Prem House Rotherham is operated by Prem House Limited. The service has eight beds, three operating theatres were on site, but we were told that only one was in use and two clinic rooms.

The hospital building also has another provider and location registered at this address. These are owned by the same individual.

The service provided cosmetic surgery services.

We carried out an unannounced responsive inspection following concerns raised about patient safety. We carried out the inspection on 13 and 14 March 2018 and inspected parts of the safe and well-led domains in surgery.

During our inspection there were no planned surgical procedures due to take place and the hospital was in the process of being sold. The registered manager told us that the hospital was closed for two weeks,from 9 March until 25 March, however they were still providing clinic services, such as consultations and wound checks. The next planned theatre list was for 25 March. We were therefore unable to speak with patients, but we spoke with staff that were in the hospital on the dates we inspected, including the registered manager, and reviewed patient and hospital records.

Services we do not rate

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.

We found the following issues that the service provider needs to improve:

• Leadership was poor. There was confusion from staff as to who they were employed by and we found that staff were potentially unemployed at the time of our inspection. This was only rectified when we raised it with the registered manager.
• Governance processes were not robust and there was a lack of assurance.
• Medical advisory committee (MAC) and governance meetings had not taken place since July 2017. The registered manager told us this was due to the sale of the hospital.
• Staff records were not kept up to date and information was not held centrally to provide assurance that staff had up to date indemnity insurance, practicing privileges and training. Although this information was provided following the inspection the systems were not in place to ensure availability of this information when required and to provide assurance that the provider was aware of when staff training, etc needed to be reviewed.
• There was a mixture of documentation used which related to two different providers registered with CQC at the same location; this meant that it was not clear about which provider was carrying out the regulated activity and who was accountable for the patients’ care.
• There were unsecured old patient records stored in the hospital.
• Staffing in theatres did not comply with national guidance, as there was only one scrub practitioner instead of two.
• The air conditioning system had not had regular verification testing, however following our inspection this was arranged.
• Water safety records showed areas of non compliance with the approved code of practice and guidance on regulations for legionnaires’ disease.

We also found the following areas of good practice:

• The environment was visibly clean.
• Audits showed that infection rates were low and had decreased over the last year.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with three requirement notices. Details are at the end of the report.

Ellen Armistead

Deputy Chief Inspector of Hospitals (North)