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Inspection Summary


Overall summary & rating

Good

Updated 21 February 2020

This service is rated as Good overall.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We carried out an announced comprehensive inspection at Dr M R Rakus on 21 January 2020. This was the first CQC inspection of this location under the current CQC inspection methodology, although the location had previously been inspected in 2013.

This service is registered with CQC under the Health and Social Care Act 2008 in respect of some, but not all, of the services it provides. There are some exemptions from regulation by CQC which relate to particular types of regulated activities and services and these are set out in Schedule 1 and Schedule 2 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Dr M R Rakus provides a range of non-surgical cosmetic interventions, which are not within CQC scope of registration. Therefore, we did not inspect or report on these services.

Dr Rakus is the registered manager of the service. 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:

  • The service provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The service organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
  • The way the service was led and managed promoted the delivery of high-quality, person-centre care.

The areas where the provider should make improvements are:

  • The service should ensure that all staff have undertaken fire safety and information governance training, and ensure that records of all training completed by staff are kept at the clinic, including those for doctors with practising privileges.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Updated 21 February 2020

We rated safe as

Good because:

The service had the systems and processes that it needed to deliver safe care. The service learned from incidents and had reliable systems and processes to ensure that medicines and equipment were used and managed safely

Safety systems and processes

The service

had clear systems to keep people safe and safeguarded from abuse.

  • The provider conducted safety risk assessments. It had appropriate safety policies, which were regularly reviewed and communicated to staff including those working under practising privileges (this is where a medical practitioner is granted permission to work in a private hospital or clinic in independent private practice). who were not employed by the service. They outlined clearly who to go to for further guidance. Staff received safety information from the service as part of their induction and refresher training. The service had systems to safeguard children and vulnerable adults from abuse.
  • Although this service had not been required to make a safeguarding referral, it had systems in place to work with other agencies to support patients and protect them from neglect and abuse. Staff took steps to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect.
  • The provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate, including for clinicians working under practising priviliges. Disclosure and Barring Service (DBS) checks had been requested for all staff. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).

  • All staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns. Staff who acted as chaperones were trained for the role and had received a DBS check.
  • There were notices advising patients that chaperones were available if required.
  • There was an effective system to manage infection prevention and control, including for the risk of Legionella.
  • The provider ensured that facilities and equipment were safe and that equipment was maintained according to manufacturers’ instructions. We noted that one oxygen mask was out of date, and the service took immediate action to ensure that these were removed. All other equipment that we checked was in date. There were systems for safely managing healthcare waste.
  • The provider carried out appropriate environmental risk assessments, which took into account the profile of people using the service and those who may be accompanying them. Some risk assessments had been carried out by the provider, with others provided by the building owner.

Risks to patients

There

were systems to assess, monitor and manage risks to patient safety.

  • There were arrangements for planning and monitoring the number and mix of staff needed.
  • There was an effective induction system for all staff tailored to their role.
  • Staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention. They knew how to identify and manage patients with severe infections, for example sepsis.
  • There were suitable medicines and equipment (including oxygen and a defibrillator) to deal with medical emergencies which were stored appropriately and checked regularly.
  • When there were changes to services or staff the service assessed and monitored the impact on safety.
  • There were appropriate indemnity arrangements in place. There was a corporate indemnity for all clinicians working at the service.

Information to deliver safe care and treatment

Staff

had the information they needed to deliver safe care and treatment to patients.

  • Individual care records were written and managed in a way that kept patients safe. The care records we saw showed that information needed to deliver safe care and treatment was available to relevant staff in an accessible way.
  • The service had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.
  • The service had a system in place to retain medical records in line with Department of Health and Social Care (DHSC) guidance in the event that they cease trading.
  • Clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance. The service had close working relationships with other providers in relevant fields to whom they might refer, for example dermatologists.

Safe and appropriate use of medicines

The service

had reliable systems for appropriate and safe handling of medicines.

  • The systems and arrangements for managing medicines, including prescribed medicines, emergency medicines and equipment minimised risks.
  • Staff prescribed, administered or supplied medicines to patients and gave advice on medicines in line with legal requirements and current national guidance. Processes were in place for checking medicines and staff kept accurate records of medicines. Where there was a different approach taken from national guidance there was a clear rationale for this that protected patient safety.
  • There were clear processes in place to verify patient identity.

Track record on safety and incidents

The service

had a good safety record.

  • There were comprehensive risk assessments in relation to safety issues.
  • The service monitored and reviewed activity. This helped it to understand risks and gave a clear, accurate and current picture that led to safety improvements.

Lessons learned and improvements made

The service learned and made improvements when things went wrong.

  • There was a system for recording and acting on significant events. Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • There were adequate systems for reviewing and investigating when things went wrong, although this service had not been required to do so in relation to its regulated services.

Effective

Good

Updated 21 February 2020

We rated effective as

Good

because:

The service assessed need and delivered care in line with current legislation, standards and evidence-based guidance. There was a programme of quality improvement, including regular audits through which the effectiveness and appropriateness of the care provided was reviewed.

Effective needs assessment, care and treatment

The provider had systems to keep clinicians up to date with current evidence-based practice. We saw evidence that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance (relevant to their service).

  • The service used information about care and treatment to make improvements, and clinicians regularly attended training events and conferences in order to ensure that they were up to date.
  • The service made improvements through the use of completed audits. Clinical and non-clinical audit was in place to ensure that both clinical care was of a high standard and that systems were followed. The service undertook clinical notes audits and had recently conducted an audit to determine whether or not consent was being taken in line with guidelines.

Monitoring care and treatment

The service was actively involved in quality improvement activity.

  • The service used information about care and treatment to make improvements, and clinicians regularly attended training events and conferences in order to ensure that they were up to date.
  • The service made improvements through the use of completed audits. Clinical and non-clinical audit was in place to ensure that both clinical care was of a high standard and that systems were followed.

Effective staffing

Staff had the skills, knowledge and experience to carry out their roles.

  • All clinical staff were appropriately qualified. The provider had an induction programme for all newly appointed staff. We noted that some non-clinical staff in the practice had not received formal training in infection control, information governance or fire safety. However, all relevant leads had been trained, and staff were aware of up to date guidance in all three areas.
  • Relevant professionals (medical and nursing) were registered with the General Medical Council (GMC)/ Nursing and Midwifery Council and were up to date with revalidation
  • The provider understood the learning needs of staff and provided protected time and training to meet them. Up to date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop.

Coordinating patient care and information sharing

Staff worked together, and worked well with other organisations, to deliver effective care and treatment.

  • Patients received coordinated and person-centred care. Where patients’ required referral to third party organisations, these were completed quickly and clearly.
  • Before providing treatment, doctors at the service ensured they had adequate knowledge of the patient’s health, any relevant test results and their medicines history. The consent procedures at the service were thorough in this regard.
  • All patients were asked for consent to share details of their consultation and any medicines prescribed with their registered GP on each occasion they used the service.
  • The provider had risk assessed the treatments they offered.
  • Patient information was shared appropriately (this included when patients moved to other professional services), and the information needed to plan and deliver care and treatment was available to relevant staff in a timely and accessible way. There were clear and effective arrangements for following up on people who had been referred to other services.

Supporting patients to live healthier lives

Staff were consistent and proactive in empowering patients, and supporting them to manage their own health and maximise their independence.

  • Where appropriate, staff gave people advice so they could self-care.
  • Where patients needs could not be met by the service, staff redirected them to the appropriate service for their needs.

Consent to care and treatment

The service obtained consent to care and treatment in line with legislation and guidance

.

  • Staff understood the requirements of legislation and guidance when considering consent and decision making.
  • Staff supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.
  • The service monitored the process for seeking consent appropriately.

Caring

Good

Updated 21 February 2020

We rated caring as

Good

because:

The service treated patients with kindness, dignity and compassion.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Staff understood patients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all patients.
  • The service gave patients timely support and information.
  • The service conducted its own customer satisfaction surveys which showed that the majority of patients were happy with the service.

We received 28 CQC comments cards which had been completed by patients in the two weeks prior to the inspection. We were not able to elicit which of the patients were attending for care in the scope of CQC registration. All of the cards were positive, patients said that staff were helpful and that clinicians involved them in decisions relevant to their care. They were also positive about the individual care that they had received.

Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about care and treatment.

  • Patients were told about multi-lingual staff who might be able to support them. Information leaflets were available in easy read formats, to help patients be involved in decisions about their care.
  • Patients told us through comment cards, that they felt listened to and supported by staff and had sufficient time during consultations to make an informed decision about the choice of treatment available to them.
  • Staff communicated with people in a way that they could understand, for example, communication aids and easy read materials were available.

Privacy and Dignity

The service respected patients’ privacy and dignity.

  • Staff recognised the importance of people’s dignity and respect.
  • Doors were closed during consultations and conversations taking place in these rooms could not be overheard.
  • Staff knew that if patients wanted to discuss sensitive issues or appeared distressed they could offer them a private room to discuss their needs.
  • Patients medical records were securely stored electronically.

Responsive

Good

Updated 21 February 2020

We rated responsive as

Good

because:

The service provided responsive care to its patients. Patients could pre-book and attend on the day, and services were targeted at the needs of patients’ groups.

Responding to and meeting people’s needs

The service organised and delivered services to meet patients’ needs.

It took account of patient needs and preferences.

  • The facilities and premises were appropriate for the services delivered.
  • The website for the service was very clear and easy to understand. In addition, it contained clear information about the procedures offered.
  • The waiting area was large enough to accommodate the number of patients who attended on the day of the inspection.

Timely access to the service

Patients were able to access care and treatment from the service within an appropriate timescale for their needs.

  • Patients had timely access to initial assessment, test results and diagnosis (where relevant) and treatment.
  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • Patients reported that the appointment system was easy to use.
  • Referrals and transfers to other services were undertaken in a timely way. There were systems in place to urgently refer and monitor these referrals if they were required.

Listening and learning from concerns and complaints

The service took complaints and concerns seriously and responded to them appropriately to improve the quality of care.

  • Information about how to make a complaint or raise concerns was available. Staff treated patients who made complaints compassionately.
  • The service informed patients of any further action that may be available to them should they not be satisfied with the response to their complaint.
  • The service had complaint policy and procedures in place. The service learned lessons from individual concerns, complaints and from analysis of trends. It acted as a result to improve the quality of care.

Well-led

Good

Updated 21 February 2020

We rated well-led as

Good because:

The location was compliant with CQC regulations relevant to the provision of well led care. The service had clear vision and values and leadership. There were comprehensive governance procedures in place.

Leadership capacity and capability;

Leaders had the capacity and skills to deliver high-quality, sustainable care.

  • Leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them.
  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.

  • The provider had effective processes to develop leadership capacity and skills, including planning for the future leadership of the service.

Vision and strategy

The service had a clear vision and credible strategy to deliver high quality care and promote good outcomes for patients.

  • There was a clear vision and set of values. The service had a realistic strategy and supporting business plans to achieve priorities.

  • Staff were aware of and understood the vision, values and strategy and their role in achieving them

  • The service monitored progress against delivery of the strategy.

Culture

The service had a culture of high-quality sustainable care.

  • Staff told us that they felt respected, supported and valued. They were proud to work for the service.

  • The service focused on the needs of patients.

  • Staff told us they could raise concerns and were encouraged to do so. They had confidence that these would be addressed.

  • There were processes for providing all staff with the development they need. This included appraisal and career development conversations. Staff were supported to meet the requirements of professional revalidation where necessary. However, several non-clinical staff had not completed some mandatory training.

  • There was a strong emphasis on the safety and well-being of all staff.

  • The service actively promoted equality and diversity. It identified and addressed the causes of any workforce inequality. Staff felt they were treated equally.

  • There were positive relationships between staff and teams.

Governance arrangements

There were clear responsibilities, roles and systems of accountability to support good governance and management.

  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective. The governance and management of partnerships, joint working arrangements and shared services promoted interactive and co-ordinated person-centred care.

  • Staff were clear on their roles and accountabilities

  • Leaders had established proper policies, procedures and activities to ensure safety and assured themselves that they were operating as intended.

Managing risks, issues and performance

There were clear and effective processes for managing risks, issues and performance.

  • There was an effective, process to identify, understand, monitor and address current and future risks including risks to patient safety.
  • The service had processes to manage current and future performance. Performance of clinical staff could be demonstrated through audit of their consultations, prescribing and referral decisions. Leaders had oversight of safety alerts, incidents, and complaints.
  • Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to change services to improve quality.
  • The provider had plans in place and had trained staff for major incidents.

Appropriate and accurate information

The service acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance.
  • Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information.
  • The service used performance information which was reported and monitored, and management and staff were held to account

  • The information used to monitor performance and the delivery of quality care was accurate and useful.

  • The service submitted data or notifications to external organisations as required.

  • There were robust arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.

Engagement with patients, the public, staff and external partners

The service involved patients, the public, staff and external partners to support high-quality sustainable services.

  • Staff could describe to us the systems in place to give feedback. There were regular meetings for all employed staff, and meetings between all of the clinicians in the practice. These were minuted and we saw that information was being shared.
  • The service was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

There were systems and processes for learning, continuous improvement and innovation.

  • There was a focus on continuous learning and improvement.
  • Leaders and managers encouraged staff to take time out to review individual and team objectives, processes and performance.