The Centre for Reproductive and Genetic Health

Updated 5 April 2022

The Centre for Reproductive and Genetic Health is operated by The Assisted Conception Unit Limited. The service provides surgical procedures but has no overnight stays. The surgical procedures and Hysterosalpingo Contrast Sonography (HyCoSy) are subject to regulation by the Care Quality Commission (CQC). The service is also licensed by the Human Fertilisation and Embryology Authority (HFEA).

We inspected surgical procedures, which treats conditions of the womb such as fibroids and polyps and HyCoSy which is an investigation of the fallopian tube. These procedures are done as a part of fertility treatment and are self-funding.

From February 2021 to January 2022 the service provided:

• 172 division and curettage procedures
• 41 hysteroscopy procedures
• 48 fibroid or polyp removal procedures
• 64 HyCoSy scans

The service has a registered manager.

The main service regulated by the CQC was surgery. Where our findings on diagnostic imaging – for example, management arrangements – also apply to other services, we do not repeat the information but cross-refer to the surgery service.

Updated 5 April 2022

We have not previously inspected the service. We rated it as outstanding 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 well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records.
• Staff provided good care and treatment 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, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.
• 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 emotional support to patients, families and carers.
• The service planned care to meet the needs of local people, 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 for treatment.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. The service engaged well with patients to plan and manage services and all staff were committed to improving services continually.

However:

• Emergency medicines and equipment were available on each floor. The service checked the emergency medicines and equipment daily. However, we observed two of the oxygen cylinders had not always been checked daily in line with the service’s procedure for resuscitation equipment.

Updated 5 April 2022

We have not previously inspected the service. We rated it as outstanding 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 well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them.
• The service used technology innovatively to ensure people had timely access to treatment, support and care. There was an application which allowed secure access to treatment summaries, prescriptions and referral letters. Patients could book appointments and send secure messages to staff.
• Clinical pathways were developed to reduce the burden on patients to attend multiple appointments and were designed to offer a seamless treatment experience.
• The service was patient focused. There were two dedicated telephone lines, one operated by a consultant and the other by a nurse. Patients could call either a doctor or nurse seven days per week with any query they had. Patients said they received a quick response to their queries.
• There was an embedded system of leadership development and succession planning. The service appointed deputies in key management roles to assist managers and develop their management skills for succession planning.
• Plans were consistently implemented and had a positive impact on the quality and sustainability of the service. The service had quality objectives including clinical excellence, patient safety, patient experience and regulatory compliance. The quality objectives were regularly reviewed by the management team.
• There was a systematic and integrated approach to monitoring, reviewing and providing evidence of progress against the strategy and plans. There was a list of key performance indicators (KPI) which the service regularly measured as part of the audit system such as the volume and scope of work, incidents, staffing levels, complaints, incidents and legislation and regulatory requirements.

Updated 5 April 2022

We have not previously inspected the service. We rated it as outstanding because:

• The service provided mandatory training in key skills to all staff and made sure everyone completed it.
• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse.
• The service controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. They kept equipment visibly clean.
• Doctors, nurses and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
• The service was inclusive and took account of patients’ individual needs and preferences. Staff made reasonable adjustments to help patients access services.
• Leaders had the skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in the service for patients and staff. They supported staff to develop their skills and take on more senior roles.

However:

• Emergency medicines and equipment were available on each floor. The service checked the emergency medicines and equipment daily. However, we observed two of the oxygen cylinders had not always been checked daily in line with the service’s procedure for resuscitation equipment.

Diagnostic imaging is the smaller proportion of the clinic’s activity. The main service was surgery. Where arrangements were the same, we have reported findings in the surgery section.