Inspection of private clinics

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Hello to all,

Earlier this year, I came across a report made upon a private medical clinic, by the Healthcare Commission. Very extensive it was too (over 50 pages long)...covering instrument maintenance, risk assessment, staff training, complaints procedures, cleanliness etc.

I was reminded of a study I undertook as an ergonomist, in which several pods told me confidentially about the rather substandard conditions in which they worked: autoclaves that didn't work properly, clinical waste that was allowed to pile up, poor/broken seating causing back pain etc.

I don't have much personal experience of private work, but am wondering: do private podiatry clinics ever get checked? I see that the Healthcare Commission cover 'private clinics', but does that include podiatry? None of the subjects in my study ever mentioned clinic checks...but other professions are checked, so surely pods should be, too?

I'd be really interested if any folk on here have had experience of a HC check: how it was conducted, and if they know of any instances where a clinic has failed a check (and why). The story of flies buzzing around a stale, smelly 'skin bin' cannot be an isolated case, and one would hope the HC would step in, in such a case.

 

victoriah

I take it with no replies, the answer must be podiatry private practice has no external scrutiny. Guidelines yes, but no actual audit ?

I would be interested to discover what sterilisation procedures are best suited to private practice from the practical and economical perspective.

Autoclaves, CSSD, and single use instruments

What say you?

toeslayer

 

Hello Toeslayer,
At the moment there is no external scrutiny of private chiropody/podiatry clinics that I know of in UK.
I have been hearing rumours for some time about the Health Commission inspections but nothinig tangible has appeared so far.
The SCP has clinical standards that include cross infection and decontamination procedures. The SCP supports the use of bench top autoclaves and ultrasonic cleaners and from 2010 all autoclaves are required to have a printer fitted. There is a minimum reccomended use time for autoclaves instruments. I believe the cost of all this puts us at a disadvantage in the market place.
I do not know what the standards are for other professional organisation.
There has been much discusion on the SCP site about single use instruments and instrument traceability. I know the NHS in my area will soon be going over to CSSD, but this is their own initiative and not a requirement for IPPs.
Dido

 

Hi

The Institute requirements are similar, if not identical to the Society.

The Healthcare Commission certainly have the right to inspect any private clinic, including podiatry but they do not seem to have carried out out any yet. Perhaps they have not reached 'p'!

Jack Golding has posted on this site concerning care standards and private operating theatres. Presumably any pod carrying out nail surgery will come under that legislation.

Bill Liggins

 

All,

Please do not quote me on this but I think the first inspection of a private 'Podiatry clinic' was carried out by the Health Care Commission late last year.

It may even have been J Golding's. But that was a Podiatric surgeons 'surgery', if you can understand the difference.

I also believe that the HCC do have powers to inspect podiatry premises but have problems with manpower.

The Society has an accreditation scheme which they hope would go some way to supplying the sort of assurance the HCC would need.

I also believe the HCC is due to be altered in the near future, so who knows what will happen.

All very complicated, and Wales has it's own rules.

I think Kevin Hill and Ralph Graham at the Society were well up on this. Somewhere BUPA were involved as well.

Perhaps Podiatry will eventually be forced into domiciliary work only?

Bob

 

Hello all,

I am unsure if I have done the wrong thing here but I have copied & pasted a section from SCPs website (am I allowed to do this?)

Anyway I hope it is pertinant to the discussion.


Standards for the clinical environment

The following standards are recommended for clinical environments for podiatric practice in primary care:

1. The treatment room should be of adequate size for scope of practice.
2. Privacy should be assured; conversations in the room should not be easily overheard.
3. The room should be well ventilated, by natural or artificial means.
4. The room should be heated when required.
5. The room should have good general lighting, natural or artificial.
6. There should be an adjustable directional light; preferably colour corrected.
7. The flooring should be impervious, non slip with splash-back skirting capable of being cleaned and disinfected.
8. Walls and ceilings should be dry and free from cracks or visible defects.
9. The examination couch, operator chair and work station should have an intact impervious cover and be capable of being cleaned and disinfected.
10. Work surfaces should be impervious and capable of being cleaned with disinfectants.
11. There should be a designated and accessible hand washing basin with sensor or lever operated mixer taps providing hot and cold water.
12. Antiseptic hand washing solution and/or alcohol hand rub should be available in wall mounted containers.
13. Liquid soap and paper towels should be available in wall-mounted containers.
14. A sharps bin container conforming to UN3291 should be accessible in the treatment room above waist height and preferably fixed to the wall.
15. Pedal operated waste bins with a yellow bag should be available for clinical and hazardous waste.
16. There should be a designated area for the decontamination of instruments, ideally in a separate room.
17. There should be two sinks (or a sink and a dedicated bowl) for the cleaning of used instruments prior to disinfection.
18. There should be secure facilities for the hanging of clothing and keeping of valuables.




How to find out more about health and safety law and how it is enforced
More information, including what businesses must do by law, can be found in these free HSE leaflets available from HSE:

An introduction to health and safety INDG259

Health and safety regulation - a short guide HSC13

The Health and Safety Executive - working with employers HSE35

The Health and Safety Executive and you HSE34

The Health and Safety Commission:
Enforcement Policy Statement MISC030

The future availability and accuracy of the publications listed above cannot be guaranteed.

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HSE priced publications are also available from good booksellers.

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Regards as always,

 

Hello Twirly,
I don't think there is a problem posting the SCP's clinical standards, which are very comprehensive.
In the interest of completeness perhaps we could have sight of those for the BChA, and the 2 FHP organisations. Perhaps David H could oblige?
Thanks
Dido

 

Hi Dido,

Great idea. It would be good to know everyone's 'singing from the same hymn sheet.'

I love the idea of sharing information. Makes our world of Pod' less cloak & dagger.

Can only improve the situation (hopefully).

Regards,

 

Thanks for all those replies guys. Seems an odd situation that clinics aren't routinely checked. I'm sure the GBP aren't aware of this!

I can think of one example from my research in which a subject stated that the autoclave had broken 'years ago', and they simply cleaned their instruments in 'hot water'

I'm not even sure if clinics even have to be 'registered' as such, with anybody, anywhere. One of my friends just hired out a room in her neighbour's house, and off she went...not even a proper 'clinic' as such.

It's all a bit worrying, and further evidence that this profession needs upgrading if it wants to be taken seriously.

 

Hi Victoriah et al

How achievable or enforcable are these cliniclal environment standards? While we all strive to conform to the standards set down, there are times when some of them are beyond our means- for example, I rent a room in a GP surgery- therea are some criteria from the SCP list that I cannot meet due to the set up of the room. Would this mean that I could no longer practise on those premises?

The accreditation scheme was put to us at a branch meeting and did seem a good idea, but even that seems difficult to acheive unless you are building a state of the art clinic from scratch.

There has to be some leeway for the work environment- surely as professionals we should be given credit for using our integrity in assessing the suitability of our clinics?


cornmerchant

 

Hello all,

When I initially began the process of setting up my clinic in 1998 I contacted the local council, HSE etc for advice.

I was told if I intended to run a tattoo parlour, a dental surgery or a sandwich shop I would indeed be expected to be subject to random inspection.

However as a practicing Podiatrist no such liabilities (other than those recognised by my governing body) were anticipated.

Oddly enough though I regularly recieve & comply with my 'Duty of care' for clinical, sharps etc waste disposal.

Puzzled? I was/Am.

My guess would be as long as you don't make your patients a chip butty post treatment, do not impregnate their skin with colourant dye & refrain from molar removal alls good with the world!

Funny ole world innit.

 

Hi Dido.
I'm a BChA member and I don't recall seeing a list of guidelines for how our surgeries ought to be. That is something remiss in my opinion. The society accrediation scheme seems a good thing imho. I think that to meet all the guidelines above you would need a great deal of cooperation from your landlord or your own surgery which you own and a lot of money to do all the stuff.

Interestingly if you've read the transcript of the Baldwin case (which is available from the HPC) you will notice that he was told to get a continous impervious flooring which went above the level of the skirting board. This is not on the SCP list (or have I missed it)? I'm not trying to be funny or a Troll in stating this, so please don't slap me.

As far as a flooring that goes up above the skirting board, I've only ever seen it in one Private Practise locally. If you look at YOU TUBE and watch the videos of Emma Supple's surgery (I'm not taking her name in vain or trying to be cheeky if she's reading this) you notice that her flooring stops at the skirting board (unless its now changed). I suspect this is the case for most Podiatrists in PP nationally?

So how far does one go? Particularly if you don't own the surgery. And what does happen in the SCP if your surgery isn't accredited? Nothing? Unless you have a dirty surgery and someone complains to the HPC?

The Society although being the largest professional body are not the makers or enactors of the 'law' regarding podiatry. The HPC is the decider of if a someone's "fitness to practise is impaired by reason of X". The Health Care comission can and do report people to the HPC though. So we do ALL need the correct guidance.

I do not post this to be society bashing. I think it laudable that you have easily available guidelines and I don't think we in the BChA do. Hopefully I'm wrong?

Wonderingly,

Robin.

PS.

As far as costs is concerned it obviously costs money. The shame is that either practitioner's fees do not truly reflect the costs incurred to them. Or if a practitioner charges a realistic fee the public do not always percieve the value of their treatment and what has had to go into it re: the above. This I think is a major gripe regarding FHP's(and I'm not trying to defame them). The fact is that they currently cannot get struck off and although many do try to do the right things, the fact remains that they can't have the HPC come knocking at their door if they break the HPC rules we have to keep.

 

Hi Robin,

I am inclined to agree.

The HPC indeed sets the rules for the registered Pods.

However, it would be far fairer if they actually had an elected clinician setting the standards.

As you identified it is the lowly & meek (us) the fee paying Pods who are subject to the whims of the council (HPC).


Give me any policy which in practice is viable & workable & I will wholeheartedly adhere to each & every letter.

Unfortunately what tends to happen is 'the powers that be,' release unworkable standards & judge us all by any failure to comply.

IMO it all again <sigh> comes down to unification. Standing as a single voice to state that which is workable without the daft politics & mud slinging.

I want what I believe most of us want. 1 unified body committed to the professional forwarding of the profession of Podiatry.

One list of demands which we all agree on.

A base point of clinical skills whereby our facilities and our skills flourish instead of the bog of division & indecision we seem to be in currently.

I didn't intent to go off on a rant but sometimes all roads appear to lead to the same destination.

Regards,

 

sorry twirly but you are totally off track with this tread.

The Health Care Commission HCC and the Health Professions Council HPC are two very different regulators.

The SCP while giving guidance do not set government standards.

The Baldwin decision was IMO a very bad decision, try asking the HPC or the SCP questions about it?

Your desire for unity is laudable, but are there not other threads on which you can explore that.

Robin why do you think the SCP have invited all HPC pods to join? Could it possibly because they are the body that addresses these issues? And perhaps that is why the members pay such exorbitant fees?

Sorry you made some very good points and it is wrong to promote one organisation over another..

Bob Golding

 

netizens

There are two components to guidelines i.e. legal obligations, and well meant professional recommendations. The first is mandatory and the second merely advisory.

Practitioners use the professional recommendations to establish new clinical facilities and or updated exisiting clinical areas (with their employers). This usually involves negociated levels of clinical care e.g. surgical podiatry or orthotic service. Sometimes the professional guidelines are very helpful (particularly when both parties are relatively ill informed) but usually like all sets of rules (and in this case made up from serendipidous sources), somewhat restrictive.

As a minimal guide, professional recommendations have a surface validity, but it is the legal obligation (and health and safety in the workplace aspects) which carry the clout.

Many years ago when I had a mid parting and people had acknowledged the present danger of blood borne viruses I did some investigative work into the standards of practice of infection control in podatry practice. As a researcher I was privvy to other unpublished research, the results of which may have been the cause of my premature baldness. Overall the findings were daming and pod practice in the UK (private and public) did not involve universal precautions. I corresponded with the Department of Health and they confirmed guidelines had been published for non registered chiropodist but not registered chiropodists. After many conversations with various parties I concluded the registered chiropodists felt infection control was an integral part of the training and therefore there was no need to make a special issue of the matter. As I taught infection control at a public university I could sympathise with the sentements but also as someone involved with CPD (at the time) was acutely aware of practitoners ignorance as to the risks they ran. I did communicate with professional associations about the absense of guidelines but did not recieve a satisfactory answer. Privatley I was told by the authorities the reluctance to set podiatry standards for registered pods in the UK was the financial burden most practitioners would then face, plus the added cost of policing the system.

In all conscience I compiled a set of guidelines for podiatrists on infection control which was published privately. Within twelve months the Society had their own guidelines.


One of the downsides to professional guidelines
These rarely take into account ergonomics which is very important (to our health) but frequently ignored because it is not mandatory). A colleague undertook a pilot project to compare groups in a local hospital with relation to days of work due to back pain. He received 100% return which is most unsual and found when he compared the occupational groups, podiatrists scored highest.

In the more recent past I helped a Master's student reading for a higher degree in ergonomics, she was interested in RSI potentially caused by the design of clincal furniture. We searched the chiropody/podiatry journals from the earliest published to the most recent and radomly selected examples at ten year intervals. From articles and adverts within we made a profile of clinical furniture (including operator's chair. work units and patients couch) used over the last hundred years. Exempting hydraulics, clinical furtniture used by podiatrists had not changed in a century.

The clinical furniture available to the podologues (Europe) in the same period is often far superior to the standard clinical furniture described in the Commonwealth professional journals.

What say you?

toeslayer

 

Toeslayer

From articles and adverts within we made a profile of clinical furniture (including operator's chair. work units and patients couch) used over the last hundred years. Exempting hydraulics, clinical furtniture used by podiatrists had not changed in a century.


Rubbish.

And what has this got to do with the thread?

 

R.E.G.

>Rubbish.

Ah I think I have a critic.
The ergonomics of clinical furniture has not changed in a century and for that matter nor has the type of injuries associated with the practice of podiatry . Look forward to reading information to the contrary

>And what has this got to do with the thread?

I was considering, "One of the downsides to professional guidelines," that's the same guidelines that would set the criteria for "external inspections"

Now if that is not relevant R.E.G.:boxing:

see you at four , behind the bike sheds

toeslayer

 

Toeslayer,

Perhaps rubbish was a bit strong, but a 100 years is a long time, unless you meant the end of the 20th century.

I have a Dexta patient couch controlled by electric foot pedals, it moves in all 3 planes. I did try an old hydraulic 'barbers' chair when I trained though.

Nail drills now come in two forms wet and dry and use micro-motors rather than a foot operated treadle.
Scalpel now have disposable blades and a variety of shapes.
Magnifying lights use florescent tubes rather than reflects from gas flames.
Nippers come in all shapes and sizes.
Most visiting chiropodists use motor transport rather than bicycles.
We have black Biro's with gel grips instead of quill pens

Do you need any more?

Not too sure about the 'guidelines'. My impression is they are driven by DOH paranoia.

The SCP 'Accreditation scheme' is said to (cannot remember the modern jargon) 'mirror' the DoH/HCC standards.

IMO unfortunately some of these are overkill for the requirements of safe general private chiropody practice. Having said that I do have an accredited practice.

I do not know what you used to do behind the bike sheds, but with an offer like that probably not the same as me

Bob

 

Hi Bob

> unless you meant the end of the 20th century.

You are right of course I got a bit carried away. The review indicated there had been significantly no change since the beginning of publications which would be circa 1913 onwards. So we are just short of the century. Lythographs of corncutters (corn operators) however from the 17th and 18th century would support the positon of clients and corn operator has not changed that much.

>I have a Dexta patient couch controlled by electric foot pedals, it moves in all 3 planes. I did try an old hydraulic 'barbers' chair when I trained though.

Sure more recent innovations have occurred (thank goodness) but they still prefer the old client operator position. I saw several chairs at a recent European conference which gave much greater access to the heel area than I have ever seen with 'conventional patient chairs.' There also seem to be an increased emphasis on the operator standing.

My comments related to furniture and not instrumentation. But it is interesting that nail drill handles, scalpels handles show a remarkable lack of ergonomics in their design. Nail nippers especially have been implicated in RSI occupational injury and nail drills (wet or dry) are not accepted overall as safe, so there is room for improvement. I accept these have evolved and hopefully will continue to do so.

The standards of practice in UK and Australasia are almost identical and based on commonality, shared practice of peers, and international guidelines. However as I was trying to illlustrate in th previous posting the sum of the parts (in guidelines) is rarely equal to the whole and no matter how good guidelines appear they are not perfect. It appears from the discussion despite accepted guidelines being in existance the policing of private practice is less common than the public sector where clinical audits necessitate greater compliance.

cheers
toeslayer

 

Toeslayer
I am sure that ergonomics have a place somewherein this time of litigation- knew of a woman who tried to get money by saying the company had failed to supply a suitable chair- she was 25 stone and developed a bad back. (She did fail in her attempt.)

I would point out that private practitioners are much less likely to take days of sick with back ache, so the study you spoke of was a little biased. It may have been better to find out who suffered with back problems, across the board, not just in the NHS.

Cornmerchant

 

Cornmerchant

>
I am sure that ergonomics have a place somewherein this time of litigation- knew of a woman who tried to get money by saying the company had failed to supply a suitable chair- she was 25 stone and developed a bad back. (She did fail in her attempt.)

I cannot comment.

>I would point out that private practitioners are much less likely to take days of sick with back ache, so the study you spoke of was a little biased. It may have been better to find out who suffered with back problems, across the board, not just in the NHS.

For the record and from my memory the study included groups within a hospital population at a certain time which included patients visitors as well as allied health staff, nurses and medical practitioners etc. So it was not entirely biased. What was all the more remarkable was there was a 100% return (postal questionaire) which is a very high response rate and was taken by the organisers as an indication how important (presumable relevant) the enquiry was to the complete community. It was only a pilot and the results were purely illuminary but the inference was clear it did suggest injury at work was possible and higher rate reported in the podiatry workforce was significant when compared to other occupational groups. These finding would suggest it was something the pods did. The most likely cause of occupational related injury would be the furniture unless the sample group had by chance a previous history of backache or an adjunct incident. This was not apparent from the pre-screening of the subjects. One might safely extrapolate from the results the similar distribution would be found in all podiatry populations and conclude as a professional group they are prone to occupationally related back ache (whether they take days off work or not) when compared to other occupational groups. In a larger study the findings would justify inclusion of podiatrists from across the workplace.


toeslayer

 

Hello Robin.
The Baldwin case that you mention caused a flurry of postings and discussion on the SCP Members forum. Responses varied from complete incredulity to downright outrage. Any attempts to obtain a comment from the HPC itself were met with a stony silence. It seemed that 'the editor's decision is final and no correspondence will be entered into'.
Following that, there was an in-depth discussion on the SCP forum re flooring materials.
It would appear, and this is purely my opinion, that Mr Baldwin was judged on "best practice". As Cornmerchant states, this is nigh impossible to achieve unless building a clinic from scratch. As it appears that BChA, (and I am not "sniping", just making a statement based on information previously supplied) does not have written Standards of Clinical practice, it could be argued that Mr Baldwin was at a disadvantage.
I have only ever seen the HPC required type of flooring (which continues up the wall to skirting board level) three times. Two were in private surgeries and the other is at my newly refurbished vet's surgery!
Having read all the HPC hearings relevent to Podiatry I can only conclude that we should be mindful of the 11th Commandment, ie "Thou shall not be found out"
Cynically.
Dido