Prem House Clinic Ltd is operated by Prem House Clinic Ltd. The clinic provides cosmetic surgery services for private fee-paying adult patients over the age of 18 years. Most patients are admitted for planned day case surgery procedures but can be accommodated overnight if required. Facilities include four consultation rooms, a ward with seven beds and one operating theatre.

The main service provided by the clinic is surgery. We inspected this service using our comprehensive inspection methodology on 30 October 2018.

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.

Services we rate

This is the first time we have rated this service. We rated it as Good overall.

We found the following areas of good practice:

• Staff recognised incidents and reported them appropriately. The service had suitable premises and equipment and looked after them well.
• The service provided care and treatment based on national guidance and evidence of its effectiveness.
• Staff cared for patients with compassion. Feedback from patients confirmed staff treated them well, and with kindness. Staff provided emotional support to patients to minimise their distress.
• The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.
• The service provided mandatory training in key skills to all staff and made sure everyone completed it. Staff had training on how to recognise and report abuse and they knew how to apply the required actions.
• The service made sure staff were competent for their roles. Doctors, nurses and other healthcare professionals supported each other to provide good care.
• Staff sought consent from patients prior to delivering care and treatment. The service took account of patients’ individual needs.
• The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.
• Managers promoted a positive culture and had the right skills and abilities to run a service providing high-quality sustainable care.
• There was a clear vision for the service and the mission statement and philosophy of care had been shared with and was understood by staff across the service.
• The service had effective governance systems and processes for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.

However, we also found the following issues that the service provider needs to improve:

• The incident log summary record used for identifying themes and trends was not fully complete and kept up to date.
• The risk register record had not been kept up to date.
• The service did not have a formal strategy document in place.
• The clinic did not store emergency bloods; however there was an arrangement with a neighbouring NHS acute trust for the supply of emergency blood if needed.
• The named safeguarding lead was not trained to level 4 safeguarding training, in accordance with the intercollegiate document; AdultSafeguarding: Roles and Competencies for Health Care Staff (August 2018).

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 Region)

The location of Prem House Clinic Limited (known as Prem House Clinic) is part of a larger provider known as Prem House Clinic Limited. Prem House Clinic is an independent hospital based in Liverpool, which provides surgical cosmetic services.

We undertook a focussed follow up inspection on 31 July 2017 to review action taken by the provider in response to a warning notice issued 18 August 2016.

We regulate cosmetic surgery services but we do not currently have a legal duty to rate them when they are provided as a single specialty service. We highlight good practice and issues that service providers need to improve and take regulatory action as necessary.

The warning notice issued 18 August 2016 highlighted areas where the provider was required to make improvements. These included:

• Ensuring staff understood what constituted an incident and incidents were reviewed to ensure improvements in standards of care.
• Ensuring there were effective systems and processes in place to assess, record and mitigate risks relating to patient safety.
• Ensuring there were robust systems in place for the safe management and administration of medicines.
• Ensuring staff were up to date with annual and three yearly mandatory training, especially in basic, immediate and advanced life support training safeguarding.
• Ensuring robust systems were in place to ensure that surgeons undertaking procedures are competent and work within the scope of their qualifications, skills and experience.

During our focussed follow up inspection on 31 July 2017, we found the provider was compliant with the requirements of the warning notice.

We found the following areas of improvement:

• Staff knew how to report incidents; incidents were discussed at clinical governance meetings and feedback was provided to staff in monthly clinical staff meetings.
• There were effective systems and processes in place to assess record and mitigate risks relating to patient safety. Staff had received training in completion of the national early warning system (NEWS) and records were audited to assess compliance.
• Medicines management had significantly improved to provide safe care and treatment for patients.
• All staff were compliant with mandatory safeguarding training. Annual basic life support training (BLS) had been completed by 100% of staff and seven out of nine ward staff and three theatre staff had completed immediate life support (ILS).
• There were systems in place to ensure that surgeons undertaking procedures were competent and worked within the scope of their qualifications, skills and experience.

Ellen Armistead

Deputy Chief Inspector of Hospitals (North Region)

Prem House Clinic Limited had one operating theatre and seven beds, divided into a four bedded ward, a two bedded room and a single room.

During this responsive inspection we looked at specific parts of the regulations for which we had received concerns. The team included a specialist advisor (theatre nurse) who observed a cosmetic surgery list. We talked with eight staff members including the manager, a consultant anaesthetist, and a consultant surgeon. We reviewed four sets of notes, which included a patient who had received post-operative care. We did not have an opportunity to speak with patients, although we did review patient surveys and observed interactions between patients and staff. Feedback from the provider's patient survey was mostly positive, with only a few negative comments about the ward decoration.

We found that staff planned and delivered care and treatment to ensure people’s safety and welfare and that people’s care and treatment reflected relevant research and guidance. Although people were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard, the provider did not have adequate systems in place to supervise and appraise staff. This meant that the service had not provided all staff with relevant feedback so they could learn and develop.

The provider monitored the quality of the service through a programme of clinical audits and registers which was mostly robust and effective. The provider was responsive to some concerns, but did not adequately identify or investigate all concerns, such as outlying infection control rates or allegations of bullying or harassment. This meant they had missed opportunities to improve the quality and safety of the service.

At our last inspection in May 2013 we found there was not an effective system for monitoring the service provision to protect the patients. Action was needed for this essential standard.

Following the inspection we received an action plan from the provider (owner) and this addressed the issues raised. On this inspection we looked to see if these standards had been maintained.

We found the provider had developed improved systems for assessment and monitoring the quality and safety of the service the patients received. These were now more consistent, so that the manager and staff were better able to identify and make any necessary improvements to the service. We saw audits (checks) and this provided an over view of the servie provision. For example, standards of cleanliness, complaints, patient satisfaction feedback, health and safety and completion of patient records were being monitored to help assure a safe, effective service.

Patients' feedback had been sought regarding the 'patient experience' and positive comments had been received.

During our visit to Prem House Clinic we spoke with four patients. We received positive comments from them about the care and treatment they received. A patient told us, "I had really good treatment from the start." As part of our inspection we spoke with four members of staff who had varying skills and qualifications to find out how they provided care and support to patients.

We observed staff providing patients with advice and clear explanations about their treatment and surgical options. Patients informed us they met with their consultant and the staff prior to surgery and their care and treatment options had been fully discussed with them. They told us their written consent was sought once they were fully informed and ready to proceed with surgery. Patients' written consent had been obtained prior to their admission to the clinic for their chosen treatment.

Patients had a written care pathway (plan of care) from admission, to the process of anaesthesia, surgery, recovery, discharge and post operative (after) care. The care pathway recorded the care and treatment the patient needed and received from the staff.

There was an effective recruitment procedure in place. This included police checks of prospective employees to ensure their suitability to provide care to patients at the clinic.

Patients had access to a complaints procedure. There was not however an effective system for monitoring the service provision to protect the patients.

We spoke with four patients at the time of our inspection about their care and treatment. Patients told us they had received an information pack prior to their treatment and this provided detailed information about the hospital, their prospective treatment and pattern of recovery. Patients told us they were fully informed of the choices available to them and the risks involved with their treatment to ensure they were able to make informed decisions.

Patients informed us they met with their consultant and members of the nursing staff prior to the surgery and at this meeting their care, treatment and options had been fully explained to them. Patients informed us the consent form had been fully explained to them, so they were aware of what they were signing. One patient reported, “The staff answered all my questions at my first appointment and went through the consent form."

Patients said their follow up clinic appointments were arranged promptly. They told us they were given an ‘on call’ number to phone 'out of hours' should they wish to speak to someone, if they felt unwell or needed advice.

Patients made the following comments about the staff, “The staff are very good”, “The nurses and doctors gave me all the advice I needed and were professional” and “The whole experience was good.”

Prem House Clinic is an independent hospital, based in Liverpool which provides surgical cosmetic services and is part of Prem House Clinic Limited. The majority of surgical procedures are day case breast augmentations but also blepharoplasty and abdominoplasty to patients over the age of 18 years of age are provided.

The hospital’s senior management team consists of a director and the registered manager. Clinical advice is provided from the chair of the medical advisory committee (MAC).

We inspected Prem House Clinic as part of our comprehensive inspection programme and we carried out an announced inspection on 13 July 2016. At the time of our initial visit there was no surgery planned for the day. We also carried out an unannounced inspection on 18 July 2016, which was the first day surgery was planned following our announced inspection. We have not rated this service because we do not currently have a legal duty to rate this type of service or the regulated activities which it provides. A warning notice has been issued to the provider setting out improvements that need to be made.

Are services safe at this hospital

• The majority of staff we spoke to were unaware what constituted an incident and issues such as, surgical site infections, which would be considered incidents, were not being reported. We were not assured that learning from incidents was being cascaded to staff to improve standards.
• The adverse incident management policy did not reflect the duty of candour requirements. There was a theatre standards policy but this was not always being implemented and the World Health Organization (WHO) five steps to safer surgery were not being followed in full.
• The processes and procedures for the safe management of medicines was not robust. We found that the prescribing of medication was not clear and there were occasions when medication had been given to patients more often than was recommended. There was also medication which did not have the expiry date on and medication that was dispensed for a specific individual was being used as medicine for other patients
• It was unclear if essential equipment had been regularly checked and there was suction tubing, two interlock connectors and yellow blood bottles in the resuscitation trolley that would be used in an emergency which were out of date. There were times when patient records were left unattended and the integrated care pathway documentation was not always being fully completed.
• There was a lack of guidance for staff on what to do following the completion of risk assessments.
• The out of hours service was not being monitored to measure its effectiveness and to improve standards in care. The majority of staff we spoke to were unaware how this service operated and a patient said they had been unable to access the service.
• Staffing levels and skill mix were planned and reviewed to ensure there was sufficient numbers of staff to provide safe care.
• There were good hand hygiene practices were observed and posters available for the public outlining how to wash their hands to help control infections. Environmental risk assessments were completed on an annual basis on all areas such as the ward and theatre.

Are services effective at this hospital

• Best practice guidance, such as those from the National Institute for Health and Care Excellence (NICE), was not always being clearly documented, especially in relation to undertaking routine pregnancy testing or asking patients if they may be pregnant, before procedures.
• Whilst food and drink was available for patients at the hospital the malnutrition screening tool, which was completed during consultation, did not outline the score correctly for staff to refer to for nutritional assessments.
• The hospital was not monitoring patient outcomes effectively. There was not a review system in place to ensure that surgeons undertaking procedures were competent. Not all doctors were fully engaged with the annual appraisal process.
• The hospital were not routinely collecting and reporting on cosmetic patient reported outcomes( Q-PROMs) data which is a recognised tool to collect patient satisfaction with their operation.
• Patient pain was managed effectively and staff worked well together. Consent processes were based on national guidance. The hospital had a local audit programme in place.
• The Private Healthcare Market Investigation Order (2014) requires every private healthcare facility to collect a defined set of performance measures and to supply that data to the Private Healthcare Information Network (PHIN). Hospitals were required to collect this data from January 2016, ready for submission in September 2016. The hospital had a process in place to record this information and was aware of the requirement.

Are services caring at this hospital

• Patients were treated with dignity and respect and were fully involved in their care.
• Staff explained procedures to them in a way they understood.
• Patients spoke positively about the care they had received and had been given all the information they required.

Are services responsive at this hospital

• The facilities and premises were appropriate for the services that were planned and delivered. However, the anaesthetic room was not used and patients were anaesthetised in theatre. This meant they had to pass the recovery area and there were times when they saw other patients who were being recovered from surgery. One such patient was in distress and this caused anxiety in a patient awaiting surgery.
• Discharge arrangements were not always robust and the theatre standards policy was not always being implemented.
• There was a lack of policies for some key areas such as female genital mutilation and some policies contained inaccurate information.

• The hospital did not use the Independent Sector Complaints Adjudication Service which meant that the only process of appeal was for the complaint to be dealt with internally by the director.
• Consultation clinics were regularly monitored to make sure they were running on time. On rare occasions when clinics ran late, staff would ensure patients were kept informed. The hospital arranged appointment and surgery times to meet the needs of the individual patient.
• Information leaflets were available for patients and staff could access interpreter services if required.

Are services well led at this hospital

• There was a governance reporting structure with meetings being held on a monthly or quarterly basis. However, there was limited assurance that learning from incidents or complaints were discussed or disseminated to staff to help improve standards of care.
• There was no formal risk register in place to highlights risks to the service or outline how they would be mitigated in an effective and timely way.
• The hospital sought feedback from patients about the care received through their own surveys.
• Staff were positive about the leadership of the service and enjoyed working at the hospital.

Our key findings were as follows:

Incidents

• The hospital had an adverse incident management policy and procedure. However, the majority of staff were unaware what constituted an incident. What would be considered incidents were not being reported. For example, patients returning to theatre or surgical site infections. We were not assured that learning from incidents was being cascaded to staff to improve standards. The adverse incident management policy did not reflect the duty of candour requirements.

Assessing and responding to risk

• The five steps to safer surgery were not being fully followed.
• It was unclear if the anaesthetic equipment and breathing circuits had been regularly checked and there were a number of consumable items in the resuscitation trolley that were out of date. There was suction tubing, two interlock connectors and yellow blood bottles
• Following discharge, patients could call the hospital for advice or reassurance. However, the calls to this service were not being monitored to look for trends to help improve standards of care. The majority of staff we spoke to were unaware how this service operated and a patient said they had been unable to access this service.
• Discharge arrangements were not robust.

Medicines

• The processes and procedures for the safe management of medicines were not robust. We found that the prescribing of medication was not clear and there were occasions when medication had been given to patients more often than was recommended. There was also medication which did not have the expiry date on.
• We found medicines that had been dispensed for a specific individual were being used as medicine for other patients and quarterly audits of controlled drugs had not highlighted issues with controlled drugs.

Records

• Patient records were left unattended at times which increased the risk of them being accessed by unauthorised personnel.
• The integrated care pathway documentation was not always being fully completed and there was a lack of guidance for staff following the completion of risk assessments.

Evidenced based care and treatment

• National Institute for Health and Care Excellence (NICE) guidance was not always being followed.

Competent staff

• There was a lack of monitoring of staff competencies.
• All doctors were not fully engaged with the appraisal process and mandatory training levels were low, especially in life support.

Access and Flow

• The patient journey through the hospital was not always as person centred as it could have been. As the anaesthetic room was not being used, patients had to pass the recovery area where patients who had just had their operation were recovering.

Complaints

• The hospital did not use the Independent Sector Complaints Adjudication Service which meant that the only process of appeal was for the complaint to be dealt with internally by the director.
• The complaints policy contained inaccurate information.

Governance and risk management

• There was a governance reporting structure and the main governance committee was held on a monthly basis. However, learning from incidents or complaints or trends were not discussed to help improve standards.
• We saw no evidence that other doctors working at the hospital under practicing privileges attended the medical advisory committee to help give clear clinical oversight of the clinic.
• There was no formal risk register to identify potential risks to the organisation or to patients. This offered no assurance that risks were being mitigated in an effective and timely manner.
• Policies were not always being fully implemented, for example, the complaints policy contained inaccurate information. Policies were not available for some key areas, such as female genital mutilation.

There were areas where the provider needs to make improvements. A warning notice has been issued to the provider. Importantly, the provider must:

• Ensure there are effective systems and processes in place to assess, record and mitigate risks.
• Ensure processes are in place and followed to guarantee equipment for resuscitation are in date.
• Ensure there is a safe process in place for the management of medicines.
• Ensure safe storage of patients’ records.
• Ensure staff adhere to all policies and ensure the theatre standards policy is fully implemented.
• Ensure the integrated care pathway documentation is completed accurately and the paperwork is correct, especially the malnutrition screening tool.
• Ensure that risk assessments include relevant guidance for staff.
• Ensure that relevant best practice guidance is implemented and ensure routine pregnancy testing or recording of patients last menstrual period is recorded in all cases.
• Ensure full compliance with the use of the early warning scoring (EWS) system and that staff are fully competent in the use of the system.
• Ensure that policies are reviewed to ensure they contain accurate and up to date information. Especially the complaints policy, discharge policy, admission policy and adverse incident policy together with developing a female genital mutilation policy.
• Ensure the service is meeting the recommendations from the Review of the Regulation of Cosmetic Interventions in relation to collecting QPROMS and SNOMED coding information.
• Ensure that all doctors have up to date appraisals.
• Ensure that all staff receive regular supervision meetings
• Ensure that all staff are up to date with mandatory training, especially in basic, intermediate and advanced life support as well as safeguarding training.
• Ensure that patient outcomes are fully monitored.
• Ensure that there are robust systems in place to ensure competencies of doctors performing surgery are regularly monitored.
• Ensure that incident processes and procedures are reviewed and that staff understand what constitutes an incident and that learning is identified and cascaded to staff to improve services.
• Ensure that the out of hours on call service is fully monitored to inform improvements in standards of care.
• Ensure that the patient journey is reviewed, especially from being anaesthetised to discharge.
• Ensure there are robust systems in place for the safe management of medicines.
• Ensure that a copy of the discharge information is sent directly to the patient’s general practitioner.

In addition the provider should:

• Consider how doctors engage with the medical advisory committee.
• Consider how the responsible officer engages with governance meetings.

Professor Sir Mike Richards

​Chief Inspector of Hospitals