or information was being sought patients and those close to them had their opinions and concerns taken into consideration.
• Staff recognised when patients and those close to them needed additional support to help them understand and be involved in their care and treatment, and enabled them to access it.
• Patients were offered a chaperone. There was information displayed in the waiting room and in consultation and treatment rooms about the chaperone service..
• The provider aimed to be flexible to arrange appropriate days for patients who lived alone and needed support or required personal care after the operation. The service gave patients extensive information about their care and treatment so patients could make an informed decision about their care.

We rated responsive for surgery as good because:

• The provider worked with commissioners and the local NHS acute trust to plan services.
• Information about the needs of the local population was used to inform how services were planned and delivered.
• Patients could access care and treatment in a timely way.
• Reasonable adjustments had been made so that patients with a disability could access and use services on an equal basis with others.
• There were arrangements for people who needed translation services.
• The hospital had a complaint policy and handled complaints in a timely manner. There was evidence the service made changes because of lessons learnt from complaints.
• Referral to treatment time exceeded targets and meant that patients were seen within 18 weeks from referral.
• Learning took place and changes were made in response to feedback.

We rated well led for surgery as good because:

• The provider had a clear vision and a credible strategy.
• The provider used patient feedback to ensure continuous learning and improvement.
• Staff were able to articulate the vision and values of Probus Surgery Limited.
• The governance framework ensured that responsibilities were clear and that quality, performance and most risks were monitored, understood and managed. There were systems for identifying, recording, managing and mitigating risks.
• The leadership and culture reflected the vision and values of Probus Surgery Limited. Leaders encouraged openness and transparency.
• The culture was centred on the needs and experience of patients and encouraged candour, openness and honesty.
• Staff we spoke with felt respected and valued.
• Staff felt actively engaged so that their views were reflected in the planning and delivery of services and in shaping the culture.
• Services were improved and sustained a number of ways. The centre had received high levels of customer satisfaction from patients and their families. The provider felt that this was because the centre provided a “personal and friendly approach” to all of its patients.

However:

• Actions identified to mitigate some of the risks on the risk register did not have specific dates identified for review or completion. The issues we identified in relation to the administration of practising privileges and low compliance with mandatory training had not been included on the risk register. The provider acknowledged there were some issues with the administration of practising privileges which they would immediately address during and after the inspection.