The Care Quality Commission
  • Hospital
  • Independent hospital

Gosforth Private Clinic

Overall: Inadequate read more about inspection ratings

18 Elmfield Road, Gosforth, Newcastle upon Tyne, Tyne and Wear, NE3 4BP (0191) 284 1355

Provided and run by:
J M A Healthcare Limited

All Inspections

15 December 2021

During an inspection looking at part of the service

This was a short- notice announced focused, follow up inspection. This meant the provider had limited notice that we were inspecting. Following our previous inspection in September 2021, we took action to suspend the service from providing regulated activity. This inspection was undertaken to check the service had made sufficient improvements to allow the provision of regulated activities to resume.

Due to the focused nature of this inspection we did not rate the service and the ratings from our previous inspection remained unchanged.

This inspection found the provider had made sufficient improvement in quality and safety, which meant we did not take further action to extend the provider’s suspension.

This was because:

  • Staff understood how to protect patients from abuse. Most staff had completed training on how to recognise and report abuse and they were clear how to apply it.
  • The maintenance and use of facilities, equipment and premises mostly kept people safe.
  • We found evidence of how staff identified and quickly acted upon patients at risk of deterioration.
  • There was a new process in place to ensure records were managed and stored securely.
  • The service had improved processes to make sure staff were competent for their roles, although further improvements were required.

However:

  • The service did not provide mandatory training in key skills to all staff. Although there was now a system in place to make sure everyone completed it, it was not robust.
  • The service did not always control infection risk well.
  • There was not a robust system in place to ensure patients were supported to make informed decisions about their care and treatment.
  • Not all leaders understood the responsibilities and obligations they had as the provider to meet the standards required by the regulations.
  • Leaders did not always operate effective governance processes throughout the service, although there were some improved governance processes in place.

14 September 2021

During a routine inspection

This is our first inspection of this location. We rated it as inadequate because:

  • The provider was unable to provide any policies, procedures, risk assessments or standard operating procedures that they used to make sure patients were safe from the risk of harm.
  • There was no policy in place accessible to staff about how to manage deteriorating patients.
  • There was no information for staff working at the service about their responsibilities in relation to clinical records.
  • There were no clinical records held onsite, the provider was unclear how clinicians documented in and managed clinical records and there was no policy stating how or where clinical records should be stored.
  • The provider was unable to assure us that there was a consent policy or that staff followed the correct process to obtain patient consent.
  • The provider had no duty of candour policy and was unsure of their full responsibilities in the case of an incident requiring formal duty of candour.
  • The provider kept staff files, but these were not all up to date. There was no process in place to assure the provider that staff had an up to date registration, revalidation or performance appraisal nor was there a system in place to check staff working at the service had undergone up to date statutory and mandatory training.
  • There was a limited governance processes in place, and this did not include how the provider monitored performance to ensure care and treatment was delivered in line with national guidance or the regulations.
  • The provider did not have a safeguarding policy that was accessible to all staff. The safeguarding lead had not undergone the relevant training required to be a safeguarding lead and the staff we spoke with did not fully understand their responsibilities in relation to safeguarding vulnerable adults or children or who they would contact should they have concerns about the safety of a person.
  • There was limited evidence of cleaning schedules and when we inspected the clinic rooms, we found some equipment to be visibly dusty. National guidance had not been followed for two procedures carried out in theatre. This increased the infection control risk to patients.

Following this inspection, under Section 31 of the Health and Social Care Act 2008, we suspended the provider in respect to the regulated activities for a limited time to give the provider opportunity to take action to reduce risks to patients. We took this urgent action as we believed a person would or may be exposed to the risk of harm if we had not done so.

However:

  • The reception area was visibly clean and tidy.
  • The building was easy to access for those with a disability.
  • Cleaning equipment and substances hazardous to health were locked away.
  • Portable appliance testing (PAT), servicing and calibration, were completed and up to date.
  • Social media feedback about Gosforth Private Clinic was predominantly positive and patients felt cared for.