We carried out an announced comprehensive inspection on 22 March 2018 to ask the service the following key questions; Are services safe, effective, caring, responsive and well-led?
Our findings were:
Are services safe?
We found that this service was not providing safe care in accordance with the relevant regulations.
The impact of our concerns is minor for patients using the service, in terms of the quality and safety of clinical care. The likelihood of this occurring in the future is low once it has been put right.
Are services effective?
We found that this service was not providing effective care in accordance with the relevant regulations.
The impact of our concerns is minor for patients using the service, in terms of the quality and safety of clinical care. The likelihood of this occurring in the future is low once it has been put right.
Are services caring?
We found that this service was providing caring services in accordance with the relevant regulations.
Are services responsive?
We found that this service was providing responsive care in accordance with the relevant regulations.
Are services well-led?
We found that this service was not providing well led care in accordance with the relevant regulations.
The impact of our concerns is minor for patients using the service, in terms of the quality and safety of clinical care. The likelihood of this occurring in the future is low once it has been put right.
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.
Our key findings were:
- There were systems in place for the overall management of significant events and incidents.
- Although the provider had some systems and processes in place to keep patients safe some of these were were not sufficiently effective or embedded. This included risks in relation to unforeseen medical emergencies and the use of chaperones.
- There was an overarching governance framework which supported the delivery of good quality care.
- The provider demonstrated that they understood their responsibilities and had received training on safeguarding children and vulnerable adults relevant to their role.
- The premises appeared well maintained and visibly clean and tidy.
- The practice had not sought feedback from patients and the public. The provider told us that due to the low number of patients that had used the service since opening, they had not implemented a system to gather patients’ views and no audits had been completed to support the delivery of safe care and treatment.
- Services were planned and delivered to take into account the needs of different patient groups and to help ensure flexibility, choice and continuity of care.
- The provider had established a good network within the private healthcare sector for advice and support if needed.
- The GP provider told us that currently the regulated service offered accounted for less than 5% of his working week.
- The provider had effective systems for obtaining consent and patient information was well documented.
- There was a complaints process in place, however the provider told us they had received no complaints since opening the practice.
We identified regulations that were not being met and the provider must:
- Ensure effective systems and processes are established to ensure good governance in accordance with the fundamental standards of care.
- Ensure care and treatment is provided in a safe way to patients
There were areas where the provider could make improvements and should:
- Review and improve the process for advising patients of the complaints process.
- Review and take steps to improve the process for obtaining patient feedback.
- Improve the current process to ensure chaperones used by the service have had the necessary training and checks completed.
You can see full details of the regulations not being met at the end of this report.