Athena Surgical Centre

On this page

• 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

Controlled drugs, records and stationery were not being managed in line with legislation and national guidance. Medical gases were not being stored in line with national guidance. Infection prevention and control measures were not always being adhered to. The service did not always have robust processes to ensure that staff had access to all relevant information before, during and after the provision of patient care. Risk assessments were not always completed in accordance with national guidance and legislation. Staff did not always have clear, evidence-based guidance to follow in the event of patient deterioration and when assessing patient risk. Equipment was not always available in accordance with national guidance and best practice. Staff had not received training on all the equipment that they would be expected to operate as part of their role. The service’s incident policies did not always provide clear guidance for staff and we were not always assured that all necessary improvements were made following the investigation of incidents. Recruitment procedures were not always operating effectively or fully established. The safeguarding policy did not provide clear guidance for staff and the safeguarding lead had not completed the required level of safeguarding training. The recovery room was not always staffed in accordance with national guidance and legislation. Staff did not complete training on recognising and responding to patients with learning disabilities or autism at the time of our inspection. During our assessment, we found concerns which resulted in a breach of regulations 12 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 53 (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.

Staff knew what incidents to report and how to report them. Staff said they were encouraged and supported to raise concerns. Staff understood the duty of candour. Staff were aware of the importance of being open and honest with patients and families when something went wrong. Staff said that they met to discuss learning from incidents and look at improvements to patient care. Staff were able to describe themes from incidents and changes to practice as a result. Leaders were not yet able to provide information about how outcomes and safety performance compared with other similar services and how they changed over time. The service had only been operating for approximately 6 months at the time of our inspection.

The service’s adverse incident policy did not always provide clear guidance for staff. For example, the policy did not provide clear guidance and examples of the type of events that should be classed as an incident, about how staff should grade the level of harm sustained during an incident, and under which circumstances a full root cause analysis (RCA) investigation should be undertaken. In addition, the policy did not refer to requirements to inform the Care Quality Commission (CQC) of certain incidents. The provider’s duty of candour policy did not provide clear guidance for staff about the timescales within which actions should have been completed. The regulations state that actions should be taken ‘As soon as reasonably practicable after becoming aware that a notifiable safety incident has occurred ‘. Processes were in place to ensure that incidents were reported and investigated. Staff filled out paper-based incident forms, which were scanned into the electronic system and logged on an incident tracker. Staff had reported 35 incidents since registration. We were not always assured that all necessary improvements were made following the investigation of incidents. For example, we reviewed a root cause analysis (RCA) investigation report during our assessment which had identified learning around the service’s pre-operative assessment process. This included ensuring that electrocardiograms (ECGs) were carried out for all patients over the age of 55 and ensuring that face to face assessments with blood tests and baseline observations were carried for all patients having major surgery. Actions had been identified to ensure that all members of the pre-assessment team were made aware of this pre-admission criteria. However, there were no actions identified to ensure that the provider’s policy was updated. The admission policy that we reviewed as part of our inspection had not been updated to reflect the new pre-admission criteria.

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

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. This included access to pre-operative assessment and discharge information. Staff told us that they had approached the NHS hospital trust on a number of occasions prior to our inspection to request that this information was shared. Staff gave examples where it had only been identified on the day of surgery that patients were inappropriate for their service based on their complex medical history. This had occurred because staff did not have access to information from pre-operative assessments which had been carried out by the NHS hospital trust. Following our inspection, leaders had engaged in further 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 they had experienced some challenges with communication to support care provision and joined-up care. For example, partners said that patient outcomes were not always shared in a timely manner, which had resulted in delays in partners being able to send letters out to patients. Partners also had concerns that staff had not always informed them when patients needed to be moved onto the 2-week-wait pathway. The 2-week-wait pathway was introduced so that anyone with symptoms that might indicate cancer could be seen by a specialist as quickly as possible. There was therefore a risk that patients with symptoms that might indicate cancer would experience delays in their care and treatment. However, partners said that they had not identified any cases where patients had come to harm and they had worked to put a new process in place to prevent this issue re-occurring.

Pre-operative assessments were completed by the NHS hospital trust, and a further assessment was then completed by Athena Surgical Centre staff by telephone in advance of surgery. Following surgery, the administration of clinical notes for NHS patients was transferred back to the NHS hospital Trust. Discharge summaries were therefore sent by the NHS hospital trust. The service did not always have robust processes to ensure that staff had access to all relevant information before, during and after the provision of patient care. Information from pre-operative assessments and the discharge of patients was not always shared with Athena Surgical Centre by the NHS hospital trust. No pre-operative assessments or discharge summaries were contained in any of the files reviewed during our assessment. In addition, we identified concerns during our assessment that consultants retained their own notes following treatment. This meant that there would not be a complete patient record of the care and treatment provided. Staff did not always have clear, evidence-based guidance to follow to ensure safe systems, pathways and transitions. For example, the ‘Admission, Discharge and Transfer Policy’ did not have clearly defined discharge criteria. The policy simply stated that ‘Standard discharge must only happen once a patient has had at least 2.5 hours in recovery and the ward collectively. There was no reference to physiological parameters or specific discharge criteria. There were processes in place for securely sharing information with patients’ 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's safeguarding lead had not been trained to level 4 in safeguarding, as per national guidance. Following our inspection, leaders stated that the safeguarding lead had access to support and advice from the service’s clinical consultant, who was trained to level 4 safeguarding. The clinical consultant worked at the organisation 1 day a week. The safeguarding lead went on to complete level 4 safeguarding training following our inspection. 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 83.9% at the time of our inspection. It was not clear whether the training compliance rates were in line with the provider’s target as this was requested as part of our inspection but was not provided. The safeguarding policy provided during our inspection did not contain contact details for the local authority so that staff could make a referral when safeguarding concerns were identified. The safeguarding policy also included a section titled ‘Contacts and sources of assistance’, which referred to ‘Advocacy and victim support services which might be needed’, ‘Any medical practitioners who might be needed’, and ‘Other relevant statutory / voluntary organisations that could be of help.’. However, no contact details had been provided to allow staff to access these services and organisations. The safeguarding policy did not provide guidance for staff on all relevant topics. For example, the policy did not include guidance about potential child safeguarding concerns which should be considered and may be identified as part of a service treating adults.

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.

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. Staff said that they always had access to at least one member of staff who was trained to immediate and advanced level in life support. Leaders said that they recognised that patient notes lacked comprehensive details concerning venous thromboembolism and Personal Emergency Evacuation Plans (PEEPs). Following our inspection, action was taken in response to the concerns raised. This included additional training for staff and ongoing monitoring through audits.

Staff did not always have clear, evidence-based guidance to follow in the event of patient deterioration and when assessing patient risk. This included the Major Haemorrhage Protocol, the Deteriorating Patient Policy, the inclusion and exclusion criteria, the Admission, Discharge and Transfer Policy, and the Protocol for the prevention of DVT VTE (Deep vein thrombosis, venous thromboembolism). Risk assessments were not always completed in accordance with national guidance and legislation. We reviewed 5 patient records during our assessment and found that VTE assessments and Personal Emergency Evacuation Plan (PEEPs) were either missing or incomplete. We identified concerns during our inspection regarding the service’s pre-operative assessment processes. The service submitted a notification to CQC in 2023 relating to death within 30 days of surgery. The investigation report showed that the patient, whose past medical history was described as complex, had their pre-operative assessment carried out by telephone and no electrocardiograms (ECG) and or baseline observations had been carried out. There was no evidence of any liaison with the patient’s GP. Learning had been identified around ensuring that ECGs were carried out for all patients over the age of 55 and ensuring that face to face pre-operative assessments with blood tests and baseline observations were carried for all patients having major surgery. However, the policies reviewed during our inspection had not been updated to reflect this. 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, life support training for staff, 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.

Staff mostly told us the environment was safe and that they had access to suitable equipment to carry out their role. Staff did raise concerns about the process in place for ordering consumable equipment, as there was no member of staff responsible for this task. Some staff provided feedback about the lack of space within clinical areas, including theatres and recovery. Staff provided some examples of how this could impact on the care provided. For example, there was no space for a C-arm imaging machine within theatres. Some staff also noted that leaders had chosen to purchase used equipment when they established the service, based on financial considerations. Staff said that they would prefer to use newer and more state-of-the-art equipment. However, they acknowledged that the equipment being used did not impact on the safety of the service provided.

Equipment was not always available in accordance with national guidance and best practice. For example, intraosseous access equipment, central venous catheter equipment and invasive blood pressure equipment were not available in the theatre department. Leaders stated that an anaesthetist had carried out a risk assessment which determined that this equipment was not necessary for their service. However, following our inspection, leaders took action to order the equipment. Anaesthetic breathing systems were not being changed in accordance with the manufacturer’s guidance. Anaesthetic circuits were being changed on a monthly rather than a weekly basis. Leaders stated that this was because the service had a low theatre occupancy rate and did not admit high-risk patients or patients with active airway infections. Following the inspection, leaders updated their process to ensure that anaesthetic breathing systems were changed on a weekly basis. All consumables checked during our inspection were within their expiry date. All equipment checked during our inspection was up-to-date for servicing. However, equipment had not always been labelled with asset stickers or servicing labels to allow staff to track equipment or identify equipment which was overdue for servicing. The service did have an asset register, available electronically, which allowed leaders to monitor the equipment used with the service and the dates that equipment needed to be serviced. 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.

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. All equipment was up to date for servicing at the time of our inspection. Staff carried out daily and weekly safety checks of specialist equipment. This was confirmed through a review of checklists during our inspection. Staff had not received training on all the equipment that they would be expected to operate as part of their role. For example, staff equipment training records did not include training on the use of rapid infusers. In addition, we requested assurances that Anaesthetists had been trained to use the particular type of emergency equipment that was stocked at Athena Surgical Centre, but this was not provided. The service was not utilising intermittent pneumatic compression equipment for VTE prophylaxis at the time of our assessment visit. This was not in line with the provider’s ‘Protocol for Prevention of DVT VTE’, which stated that flowtron boots should be used in theatres for patients at increased risk of VTE. However, the equipment had already been ordered and it arrived in the department during our assessment. Staff had carried out a range of environmental risk assessments, including for fire, Legionella, and substances which met the COSHH regulations. Staff carried out weekly testing of the fire alarm system.

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

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 held regular 1 to 1 meetings with their manager, where 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. Some staff raised concerns about staffing levels in the recovery area, and a lack of supernumerary staff to provide support in theatres.

Our observations showed that the service mostly had enough staff to keep patients safe. However, Staffing levels in the recovery area were not always in line with national guidance. At the start of our inspection we observed only 1 nurse working in the recovery area, despite 3 theatres being in use. The Royal College of Anaesthetists ‘Guidelines for the Provision of Postoperative Care 2019’ state that a minimum of two members of staff should be present when there is a patient in recovery who does not fulfil the criteria for discharge to the ward. The nurse working in the recovery area on the day of our inspection was an agency member of staff, who had not previously worked for the service.

Recruitment procedures were not always operating effectively. For example, the service had not always obtained disclosure and barring service checks, evidence of clinical qualifications or evidence of training completion for consultants working under practicing privileges. Recruitment procedures were not fully established. For example, the Disclosure and Barring Service (DBS) policy did not set out the frequency at which DBS checks would be renewed. Disciplinary policies did not include information about sharing concerns about clinical staff member's behaviour or performance with other employers. Staff did not complete training on recognising and responding to patients with learning disabilities or autism at the time of our inspection. From 1 July 2022, all health and social care providers registered with the CQC were required to ensure that their staff received training in how to interact appropriately with people who have a learning disability and autistic people, at a level appropriate to their role. Staffing levels in the recovery area were not always in line with national guidance. Our review of staffing rotas showed 9 occasion in the 3 months prior to our inspection where only 1 member of staff was allocated to the recovery area. Staff were 96% compliant with mandatory training at the time of our inspection. It was not clear whether the training compliance rates were in line with the provider’s target as this was requested as part of our inspection but was not provided. The service did not monitor vacancy, turnover, agency usage or sickness rates. We requested this information as part of our inspection and this was not provided. The service had not yet carried out appraisals as staff had not yet been employed for a full year at the time of our inspection. Leaders were able to demonstrate that poor or variable staff performance had been identified and managed appropriately.

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. Leaders acknowledged that curtains had not been changed at the frequency set out in the provider policy. Leaders said that they had already recognised that bins needed to be placed into patient rooms, and an order for bins had already been placed. Leaders said that an alternative control process was in place regarding the use of ‘I am clean’ stickers whereby equipment was cleaned and stickers applied at the end of the day, which were then removed the next morning when all equipment had been checked for cleanliness.

Staff did not have access to bins in patient rooms to safely dispose of clinical waste. This posed an infection control risk. The registered manager stated that bins had already been ordered for patient rooms. Staff did not label equipment to show when it was last cleaned. For example, through the use of ‘I am clean’ stickers. Disposable curtains had not been changed at the frequency set out in the provider policy. Curtains in patient rooms had last been changed in June 2023. The provider policy stated that curtains should be changed every 3 months. The curtains were therefore 4 months overdue for replacement at the time of our inspection. 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 ensured that sharps bins were correctly assembled, labelled appropriately and below the fill line.

The service performed well for cleanliness. Managers carried out monthly audits of infection control and prevention standards. The audits reviewed during our inspection showed high levels of compliance. Staff completed training in infection control and hand hygiene. Staff were 83% compliant with infection control training at the time of our inspection. It was not clear whether the training compliance rates were in line with the provider’s target as this was requested as part of our inspection but was not provided. Staff were 100% compliant with hand hygiene training at the time of our inspection. The service employed an in-house cleaner. Clinical staff also carried out cleaning in between patients. 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 as required. The cleaning schedule was subject to a weekly manager review and sign off. However, the cleaning schedule reviewed during our inspection had not been signed off by a manager as required. The service’s clinical consultant acted as the services’ infection prevention and control lead. The service had a contract with an external organisation for the decontamination of reusable equipment.

Staff worked effectively to prevent, identify and treat surgical site infections. There had been no incidents of healthcare acquired infection since registration.

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

The staff told us they received training in medicines management and were assessed by leaders in the service. They told us they were organising additional training for administration of IV medicines. Staff told us they knew how to report incidents. Leaders told us there were no incidents related to medicines in the previous 6 months. Leaders told us they could access pharmacy support from their local community pharmacy. However, Whistleblowers had raised concerns about the management and destruction of controlled drugs. We spoke to staff and leaders on inspection who were able to describe the process for destroying controlled drugs. However, records for destruction of controlled drugs were not complete and auditable. The service did not record the name of the patient, or the medicines being destroyed as separate entries. so we could not be fully assured that controlled drugs were being managed and destroyed in line with legislation.

The service did not follow national guidance for the storage of oxygen cylinders. We saw that empty and full cylinders were stored together in the cylinder rack. There is a risk that staff could pick up an empty cylinder for use in an emergency. The service leaders told us that full and empty cylinders were normally stored separately. However, we saw more than one empty cylinder stored in a rack with other full cylinders We saw controlled drugs requiring safe custody (temazepam) stored in the medicines cupboard with other medicines. This is not in line with the service’s medicine policy or with national guidance. We reviewed the controlled drug registers available in theatres and saw staff did not follow legislation when correcting errors and did not always fully complete entries. We saw patient records that were not fully complete. We saw instances in medicine administration records where medicines were written in shorthand, units of strength were not clear and time of administration was written in ranges and not in specific times. However, We saw the service complete daily and weekly checks of emergency medicines and equipment on crash trolleys in the service. We observed staff check if patients were in pain and administered pain relief when requested. We saw staff check patient allergies and ask for patient consent. We saw areas where medicines were stored were clean, tidy and only accessible to relevant staff members.

There was a medicines management policy in place, but it was not always being followed. For example, we saw staff did not follow the service’s policy for the management of some schedule controlled drugs (tramadol) and schedule 5 controlled drugs (lower strength morphine liquid) . The policy states that they should have safe custody and a register kept for the supply, administration and destruction. We did not see this in place. The service did not manage patients’ prescribed controlled drugs in line with the Misuse of drugs regulations. On delivery of controlled drugs to the service, the drugs were taken to the relevant theatre for the patient but were then removed from outer packaging. It was then unclear what controlled drugs belonged to which patient. The service did not follow regulation when prescribing controlled medicines. We saw instances where the prescriptions sent to the pharmacy did not meet the legal requirement as they did not specify the doses of controlled drug to be used. The service did not follow best practice for the management of prescription stationary. The service could not assure us that all prescriptions used for controlled drugs were accounted for. Whilst there was restricted access to the prescriptions, they were stored within the medicines cupboard where they could be accessible to unauthorised staff. The service audited medicines management on a quarterly basis and leaders told us learning from the audits were shared at team meetings. However, we did not see improvement from the audit we reviewed as the same issues were found on inspection. At the time of the inspection, the service did not have a T28 exemption certificate for the sorting and denaturing of controlled drugs before disposal which is needed to meet legislation requirements. Following the inspection, the service informed us they had obtained the certificate.