This service is rated as
Good
overall. Previous inspection 21/09/2019 – Requires improvement
Overall, Inadequate for safe and Requires improvement for Well led.
The key questions are rated as:
Are services safe? – Good
Are services effective? – Choose a rating
Are services caring? – Choose a rating
Are services responsive? – Choose a rating
Are services well-led? – Good
We carried out an announced comprehensive inspection at Sunnah Circumcision Service at Maryam Centre on 9 December 2020.
At the last unannounced inspection on 21 September 2019 we rated the service as Requires improvement overall, inadequate for safe and Requires improvement for Well led and issued the service with a warning notice. Previous reports on this service can be found on our website at: https://www.cqc.org.uk/Sunnah Circumcision Service at Maryam Centre.
At this inspection we followed up on breaches of regulations identified at a previous inspection on 21 September 2019.
On that inspection we found;
- Staff were not recording identity checks in line with the provider’s own policy.
- Infection control procedures failed to identify concerns picked up during our inspection, including the cleaning and storage or equipment and single use items.
- There were gaps in adult safeguarding training.
- Not documenting Identity checks for those with parental responsibility.
- Significant events were not being identified, recorded and investigated.
- There were no patient records or policies accessible to staff to refer to onsite.
At this focused inspection, we found the service had made improvements following our previous inspection. As a result of the changes to the ratings for these two questions, there has been a change in overall rating.
We have rated this service as good overall.
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 service was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.
The Sunnah Circumcision Service at Maryam Centre is located in the London borough of Tower Hamlets and provides private health services. The services offered were faith and non-faith based cultural circumcision services for all age groups, including adults. The patients seen at the practice are often seen for single treatments and as such the clinic does not keep a patient list.
The services doctor is 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 service is run.
Our key findings were;
At the 2019 inspection:
- The service had not been logging significant events appropriately, although they were dealing with them. At this inspection they were logging them, dealing with them analysing them and sharing learnings.
- We found some gaps in safeguarding and basic life support training. At this inspection we found that the provider had completed the required inspection soon after the 2019 inspection.
- We found that the service did not have an adequate process in place to verify patients’ identities. At this inspection we found that they had introduced a new for which checked the patient’s identity and that they had parental responsibility.
- We identified some infection control risks regarding storage of cleaning equipment and single use items. At this inspection we found that the cleaning materials were stored in a designated cleaning cupboard and single use items were stored in their own cupboard and rotated regularly.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care