The Care Quality Commission has ordered a London charitable hospital to make improvements to its surgical services following a recent inspection.
The CQC carried out an unannounced inspection of the surgical services at the London Clinic in June. The private hospital provides a range of surgical procedures, as well as diagnostics and screening, treatment of disease or injury, and management of the supply of blood and blood derived products.
The CQC revealed the inspection followed concerns which arose after several departmental ‘never events’ – mistakes that should never happen during medical treatment. The service reported four never events in total between January and September 2020. These involved surgical items which were left in the body after surgery and one case of wrong tooth extraction.
Following the inspection, the rating for surgical services was downgraded from good to requires improvement. The surgical service has been rated inadequate for being well-led, requires improvement for being safe, effective and responsive and good for being caring. The London Clinic has also been served with a warning notice requiring it to improve governance of the surgical service.
The overall rating for the hospital is good and it is rated good for being safe, effective, caring and responsive, but requires improvement for being well-led.
What inspectors found
CQC inspectors found that hospital leaders did not always have the skills and abilities to run the service, that risks were not always identified and escalated appropriately, that use of bank or agency staff was high, that policies were out of date and systems to review policies were ineffective, that the service lacked strong systems for monitoring the outcome of care and treatment, that staff did not always investigate complaints fully and that staff could not always find data when required in easily accessible formats to understand performance, make decisions and improvements.
However, inspectors also found that staff felt respected, that they had training in key skills, that they controlled infections well, that they worked well together for the benefit of the patients and that they treated patients with compassion and kindness.
Inspectors also found that the service planned care to meet the needs of local people, took account of patient individual needs and that leaders and staff actively and openly engaged with patients, staff, equality groups, the public and local organisations to plan and manage services.
Concern about never events
Commenting on the CQC’s action, Nicola Wise, CQC’s head of hospital inspection for London, said: “We inspected The London Clinic because we were concerned about the number of serious incidents and never events that had taken place when performing surgery on patients. The provider told us that the COVID-19 pandemic had put additional pressures on the department because, in addition to the usual private work, they were also working with the NHS which meant that their theatre activity had significantly increased, resulting in higher volumes of more complex work and working with teams that were new to the organisation.
“Although we understand the pressures that healthcare providers have faced, and continue to face, as a result of the pandemic, never events are precisely that – they should never occur. If they do, it is important that they are thoroughly investigated to ensure that they do not happen again. In this case, each incident was fully investigated, and learning was shared with all staff.
“However, while leaders told us that they were committed to continuous learning, improvement and innovation, we did not see clear evidence of this during our inspection.
“We found that there was an inconsistent approach to dealing with incidents, and we were not assured that all staff were able to recognise what should be logged as an incident. For example, we found that there were 11 incidents in which pregnancy tests had not been carried out prior to surgery, which had been logged as ‘negligible – no harm’. If a patient who was pregnant had been operated on, both they, and their unborn child, would have been at risk of harm. By not recording these incidents as being potentially harmful, opportunities to learn lessons have been missed.
“We were also concerned to hear that some staff reported a dictatorial approach to leadership and felt they were unheard when it came to raising concerns about senior management. We heard from staff that that there was lots of fluctuation in the leadership team and that leaders of departments and teams would sometimes leave their post suddenly, without any handover period, making it challenging for staff to continue in their absence.
“We have told the provider that it must make a number of improvements to the service and we will continue to monitor it closely to ensure that these take place.”
Quality improvement
In response, a spokesperson for The London Clinic said: “This was a targeted inspection in one area of The London Clinic. The London Clinic’s overall CQC rating remains ‘good’, with ‘good’ ratings across the domains of safe, effective, caring, and responsive. The report itself recognised a number of positives in the delivery of surgical care and patient outcomes, which is corroborated in a review by the Royal College of Surgeons whom we had invited to independently assess our processes earlier this year following the incidents last year during the pandemic.
“However the CQC did identify shortcomings in our supporting governance and assurance framework, in particular how we apply lessons learned. We accept this feedback.
“We saw that these processes were disrupted at the height of the Covid pandemic, and it should be noted that a quality improvement program was already underway at the time of the CQC visit and, three months on, these are now well advanced. In this time we have made several improvements, including enhanced quality Huddles and a quality buddies system; commenced a new ‘good governance’ training programme; realigned the clinical governance responsibility and improved the complaints handling procedures.
“We want to clarify an important point about pregnancy testing that the CQC mentions in their press release that could be misunderstood by any reasonable reader. In the incidents the CQC refer to, The London Clinic has not failed to carry out pregnancy testing prior to surgery or care and no patient came to any harm, potential or otherwise. Where there were incidents of delays to pre-surgery pregnancy testing, they were fully investigated, lessons were learned and adjustments made to our policy prior to the CQC inspection.
“We are confident that our newly-integrated clinical governance framework has been given fresh impetus under new leadership and has delivered an enhanced safety culture”
