The Care Quality Commission
  • Hospital
  • Independent hospital

Archived: Deansgate Surgery

Overall: Requires improvement read more about inspection ratings

2nd and 4th Floor, Speakers House, 39 Deansgate, Manchester, M3 2BA (0161) 470 4504

Provided and run by:
Dr Khawaja Masood Munir

Important: The provider of this service changed. See new profile

All Inspections

20 June 2023 and 4 July 2023

During a routine inspection

Our rating of this service improved. We rated it as requires improvement because:

  • The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety appropriately. Infection risk was controlled adequately. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service broadly managed safety incidents in an adequate manner and learned lessons from them.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients and supported them to make decisions about their care.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided suitable emotional support.
  • The service planned care to meet the needs of patients. It took account of patients’ individual needs and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
  • Leaders ran services well using adequate information systems and supported staff to develop their skills. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients to plan and manage services and all staff were committed to improving services continually.

However:

  • Documents, policies and legal agreements provided were not always in the name of either the registered provider or the location.
  • Although feedback could be provided by patients in an easily accessible manner, we found that there was limited information or accessibility for patients to be able to complain appropriately about their care and treatment.

We rated this service as requires improvement because, although it was safe, effective and caring, responsiveness and leadership required improvement.

7 July 2022

During an inspection looking at part of the service

We inspected but did not rate this service.

Not all areas in the clinic were clean.

During our inspection, the registered manager was unable to demonstrate their assurance that all staff had the right to work in the UK and that staff had the training skills and competence to carry out their role.

Surgical records did not always include information about which staff member had performed a procedure.

The service medicines policy did not outline staff responsibilities for administration of medicines.

However:

We observed staff wearing appropriate personal protective equipment during procedures.

Following our inspection, the registered manager carried out the required checks and shared the relevant documents with us to show that all staff had the legal right to work for the service.

Staff received training in administering local anaesthetic injections and annual competency checks were performed.

31 May 2022

During a routine inspection

We rated it as inadequate because:

  • The service did not have effective governance systems in place.
  • Some staff had not had training in key skills including safeguarding.
  • The service did not control infection risk well.
  • The service did not fully assess risks to patients and record how these would be acted on.
  • The service did not manage safety incidents well and learn lessons from them.
  • The service did not manage medicines well.
  • Managers did not have clear processes to monitor the safety and effectiveness of the service and make sure staff were competent.
  • The service did not have some of the local policies, procedures and audits expected to support governance, ensure compliance with legislation and to support staff to do their roles safely.
  • The service did not manage patient consent well.

However:

  • Staff worked well together for the benefit of patients.
  • Staff treated patients with compassion and kindness and respected their privacy and dignity.
  • People could access the service when they needed it and did not have to wait too long for treatment.

Following this inspection, due to the concerns we found, we told the registered manager they were failing to comply with the relevant requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We served two warning notices under Section 29 of the Health and Social Care Act 2008. The warning notices related to Regulation 12(1) Safe care and treatment and Regulation 17(1) Good governance.

We are placing the service into special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate overall or for any key question or core service, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary another inspection will be conducted within a further six months, and if there is not enough improvement, we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.