Archived: Polmedics Limited - Bristol

We carried out an unannounced focused inspection on 10 February of Polmedics Limited - Bristol. We carried out this inspection because the provider confirmed to the Commission that this location re-commenced the provision of dental services only to patients as from 7 February 2017 following previous actions taken by the provider to voluntarily suspend all services on 19 December 2016 provided across all Polmedics Ltd locations until 31 January 2017 including Polmedics Limited – Bristol. The provider had taken this course of action following serious concerns raised following a series of inspections carried out at Polmedics Limited - Allison Street, Birmingham on 9 & 30 November 2016, Polmedics Limited - West Bromwich on 16 December 2016 and Polmedics Limited - Rugby on 17 December 2016 identifying serious concerns linked to the provider’s lack of governance and infrastructure arrangements.

This inspection was carried out at the same time as an announced inspection of Polmedics Ltd (the provider) at their administrative head office located at 36 Regent Place, Rugby CV21 2PN to assess their governance, infrastructure and leadership arrangements. During the inspection which had taken place at the administrative head office, we were informed by the provider that Polmedics Limited – Bristol was closed to patients on 10 February 2017. However, we found evidence that this location was open to patients from midday and patient appointments had been pre-booked for the day of our inspection. We therefore commenced our inspection from midday.

Our findings were:

Are services safe?

We found that this practice was not providing safe care in accordance with the relevant regulations.

Are services well-led?

We found that this practice was not providing well-led care in accordance with the relevant regulations.

Background

Polmedics Limited - Bristol is an independent provider of dental and gynaecology services and is located the in Staple Hill area of Bristol, Avon. Services are provided mainly, but not exclusively, to the Polish community who reside in the United Kingdom (UK) and employs mainly Polish clinicians and staff. Services are available to people on a pre-bookable appointment basis. At the time of our inspection, the provider had voluntarily suspended all services with the exception of dentistry as a result of concerns found during previous inspections carried out by the Commission at three other locations during November and December 2016.

The practice holds a list of registered patients and offers services to patients who reside in Bristol and surrounding areas but also to patients who live in other areas of the UK who require their services. The provider provides regulated activities from seven different locations. We were informed by the provider that there are approximately 33,000 registered patients across all Polmedics Ltd locations.

The practice is registered with the Care Quality Commission to provide the regulated activities of; the treatment of disease, disorder and injury; diagnostic and screening procedures and surgical procedures.

The practice has one dental surgery, a gynaecology room, a kitchen area with a physiotherapy room (separated by a curtain) a waiting area and a reception area. All of the facilities are on the ground floor of the premises along with toilet facilities.

At the time of our inspection, the practice employed four dentists, one trainee dental nurse and a practice manager. A previously employed practice manager is still currently the registered manager. This manager is no longer employed to work at this location and does not have day to day contact with the practice or the provider. The new practice manager had submitted an application to be the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the practice is run.

The provider is not required to offer an out of hours service. Patients who need emergency medical assistance out of corporate operating hours are requested to seek assistance from alternative services such as the NHS 111 telephone service or accident and emergency.

Our key findings were:

• The practice had limited formal governance arrangements in place. Patient outcomes were hard to identify as little or no reference was made to audits or quality improvement. For example, there was no evidence of an x-ray audit being completed.
• Arrangements to safeguard children and vulnerable adults from abuse did not reflect relevant legislation and local requirements. The practice manager was unaware who the safeguarding lead was at the practice.
• The practice did not follow guidance about decontamination and infection control issued by the Department of Health, namely 'Health Technical Memorandum 01-05 -Decontamination in primary care dental practices (HTM 01-05)'.

• The provider had not ensured that a registered manager was in place. It is a requirement of registration with the Care Quality Commission where regulated activities are provided to have a registered manager in place. The person that was named as the registered manager was no longer at this practice.

• Risks associated with the carrying on of the regulated activities were not well managed.
• The practice held medicines and life-saving equipment for dealing with medical emergencies in a primary care setting, although there were some gaps with respect to the recommended emergency medicines and equipment.
• The practice had a number of policies and procedures in place to govern activity, but some of these required updating and some policies did not reflect what we found on the day.

We identified regulations that were not being met and the provider must:

• Ensure audits of radiography are undertaken at regular intervals to help improve the quality of service.

• Ensure effective systems and processes are in place for identifying, assessing and monitoring risks and the quality of the service provision.
• Ensure arrangements to safeguard children and vulnerable adults from abuse reflect relevant legislation and local requirements.

• Ensure effective processes for timely reporting, recording, acting on and monitoring of significant events, incidents and near misses are in place.

• Ensure there is effective clinical leadership in place and a system of clinical supervision/mentorship for all clinical staff including trainee dental nurses.

• Ensure that patient safety alerts such as those issued by the Medicines and Healthcare Regulatory Authority (MHRA) are received by the practice, and then actioned if relevant. Put systems in place to ensure all doctors are kept up to date with national guidance and guidelines.
• Ensure that there are appropriate systems in place to properly assess and mitigate against risks including risks associated with infection prevention and control, Hepatitis B and other immunisations, emergency situations, decontamination of dental equipment, and legionella. Review procedures to ensure compliance with the practice annual statement in relation to infection prevention control required under The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance.

There were areas where the provider could make improvements and should:

• Ensure a system of appraisals is in place to ensure all members of staff receive an appraisal at least annually.
• Ensure appropriate policies and procedures are implemented, relevant to the practice ensuring all staff are aware of and understand them.

We carried out an announced inspection on 10 February 2017 of Polmedics Ltd (the provider) at their administrative head office located at 36 Regent Place, Rugby CV21 2PN. (We were informed by the provider that all governance and management systems in place were located at this address in Rugby and not the provider address registered with the Commission which is located in Wellingborough. We obtained verbal and written consent from the provider to carry out this inspection at their administrative head office in Rugby).

At the same time, we also carried out unannounced focused inspections of Polmedics Limited – Bristol and Polmedics Limited - Wellingborough on 10 February 2017.

These inspections were carried out due to concerns raised following a series of inspections carried out at Polmedics Limited - Allison Street, Birmingham on 9 & 30 November 2016, Polmedics Limited - West Bromwich on 16 December 2016 and Polmedics Limited - Rugby on 17 December 2016 identifying serious concerns linked to the provider’s lack of governance and infrastructure arrangements.

We inspected the provider to assess their governance and leadership arrangements in respect of these concerns, therefore it was not necessary to use all key lines of enquiry.

Our findings were:

Are services safe?

We found that the provider was not providing safe care in accordance with the relevant regulations. We have told the provider to take action (see full details of this action in the Enforcement section at the end of this report).

Are services effective?

We found that the provider was not providing effective care in accordance with the relevant regulations. We have told the provider to take action (see full details of this action in the Enforcement section at the end of this report).

Are services well-led?

We found that the provider was not providing well-led care in accordance with the relevant regulations. We have told the provider to take action (see full details of this action in the Enforcement section at the end of this report).

Background

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

Polmedics Ltd was established in 2013 and is an independent provider of dental and medical services including gynaecology, sexual health screening and other services such as consultation services which includes the diagnosis and treatment of disease and prescribing of medicines. Consultation services are provided by doctors who are referred to as internists and treats both adults and children. (At the time of our inspection, the provider confirmed that all medical services had been suspended voluntarily based on concerns found during the Commission’s inspections of three other locations during November and December 2016. It was the intention of the provider to recommence the provision of medical services in the near future).

Services are provided across seven locations in Birmingham, Bristol, Ealing, Redditch, Rugby, West Bromwich and Wellingborough primarily but not restricted to Polish patients who reside in the United Kingdom (UK). Services are available to people on a pre-bookable appointment basis and we were informed during our inspection that patients book appointments by contacting a call centre located in Poland. The provider advertise a variety of other additional services on their website such as cardiology, dermatology, midwifery, psychiatry, paediatric and orthopaedic services however, we were advised prior to our inspection that these additional services are no longer provided. The range of services advertised on the providers website differs at each location. We were informed by the provider that there are approximately 33,000 registered patients across all Polmedics Ltd locations.

Polmedics Ltd (the provider) is registered with the Care Quality Commission to provide the regulated activities of diagnostic and screening procedures, family planning, maternity and midwifery services, surgical procedures and treatment of disease, disorder or injury.

The provider had not ensured that a registered manager was in place at each location. (A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run). At the time of our inspection, one of seven locations had a registered manager in place, registered manager applications were in progress for five locations.

We were told that the provider had made recent changes to staffing levels and confirmed that 50 members of staff were employed across all locations. The staffing structure included three directors (one director acted as company secretary and one director who is a dentist acted as medical director). We were told that recent changes had taken place within the board of directors, there were previously four directors in post however, we were verbally informed that one director was dismissed by the provider due to a referral being carried out to the General Dental Council (GDC) we were unable to see any documented evidence of the dismissal process followed during our inspection. Each director has a specific area of responsibility such as premises and maintenance management, appointments system and scheduling, IT and recruitment. The provider employed one nominated individual who carried out the role of operational manager to oversee the management of all seven locations. There is a finance and human resources department which we were informed is located on the ground floor of Polmedics - Allison Street, Birmingham consisting of four members of staff. We were informed of seven managers being in post, one at each location (some managers were still awaiting commencement of their post dependent upon either a DBS check being received or confirmation as a CQC registered manager being received). The provider also employed a number of dentists, trainee dental nurses and receptionists across all locations. Some clinicians including dentists working in the locations live in Poland and travel to England on a regular basis to carry out shifts at each location.

Our key findings were:

• There was an ineffective, governance framework in place to support the delivery of the strategy and good quality care. There was a lack of effective systems and processes in place for identifying, assessing and monitoring risks and the quality of the service provision across all locations.
• There was an ineffective leadership structure in place, there was a lack of suitably trained and experienced management support in place on a daily basis at each location and there was a lack of clinical leadership and oversight at both location and provider level.
• There was no process for ensuring that the board of directors were fit and proper persons to manage the service. This is a duty required by the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Key documentation on the recruitment of individuals was missing from personnel files.
• The provider had not ensured that a registered manager was in place at each location. It is a requirement of registration with the Care Quality Commission where regulated activities are provided to have a registered manager in place.
• There was a lack of identification of risks and ineffective risk management processes in place at location and provider level to mitigate these through effective risk registers or appropriate discussion and acknowledgement of risk where highlighted by internal staff.
• The professional registration of clinical staff working at all locations were not all routinely checked at employment. The provider did not ensure that a system was in place within the organisation to ensure professional registration was routinely checked on an ongoing basis.
• The provider did not have an effective system or process within the organisation to ensure appropriate checks of current medical indemnity insurance had been carried out on all clinicians upon commencement of employment.
• There was not effective governance or monitoring processes in place to ensure that children and young people were safeguarded from abuse and improper treatment. The provider had not ensured a safeguarding lead was in place for each location. There was no policy in place in relation to female genital mutilation (FGM) and child sexual exploitation.
• There was poor quality monitoring of services in areas such as consent with clinicians having limited knowledge and understanding and not adhering to national guidance.
• The provider did not hold formal, structured, minuted meetings at either provider or location level. Meetings were either held informally or were ad-hoc. Staff we spoke with told us meetings at location level were not recorded.
• There was not an effective system in place for the reporting and investigation of incidents or lessons learned as a result. The provider did not have a process in place to ensure oversight of the reporting, recording and investigation of any incidents or significant events which may have either occurred or been reported across all locations.
• The provider had not ensured adequate arrangements were in place across all locations to respond to emergencies and major incidents as the provider had not acted upon all previous concerns raised in a timely manner during location inspections carried out during November and December 2016.

We identified regulations that were not being met and the provider must:

• Ensure an effective governance and leadership framework is in place to monitor the services provided and reduce the risk of harm.
• Ensure effective systems and processes are in place for identifying, assessing and monitoring risks and the quality of the service provision across all locations such as implementing a system of clinical audits and a system of clinical supervision/mentorship and clinical oversight for all clinical staff including trainee dental nurses. Ensure all clinical staff are competent to ensure the safety of patients using the service.
• Ensure appropriate systems are in place to properly assess and mitigate against risks including risks associated with infection prevention and control, legionella, managing emergency situations and premises and equipment.
• Ensure a review is undertaken of chaperone arrangements and that chaperone training is undertaken by staff who perform chaperone duties.
• Ensure arrangements to safeguard children and vulnerable adults from abuse reflect relevant legislation and local requirements.
• Ensure effective processes for timely reporting, recording, acting on and monitoring of significant events, incidents and near misses are in place across all locations.
• Ensure an effective process is in place to monitor patient care records so that patient information is recorded in line with the ‘Records Management Code of Practice for Health and Social Care 2016'.
• Ensure the practice's recruitment policy and procedures are suitable and the recruitment arrangements are in line with Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, with necessary employment checks are in place for all staff and the required specified information in respect of persons employed by the provider is held.
• Ensure a registered manager is in place at each location. (It is a requirement of registration with the Care Quality Commission where regulated activities are provided to have a registered manager in place).
• Review processes in place in relation to clinicians medical indemnity insurance to show that appropriate checks of clinicians own insurance is carried out prior to commencement of employment.
• Ensure that staff taking consent have the appropriate knowledge, skills and competence. Ensure consent is sought from adults and children including those that are vulnerable in line with legislation and guidance.

There were areas where the provider could make improvements and should:

• Ensure a system of appraisals is in place so all members of staff across the organisation receive an appraisal at least annually.

• Ensure appropriate policies and procedures are implemented, relevant to the organisation so all staff are aware of and understand them.

Enforcement action was taken against the provider on the 15 February 2017, when we issued an urgent notice of decision to immediately suspend their registration as a service provider (in respect of all regulated activities for which they are registered) for a period of six months. We took this action because we believed that a person would or might be exposed to the risk of harm if we did not take this action.