28 June 2018
During a routine inspection
We carried out an announced comprehensive inspection on 28 June 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 providing effective care in accordance with the relevant regulations.
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.
Our key findings were:
- The provider carried out travel vaccinations and private GP consultations as part of their regulated activities with CQC.
- The systems to keep patients safe and safeguarded from abuse needed improving. We identified several areas where risks in relation to the management of safe services had not been sufficiently managed or embedded within the service.
- The premises had recently been refurbished prior to a recent move and appeared well maintained and visibly clean and tidy.
- The provider had arrangements for the safe management of medicines.
- Incidents were acted on and used to support learning.
- Staff were supported with their learning and development needs and had access to training and regular appraisals. However, the provider had not clearly identified core training needs of all staff or had effective systems for monitoring this.
- There was evidence of clinical improvement activity, while this predominantly related to services that were outside the scope of CQC regulation it was relevant to the regulated services.
- The provider had effective systems for obtaining consent and patient information was appropriately documented.
- Feedback from people about the service they received was positive. People who had used the service felt involved in decisions and said that they were treated with dignity and respect.
- People who used the service received timely care.
- There was a complaints process and complaints seen were appropriately managed.
- There was clear leadership to support the running of the service. However, governance arrangements did not adequately identify and address all areas of risks relating to the regulated activities. The provider had also failed to properly register their services.
We identified regulations that were not being met and the provider must:
- Ensure patients are protected from abuse and improper treatment.
- Ensure effective systems and processes are established to ensure good governance in accordance with the fundamental standards of care.
- Ensure the service is properly registered with CQC.
You can see full details of the regulations not being met at the end of this report.
There were areas where the provider could make improvements and should:
- Review systems in place for supporting patients who may experience barriers to accessing information.
- Review prescribing guidance to include what medicines will or will not be prescribed through the private GP service.