10 October 2017 to 11 October 2017 and an unannounced inspection on the 19 October 2017.
During a routine inspection
Face and Eye Clinic is operated by Manchester Eye and Cosmetic Clinic Limited. The facilities include a reception with a comfortable chaired area, one operating theatre, three consulting rooms, one diagnostic room, one treatment room/laser room and four day case chairs in the post-operative discharge area.
The service provides surgery and outpatients. We inspected surgery and outpatient services.
We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 10 October 2017, along with an unannounced visit to the service on 19 October 2017.
To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.
Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.
The main service provided by this clinic was surgery. Where our findings on surgery for example, management arrangements also apply to other services, we do not repeat the information but cross-refer to the surgery core service.
Services we rate
We rated this service as good overall.
We found good practice in relation to surgical care:
- There were systems in place to protect patients from avoidable harm and learn from incidents.
- The service was visibly clean and well maintained. There were systems in place to prevent the spread of infection.
- There were effective systems in place to ensure that equipment was safe and ready for use.
- There were effective arrangements in place to ensure staff had, and maintained the skills required to do their jobs.
- Care was delivered in line with national guidance and outcomes for patients’ were good.
- The service had developed local safety standards for invasive procedures which included the use of the World Health Organisation checklist (WHO) for all surgery performed. The use of the WHO checklist ensures the correct procedure is competed on the right patient.
- There were arrangements for obtaining consent ensuring legal requirements and national guidance was met.
- The individual needs of patients were taken into account to ensure patients received safe care and treatment
- Patients’ could access care when they needed it and were treated with compassion. Their privacy and dignity was maintained at all times.
- The service management team had the confidence of patients and their team. Staff felt motivated and supported by the management team.
We found good practice in relation to outpatient care:
- The reception area was clean, modern and bright and provided ample seating for patients to sit and relax.
- We saw that patients were greeted by professional reception staff on arrival at the clinic.
- Patients were encouraged to complete patient surveys so the service could learn from their feedback.
- There was hot and cold drinks on offer for all patients who attended the clinic.
- Patients did not have to wait long following arrival before being seen by their consultant.
- There was a booking system in place to ensure patients were seen in a timely way from referral to treatment.
- There were safety procedures in place for the use of the laser.
- There were procedures in place to support patients who requested a chaperone during their consultation.
However, we also found the following issues that the service provider needs to improve:
- Access to the theatre was not secure which did not comply with Health Building Note (HBN) guidance.
- There was not a formal meeting structure in place for a Medical Advisory Committee to ensure that the medical team were regularly updated as to their performance and review their outcomes for their patients.
- There was no assurance system that all the staff had read and signed they had understood policies, procedures and risks associated with the clinic or their areas of responsibility as policies and risks were updated.
Following this inspection, we told the provider that it should make other improvements, even though a regulation had not been breached, to help the service improve. Details are at the end of the report.
Ellen Armistead
Deputy Chief Inspector of Hospitals (North)