Archived: Susan Mary Horsewood-Lee - Oakley Street

Updated 3 September 2019

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.

Dr Susan Mary Horsewood-Lee provides a private general practice service from a registered location at 34 Oakley Street, Chelsea, London SW3 5NT. Services are available to any fee-paying patient. Dr Horsewood-Lee is the sole doctor and there are no other clinical staff at the service. The doctor is supported by a Practice Manager, a Medical Secretary and a part-time clerical assistant. Services are available by appointment only between 7.30am and 6pm Monday to Friday. The service is managed by the practice doctor. The doctor is required to register with a professional body and was registered with a licence to practice.

The service is located in a converted residential and business-use property with below street level access into a reception and waiting area. The building is not accessible to wheelchair users and does not have accessible facilities. The service directs patients who need these to a local surgery which has disabled access. There are patient toilets and baby changing facilities available. There is one clinical consultation and treatment room, a reception area, a storage area, a medicines storage room and kitchen space.

The service is registered with the CQC to provide the regulated activities of diagnostic and screening procedures, family planning services and treatment of disease, disorder or injury.

We carried out an announced visit to Dr Susan Horsewood-Lee on 30 May 2019. Our inspection team was led by a CQC inspector and included a GP specialist advisor.

Before visiting, we reviewed a range of information we hold about the service in advance of the inspection and asked other organisations to share what they knew. During our visit we:

• Spoke with doctor who was the provider of the service.
• Spoke with non-clinical staff which included two administrative staff.
• Reviewed an anonymised sample of the personal care or treatment records of patients.
• Reviewed service policies, procedures and other relevant documentation.
• Inspected the premises and equipment used by the service.
• Reviewed feedback from service users including CQC comment cards.

To get to the heart of patients’ experiences of care and treatment, we always ask the following five questions:

• Is it safe?
• Is it effective?
• Is it caring?
• Is it responsive to people’s needs?
• Is it well-led?

These questions therefore formed the framework for the areas we looked at during the inspection.

Updated 3 September 2019

This service is rated as Good overall. (Previous inspection April 2018 – inspected but not rated.

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 on 30 May 2019 at Dr Susan Mary Horsewood-Lee – Oakley Street, to follow up on breaches of regulations.

CQC previously inspected the service on 27 April 2018 and asked the provider to make improvements regarding safe and well-led service. We checked these areas as part of this comprehensive inspection and found those concerns had been addressed. Following our previous inspection in April 2018, we issued two requirement notices for breaches of Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment and Regulation 17 HSCA (RA) Regulations 2014 Good governance.

Dr Susan Horsewood-Lee provides a private doctors GP service to patients at 34 Oakley Street in the Royal Borough of Kensington and Chelsea. The service is situated in premises which are owned by the provider. The service is registered with the Care Quality Commission to provide the regulated activities of Treatment of disease, disorder or injury and Diagnostic and screening procedures and family planning.

Prior to our inspection, patients completed CQC comment cards telling us about their experiences of using the service. Thirty-seven people provided wholly positive feedback about the service. Dr Horsewood-Lee was described as caring, attentive and patients felt they were treated with respect.

Our key findings were:

• Action had been taken on all of the issues identified at the previous inspection; those we required and those we recommended.
• The service had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
• We found evidence of improvement in monitoring and mitigating risks relating to the safety of service users.
• The premises were clean and well maintained, we saw evidence of actions taken to prevent and control the spread of infections.
• Not all emergency medicines were available as described in recognised guidance. There was a record kept of checks to make sure medicines were available, within their expiry dates, and in working order.
• At this inspection we found medical equipment had been calibrated to ensure it was safe to use.
• The service reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence based guidelines.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Services were provided to meet the needs of patients.
• There was a system for recording and acting on incidents, adverse events and safety alerts. The provider shared safety alerts with staff effectively.
• Staff felt involved and supported and worked well as a team.
• Patient feedback for the services offered was consistently positive.

The areas where the provider should make improvements are:

• Risk assess and make arrangements for the equipment and medicines needed for medical emergencies, including a defibrillator and pulse oximeter.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care