Archived: Cotswold Surgical Partners LLP

This service is rated as Good overall.

The service was registered with the Care Quality Commission (CQC) in October 2021 and this is the first inspection since registration.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We carried out an announced comprehensive inspection at Cotswold Surgical Partners LLP as part of our planned inspection programme.

The service is registered with CQC under the Health and Social Care Act 2008 as Cotswold Surgical Partners LLP in respect of some, but not all, of the services it provides. There are some exemptions from regulation by CQC which relate to particular types of regulated activities and services and these are set out in Schedule 1 and Schedule 2 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Cotswold Surgical Partners LLP provides a range of non-surgical aesthetic services, for example: hyaluronic acid injections, which are not within CQC scope of registration. Therefore, we did not inspect or report on these services. We inspected those procedures offered by Cotswold Surgical Partners LLP which are regulated activities, for example, consultant dermatology and plastic surgery, under local anaesthetic. Cotswold Surgical Partners LLP have a service agreement in place with the local commissioners to provide dermatology and plastic surgery services to a variety of NHS trusts and hospitals in the surrounding area, supporting skin cancer wait lists at these locations.

Cotswold Surgical Partners LLP is led by a registered manager, who is also a consultant dermatologist. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Our key findings were:

• The service had clearly defined and embedded systems, processes and standard operating procedures to keep people safe and safeguarded from abuse.
• There were systems to identify, monitor and manage risks and learn from incidents.
• The registered manager kept up to date in their specialist field and reviewed and monitored care and treatment to ensure the services provided were effective and delivered in line with evidence-based guidelines.
• Infection prevention and control systems and processes were effective. The registered manager had introduced additional measures to reduce the risk from Covid-19 during the pandemic.
• The registered manager and clinic manager worked together to ensure the continuity and flexibility of the service met the needs of people.
• Staff treated patients with kindness and respect and involved them in decisions about their care.
• The registered manager encouraged compassionate, inclusive and supportive relationships among staff so that they feel respected, valued and supported.
• The service had a clear strategy and vision. The governance arrangements promoted good quality care.

We saw the following outstanding practice:

• There was a proactive approach to understanding the needs of different groups of people and to delivering care in a way that meets these needs, which is accessible and promotes equality. For example, there was a robust digital referral triage process which was different than standardised practice. Patient digital images of dermatology areas were assessed by the lead clinicians prior to appointment to determine triage upon referral. Patients were seen by the correct clinician for their condition or re-referred to specialists due to the complexity. Therefore, the patient care journey was more time-efficient, patients did not require further treatment or re-referral within primary care pathways after consultation.
• There was a practical approach to provide integrated person-centred pathways of care that involved other service providers, particularly for people with multiple and complex needs. Such as, the receptiveness to respond to local commissioner patient surgery requests based on the unexpected closure of another provider.
• The provider had a robust medicine prescribing process in which internal audits showed increased effectiveness of the safety netting mechanism for patients which went above and beyond standardised practice.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services